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 
XML Format: Composition-eicr-composition-zika
Raw xml
<Composition xmlns="http://hl7.org/fhir"> <id value="eicr-composition-zika"/> <meta> <profile value="http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"/> </meta> <language value="en-US"/> <text> <status value="generated"/> <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> </text> <status value="final"/> <type> <coding> <system value="http://loinc.org"/> <code value="55751-2"/> <display value="Public Health Case Report"/> </coding> </type> <!-- Subject --> <subject> <reference value="Patient/ecr-patient-eve-everywoman"/> <display value="Eve Everywoman"/> </subject> <!-- Encounter (eicr-encounter reference) --> <encounter> <reference value="Encounter/eicr-encounter-eve-everywoman-20180401"/> <display value="Ambulatory Office Visit, Apr 1, 2018, 10:00am"/> </encounter> <date value="2018-01-02T22:13:23Z"/> <!-- Author (us-core-practictioner reference) --> <author> <reference value="Practitioner/ecr-practitioner-henry-seven"/> <display value="Henry Seven, MD"/> </author> <title value="Initial Public Health Case Report"/> <!-- Encounter Section --> <section> <code> <coding> <system value="http://loinc.org"/> <code value="46240-8"/> <display value="Encounters"/> </coding> </code> <text> <status value="generated"/> <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> </text> <!-- eICR Encounter - with trigger code diagnosis --> <entry> <reference value="Encounter/eicr-encounter-diagnosis-eve-everywoman-20180401"/> <display value="eICR Encounter Diagnosis: Eve Everywoman 20180401"/> </entry> </section> <!-- History of Present Illness Section --> <section> <!-- <text value="History of Present illness" /> --> <code> <coding> <system value="http://loinc.org"/> <code value="10164-2"/> <display value="History of Present illness Narrative"/> </coding> </code> <text> <status value="generated"/> <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> </text> </section> <!-- Reason for Visit Section --> <section> <!-- <text value="History of Encounters" /> --> <code> <coding> <system value="http://loinc.org"/> <code value="29299-5"/> <display value="Reason for visit Narrative"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Bad cough<br/></div> </text> </section> <!-- Social History Section (required) --> <section> <title value="Social History Section"/> <!-- <text value="Social History" /> --> <code> <coding> <system value="http://loinc.org"/> <code value="29762-2"/> <display value="Social history Narrative"/> </coding> </code> <text> <status value="generated"/> <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> </text> <!-- eICR Travel History --> <entry> <reference value="Observation/eicr-travel-history-eve-everywoman-201801"/> <display value="eICR Travel History: Eve Everywoman 2018-01"/> </entry> <!-- eICR Pregnancy Status --> <entry> <reference value="Observation/eicr-pregnancy-status-eve-everywoman"/> <display value="eICR Pregnancy Status Example 1"/> </entry> <!-- eICR Occupation History --> <entry> <reference value="Observation/eicr-occupation-history-eve-everywoman"/> <display value="eICR Occupation History: Eve Everywoman"/> </entry> </section> <!-- Problems Section (required) --> <section> <title value="Problems Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11450-4"/> <display value="Problem list - Reported"/> </coding> </code> <text> <status value="generated"/> <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> </text> <!-- eICR Condition without a Trigger Code Indicator - i.e. not a trigger code --> <entry> <reference value="Condition/eicr-condition-eve-everywoman-common-cold"/> <display value="Common cold (disorder)"/> </entry> </section> <!-- Medications Administered Section (required) --> <section> <title value="Medications Administered Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="29549-3"/> <display value="Medication administered Narrative"/> </coding> </code> <text> <status value="generated"/> <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> </text> <!-- us-core-medicationstatement reference --> <entry> <reference value="MedicationStatement/us-core-medicationstatement-eve-everywoman-azithromycin"/> <display value="Azithromycin 500 MG Oral Tablet"/> </entry> </section> <!-- Results Section (required) --> <section> <title value="Results Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="30954-2"/> <display value="Relevant diagnostic tests/laboratory data Narrative"/> </coding> </code> <text> <status value="generated"/> <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> </text> <entry> <!-- No extension-trigger this is not a trigger code result --> <reference value="Observation/us-core-observation-results-eve-everywoman-lymphocytes"/> <display value="Lymphocytes [#/volume] in Blood by Automated count - Interpretation: High"/> </entry> </section> <!-- Plan of Treatment Section (required) --> <section> <title value="Plan of Treatment Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="18776-5"/> <display value="Plan of Treatment"/> </coding> </code> <text> <status value="generated"/> <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> </text> <entry> <!-- This is a trigger code as extension-eicr-trigger-code-flag is present --> <extension url="http://hl7.org/fhir/us/ecr/StructureDefinition/extension-eicr-trigger-code-flag"> <extension url="triggerCodeValueSet"> <valueOid value="urn:oid:2.16.840.1.114222.4.11.7508"/> </extension> <extension url="triggerCodeValueSetVersion"> <valueString value="19/05/2018"/> </extension> </extension> <reference value="ProcedureRequest/eicr-procedurerequest-zika"/> <display value="Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method"/> </entry> </section> </Composition>
