This page is part of the electronic Case Reporting (eCR) (v0.2.0: STU 1 Ballot 2) based on FHIR R3. The current version which supercedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions
JSON Format: Composition-eicr-composition-zika
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{ "resourceType" : "Composition", "id" : "eicr-composition-zika", "meta" : { "profile" : [ "http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition" ] }, "language" : "en-US", "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <table class="grid"> <tr> <th>Id:</th> <td>Id: eicr-composition-zika</td> </tr> <tr> <th>Meta:</th> <td>http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition</td> </tr> <tr> <th>Language:</th> <td>en-US</td> </tr> <tr> <th>Date:</th> <td>2018-01-02T22:13:23Z</td> </tr> <tr> <th>Type:</th> <td> <span title="Code: 55751-2 Code system: http://loinc.org">Public Health Case Report</span> </td> </tr> <tr> <th>Title:</th> <td>Initial Public Health Case Report</td> </tr> <tr> <th>Status:</th> <td>final</td> </tr> <tr> <th>Subject:</th> <td> <a href="Patient-ecr-patient-eve-everywoman.html">Eve Everywoman</a> </td> </tr> <tr> <th>Author:</th> <td> <a href="Practitioner-ecr-practitioner-henry-seven.html">Henry Seven, MD</a> </td> </tr> <tr> <th>Encounter:</th> <td> <a href="Encounter-eicr-encounter-eve-everywoman-20180401.html">Ambulatory Office Visit, Apr 1, 2018, 10:00am</a> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Code:</th> <td> <span title="Code: 46240-8 Code system: http://loinc.org">Encounters</span> </td> </tr> <tr> <th>Text:</th> <td><table> <thead> <tr> <th>Encounter</th> <th>Date(s)</th> <th>Location</th> </tr> </thead> <tbody> <tr> <td>Office outpatient visit 15 minutes</td> <td>MAR 7, 2018</td> <td> <ul> <li>Urgent Care Center</li> </ul> </td> </tr> <tr> <td colspan="20"> <ul> <li> <table> <thead> <tr> <th>Encounter Diagnosis Type</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> </tr> <tr> <td colspan="20"> <ul> <li> <table> <thead> <tr> <th>Initial Case Report Trigger Code Problem Observation </th> <th>Problem</th> <th>Trigger Code</th> <th>Trigger Code codeSystem</th> <th>RCTC OID</th> <th>RCTC Version</th> <th>Date(s)</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> <td>Pertussis (disorder)</td> <td>27836007</td> <td>SNOMED CT</td> <td>2.16.840.1.114222.4.11.7508</td> <td>19/03/2018</td> <td>MAR 7, 2018</td> </tr> </tbody> </table> <table> <thead> <tr> <th>Encounter Diagnosis Type</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> </tr> <tr> <td colspan="20"> <ul> <li> <table> <thead> <tr> <th>Problem Type</th> <th>Problem</th> <th>Date(s)</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> <td>A non-trigger code diagnosis (disorder)</td> <td>MAR 7, 2018</td> </tr> </tbody> </table> </li> </ul> </td> </tr> </tbody> </table> </li> </ul> </td> </tr> </tbody> </table> </li> </ul> </td> </tr> </tbody> </table> </td> </tr> </table> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Code:</th> <td> <span title="Code: 10164-2 Code system: http://loinc.org">History of Present illness Narrative</span> </td> </tr> <tr> <th>Text:</th> <td>generated</td> </tr> </table> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Code:</th> <td> <span title="Code: 29299-5 Code system: http://loinc.org">Reason for visit Narrative</span> </td> </tr> <tr> <th>Text:</th> <td>generated</td> </tr> </table> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Title:</th> <td>Social History Section</td> </tr> <tr> <th>Code:</th> <td> <span title="Code: 29762-2 Code system: http://loinc.org">Social history Narrative</span> </td> </tr> <tr> <th>Text:</th> <td>generated</td> </tr> <tr> <th>Entry:</th> <td> <a href="Observation-eicr-travel-history-eve-everywoman-201801.html">eICR Travel History: Eve Everywoman 2018-01</a> </td> </tr> <tr> <th>Entry:</th> <td> <a href="Observation-eicr-pregnancy-status-eve-everywoman.html">eICR Pregnancy Status Example 1</a> </td> </tr> <tr> <th>Entry:</th> <td> <a href="Observation-eicr-occupation-history-eve-everywoman.html">eICR Occupation History: Eve Everywoman</a> </td> </tr> </table> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Title:</th> <td>Problems Section</td> </tr> <tr> <th>Code:</th> <td> <span title="Code: 11450-4 Code system: http://loinc.org">Problem list - Reported</span> </td> </tr> <tr> <th>Text:</th> <td>generated</td> </tr> <tr> <th>Entry:</th> <td> <a href="Condition-eicr-condition-eve-everywoman-common-cold.html">Common cold (disorder)</a> </td> </tr> </table> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Title:</th> <td>Medications Administered Section</td> </tr> <tr> <th>Code:</th> <td> <span title="Code: 29549-3 Code system: http://loinc.org">Medication administered Narrative</span> </td> </tr> <tr> <th>Text:</th> <td>generated</td> </tr> <tr> <th>Entry:</th> <td> <a href="MedicationStatement-us-core-medicationstatement-eve-everywoman-azithromycin.html">Azithromycin 500 MG Oral Tablet</a> </td> </tr> </table> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Title:</th> <td>Results Section</td> </tr> <tr> <th>Code:</th> <td> <span title="Code: 30954-2 Code system: http://loinc.org">Relevant diagnostic tests/laboratory data Narrative</span> </td> </tr> <tr> <th>Text:</th> <td>generated</td> </tr> <tr> <th>Entry:</th> <td> <a href="Observation-us-core-observation-results-eve-everywoman-lymphocytes.html">Lymphocytes [#/volume] in Blood by Automated count - Interpretation: High</a> </td> </tr> </table> </td> </tr> <tr> <th>Section:</th> <td> <table class="grid"> <tr> <th>Title:</th> <td>Plan of Treatment Section</td> </tr> <tr> <th>Code:</th> <td> <span title="Code: 18776-5 Code system: http://loinc.org">Plan of Treatment</span> </td> </tr> <tr> <th>Text:</th> <td>generated</td> </tr> <tr> <th>Entry:</th> <td>urn:oid:2.16.840.1.114222.4.11.750819/05/2018<a href="ProcedureRequest-eicr-procedurerequest-zika.html">Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method</a> </td> </tr> </table> </td> </tr> </table> <!-- <table class="header_table" style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;"> <tbody> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Document Title</span> </td> <td class="td_header_role_value">Initial Public Health Case Report</td> </tr> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Document Id</span> </td> <td class="td_header_role_value">id</td> </tr> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Document Created:</span> </td> <td class="td_header_role_value">November 6, 2017, 22:23, PST </td> </tr> </tbody> </table> <table class="header_table" style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;"> <tbody> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Author</span> </td> <td class="td_header_role_value">Henry Seven, MD</td> </tr> </tbody> </table> <table class="header_table" style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;"> <tbody> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Encounter Id</span> </td> <td class="td_header_role_value">eicr-encounter-eve-everywoman-20180401</td> </tr> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Event Type</span> </td> <td class="td_header_role_value">Ambulatory, Office Visit</td> </tr> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Event Date</span> </td> <td class="td_header_role_value">March 7, 2018 10:00:00 AM to Nov 7, 2015 10:15:00 AM</td> </tr> <tr> <td class="td_header_role_name" style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;"> <span class="td_label">Encounter Location</span> </td> <td class="td_header_role_value">Salem Medical Center, 4646 Brown Rd, Salem, MA 02368</td> </tr> </tbody> </table> --> </div>" }, "status" : "final", "type" : { "coding" : [ { "system" : "http://loinc.org", "code" : "55751-2", "display" : "Public Health Case Report" } ] }, "subject" : { "reference" : "Patient/ecr-patient-eve-everywoman", "display" : "Eve Everywoman" }, "encounter" : { "reference" : "Encounter/eicr-encounter-eve-everywoman-20180401", "display" : "Ambulatory Office Visit, Apr 1, 2018, 10:00am" }, "date" : "2018-01-02T22:13:23Z", "author" : [ { "reference" : "Practitioner/ecr-practitioner-henry-seven", "display" : "Henry Seven, MD" } ], "title" : "Initial Public Health Case Report", "section" : [ { "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "46240-8", "display" : "Encounters" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <table> <thead> <tr> <th>Encounter</th> <th>Date(s)</th> <th>Location</th> </tr> </thead> <tbody> <tr> <td>Office outpatient visit 15 minutes</td> <td>MAR 7, 2018</td> <td> <ul> <li>Urgent Care Center</li> </ul> </td> </tr> <tr> <td colspan="20"> <ul> <li> <table> <thead> <tr> <th>Encounter Diagnosis Type</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> </tr> <tr> <td colspan="20"> <ul> <li> <table> <thead> <tr> <th>Initial Case Report Trigger Code Problem Observation </th> <th>Problem</th> <th>Trigger Code</th> <th>Trigger Code codeSystem</th> <th>RCTC OID</th> <th>RCTC Version</th> <th>Date(s)</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> <td>Pertussis (disorder)</td> <td>27836007</td> <td>SNOMED CT</td> <td>2.16.840.1.114222.4.11.7508</td> <td>19/03/2018</td> <td>MAR 7, 2018</td> </tr> </tbody> </table> <table> <thead> <tr> <th>Encounter Diagnosis Type</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> </tr> <tr> <td colspan="20"> <ul> <li> <table> <thead> <tr> <th>Problem Type</th> <th>Problem</th> <th>Date(s)</th> </tr> </thead> <tbody> <tr> <td>Diagnosis</td> <td>A non-trigger code diagnosis (disorder)</td> <td>MAR 7, 2018</td> </tr> </tbody> </table> </li> </ul> </td> </tr> </tbody> </table> </li> </ul> </td> </tr> </tbody> </table> </li> </ul> </td> </tr> </tbody> </table> </div>" }, "entry" : [ { "reference" : "Encounter/eicr-encounter-diagnosis-eve-everywoman-20180401", "display" : "eICR Encounter Diagnosis: Eve Everywoman 20180401" } ] }, { "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "10164-2", "display" : "History of Present illness Narrative" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml">Persistent Cough REPORTED starting on 2018/03/05<br/> Whooping Respiration not reported<br/> Paroxysms Of Coughing REPORTED starting on 2018/03/06<br/> Post-tussive vomiting not reported<br/></div>" } }, { "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "29299-5", "display" : "Reason for visit Narrative" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml">Bad cough<br/></div>" } }, { "title" : "Social History Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "29762-2", "display" : "Social history Narrative" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <table> <thead> <tr> <th>Travel History: Date(s)</th> <th>Location</th> </tr> </thead> <tbody> <tr> <td>APR 29, 2016 to OCT 30, 2016</td> <td>Nadi, Fiji</td> </tr> </tbody> </table> <table> <thead> <tr> <th>Pregnancy Status</th> <th>Date(s)</th> </tr> </thead> <tbody> <tr> <td>Not Pregnant</td> <td>JAN 1, 2016 to MAR 7, 2018</td> </tr> </tbody> </table> <table> <thead> <tr> <th>Occupation</th> <th>Date(s)</th> </tr> </thead> <tbody> <tr> <td>Human Resource Manager</td> <td>JAN 1, 2016 to NOV 7, 2018</td> </tr> </tbody> </table> </div>" }, "entry" : [ { "reference" : "Observation/eicr-travel-history-eve-everywoman-201801", "display" : "eICR Travel History: Eve Everywoman 2018-01" }, { "reference" : "Observation/eicr-pregnancy-status-eve-everywoman", "display" : "eICR Pregnancy Status Example 1" }, { "reference" : "Observation/eicr-occupation-history-eve-everywoman", "display" : "eICR Occupation History: Eve Everywoman" } ] }, { "title" : "Problems Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "11450-4", "display" : "Problem list - Reported" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <table> <thead> <tr> <th>Condition</th> <th>id</th> <th>Trigger Condition</th> <th>Condition Category</th> <th>Condition Code/Code System</th> <th>Date(s)</th> <th>Asserter</th> </tr> </thead> <tbody> <tr> <td>Common cold (disorder)</td> <td>16</td> <td>FALSE</td> <td>Encounter Diagnosis</td> <td>82272006 / SNOMED CT</td> <td>MAR 6, 2018</td> <td>Henry Seven, MD</td> </tr> </tbody> </table> </div>" }, "entry" : [ { "reference" : "Condition/eicr-condition-eve-everywoman-common-cold", "display" : "Common cold (disorder)" } ] }, { "title" : "Medications Administered Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "29549-3", "display" : "Medication administered Narrative" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <table> <thead> <tr> <th>id</th> <th>Medication</th> <th>Dose</th> <th>Duration</th> <th>Route</th> </tr> </thead> <tbody> <tr> <td>MedicationStatement-us-core-medicationstatement-eve-everywoman-azithromycin</td> <td>Azithromycin 500 MG Oral Tablet</td> <td>1 TAB</td> <td>MAR 7, 2018 11:25</td> <td>ORALLY</td> </tr> </tbody> </table> </div>" }, "entry" : [ { "reference" : "MedicationStatement/us-core-medicationstatement-eve-everywoman-azithromycin", "display" : "Azithromycin 500 MG Oral Tablet" } ] }, { "title" : "Results Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "30954-2", "display" : "Relevant diagnostic tests/laboratory data Narrative" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <p> <b>Generated Narrative with Details</b> </p> <p><b>id</b>: us-core-observation-results-eve-everywoman-lymphocytes</p> <p><b>meta</b>: </p> <p><b>status</b>: final</p> <p><b>category</b>: Laboratory <span style="background: LightGoldenRodYellow">(Details : {http://hl7.org/fhir/observation-category code 'laboratory' = 'Laboratory', given as 'Laboratory'})</span></p> <p><b>code</b>: Lymphocytes [#/volume] in Blood by Automated count <span style="background: LightGoldenRodYellow">(Details : {LOINC code '731-0' = 'Lymphocytes [#/volume] in Blood by Automated count'})</span></p> <p><b>trigger result</b>: FALSE</p> <p><b>effective</b>: Mar 6, 2018</p> <p><b>value</b>: 5.2 10*3/uL<span style="background: LightGoldenRodYellow"> (Details: UCUM code 10*3/uL')</span></p> <p><b>interpretation</b>: High<span style="background: LightGoldenRodYellow"> (Details: http://hl7.org/fhir/v2/0078 code 'H' = 'High')</span></p> <h3>ReferenceRanges</h3> <table class="grid"> <tr> <td>-</td> <td> <b>Low</b> <b>High</b> </td> </tr> <tr> <td>*</td> <td>1.0 10*3/uL<span style="background: LightGoldenRodYellow"> (Details: UCUM code 10*3/uL')</span></td> <td>4.8 10*3/uL<span style="background: LightGoldenRodYellow"> (Details: UCUM code 10*3/uL')</span></td> </tr> </table> </div>" }, "entry" : [ { "reference" : "Observation/us-core-observation-results-eve-everywoman-lymphocytes", "display" : "Lymphocytes [#/volume] in Blood by Automated count - Interpretation: High" } ] }, { "title" : "Plan of Treatment Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "18776-5", "display" : "Plan of Treatment" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <p><b>id</b>: 5</p> <p><b>status</b>: completed</p> <p><b>intent</b>: order</p> <p><b>priority</b>: asap</p> <p><b>category</b>: Diagnostics Procedure <span style="background: LightGoldenRodYellow">(Details : {SNOMED CT code '103693007' = 'Diagnostic procedure', given as 'Diagnostic procedure (procedure)'})</span></p> <p><b>code</b>: Zika RT-PCR <span style="background: LightGoldenRodYellow">(Details : {LOINC code '80825-3' = 'Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method', given as 'Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method'})</span></p> <p><b>trigger lab order</b>: TRUE</p> <p><b>trigger value set/version</b>: urn:oid:2.16.840.1.114222.4.11.7508 / 19/05/2018</p> <p><b>performer</b>: <a href="Organization/acme-labs">Acme Labs</a></p> </div>" }, "entry" : [ { "extension" : [ { "url" : "http://hl7.org/fhir/us/ecr/StructureDefinition/extension-eicr-trigger-code-flag", "extension" : [ { "url" : "triggerCodeValueSet", "valueOid" : "urn:oid:2.16.840.1.114222.4.11.7508" }, { "url" : "triggerCodeValueSetVersion", "valueString" : "19/05/2018" } ] } ], "reference" : "ProcedureRequest/eicr-procedurerequest-zika", "display" : "Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method" } ] } ] }