HL7.FHIR.US.ECR\eICR Composition Example: Initial Public Health Case Report - Eve Everywoman, Pertussis and Zika

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Example Composition: eICR Composition Example: Initial Public Health Case Report - Eve Everywoman, Pertussis and Zika

composition-eicr-pertussis-zika

meta

versionId	32
lastUpdated	2019-10-20T11:00:43.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition

composition-clinicaldocument-versionNumber

identifier

2eec4326-bf29-4428-8d02-a334a19cfc18

status

final

type

- Public Health Case Report
  (
  55751-2
  )
- http://loinc.org

subject

Eve Everywoman

encounter

Ambulatory Office Visit

date

2017-11-06T22:13:23Z

author

Henry Seven, MD

title

Initial Public Health Case Report - Pertussis/Zika example

section

title	History of Present Illness Section
code	History of Present illness Narrative ( 10164-2 ) http://loinc.org
Persistent Cough REPORTED starting on 2016/10/05 Whooping Respiration not reported Paroxysms Of Coughing REPORTED starting on 2016/11/04 Post-tussive vomiting not reported

section

title	Chief Complaint and Reason for Visit Section
code	Chief complaint+Reason for visit Narrative ( 46239-0 ) http://loinc.org
Bad cough

section

title

Problems Section

code

- Problem list - Reported
  (
  11450-4
  )
- http://loinc.org

entry

Trigger code
Trigger Code:
Trigger Code Display:
Trigger Code System:
Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508
Trigger Code Value Set Version: 19/05/2018

Pertussis (disorder)

condition-eicr-eve-everywoman-pertussis

meta

versionId	14
lastUpdated	2019-10-10T21:14:56.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-condition

category

- Encounter Diagnosis
  (
  encounter-diagnosis
  )
- http://terminology.hl7.org/CodeSystem/condition-category

code

- Pertussis (disorder)
  (
  27836007
  )
- http://snomed.info/sct

subject

Eve Everywoman

onsetDateTime

2017-09-23

asserter

Henry Seven, MD

section

title

Social History Section

code

- Social history Narrative
  (
  29762-2
  )
- http://loinc.org

entry

eICR Travel History Example 1

observation-travel-history-eve-everywoman-201801

meta

versionId	11
lastUpdated	2019-10-05T03:15:42.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/travel-history-observation

status

final

code

Travel History
- Travel
  (
  420008001
  )
- http://snomed.info/sct

subject

Eve Everywoman

effectivePeriod

start	2018-01-15
end	2018-01-30

component

code	Location ( LOC ) http://terminology.hl7.org/CodeSystem/v3-ParticipationType
valueCodeableConcept	Fiji ( FJI ) urn:iso:std:iso:3166

component

code	Location ( LOC ) http://terminology.hl7.org/CodeSystem/v3-ParticipationType
valueCodeableConcept	Vanuatu ( VUT ) https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=1.0.3166.1

entry

ODH Usual Work Example

observation-odh-usual-work-eve-everywoman

meta

versionId	2
lastUpdated	2019-10-20T10:53:14.000-04:00
profile	http://hl7.org/fhir/us/odh/StructureDefinition/odh-UsualWork

status

final

code

- History of Usual occupation
  (
  21843-8
  )
- http://loinc.org

subject

Eve Everywoman

effectivePeriod

start	2015-01-01
end	2018-03-07

valueCodeableConcept

- Human Resources Managers
  (
  0136
  )
- https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.314

component

code	History of Usual industry ( 21844-6 ) http://loinc.org
valueCodeableConcept	Hospitals ( 8190 ) https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.315

section

title

Medications Administered Section

code

- Medication administered Narrative
  (
  29549-3
  )
- http://loinc.org

entry

Azithromycin 500 MG Oral Tablet

medicationadministration-eve-everywoman-azithromycin

meta

versionId	10
lastUpdated	2019-10-05T03:11:22.000-04:00

status

completed

medicationCodeableConcept

Azithromycin 500 MG Oral Tablet
- Azithromycin 500 MG Oral Tablet
  (
  248656
  )
- http://www.nlm.nih.gov/research/umls/rxnorm

subject

Eve Everywoman

effectivePeriod

start	2018-03-07
end	2018-03-07

dosage

route

- Oral Route
  (
  26643006
  )
- http://snomed.info/sct

method

- Swallow - dosing instruction imperative (qualifier value)
  (
  421521009
  )
- http://snomed.info/sct

dose

value	2
unit	TAB
system	http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm
code	TAB

section

title

Results Section

code

- Relevant Dx tests/lab data
  (
  30954-2
  )
- http://loinc.org

entry

Trigger code
Trigger Code:
Trigger Code Display:
Trigger Code System:
Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508
Trigger Code Value Set Version: 19/05/2018

Bordetella pertussis Ab [Units/volume] in Serum - Interpretation: High

observation-us-core-results-eve-everywoman-pertussis

meta

versionId	8
lastUpdated	2019-10-05T03:15:42.000-04:00
profile	http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab

status

final

category

Laboratory
- Laboratory
  (
  laboratory
  )
- http://terminology.hl7.org/CodeSystem/observation-category

code

Bordetella pertussis Ab [Units/volume] in Serum
- Bordetella pertussis Ab [Units/volume] in Serum
  (
  11585-7
  )
- http://loinc.org

subject

Eve Everywoman

effectiveDateTime

2016-11-07

valueQuantity

interpretation

- High
  (
  H
  )
- http://terminology.hl7.org/CodeSystem/v2-0078

referenceRange

high

value	45
system	http://unitsofmeasure.org
code	[iU]/mL

entry

Lymphocytes [#/volume] in Blood by Automated count - Interpretation: High

observation-us-core-results-eve-everywoman-lymphocytes

meta

versionId	10
lastUpdated	2019-10-05T02:50:13.000-04:00
profile	http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab

status

final

category

Laboratory
- Laboratory
  (
  laboratory
  )
- http://terminology.hl7.org/CodeSystem/observation-category

code

- Lymphocytes [#/volume] in Blood by Automated count
  (
  731-0
  )
- http://loinc.org

subject

Eve Everywoman

effectiveDateTime

2018-03-07

valueQuantity

interpretation

- High
  (
  H
  )
- http://terminology.hl7.org/CodeSystem/v2-0078

referenceRange

low

value	1
system	http://unitsofmeasure.org
code	10*3/uL

high

value	4.8
system	http://unitsofmeasure.org
code	10*3/uL

section

title

Plan of Treatment Section

code

- Plan of care note
  (
  18776-5
  )
- http://loinc.org

entry

Trigger code
Trigger Code:
Trigger Code Display:
Trigger Code System:
Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508
Trigger Code Value Set Version: 19/05/2018

Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method

servicerequest-eicr-zika

meta

versionId	9
lastUpdated	2019-10-23T13:56:36.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-servicerequest

status

completed

intent

order

category

Diagnostics Procedure
- Diagnostic procedure (procedure)
  (
  103693007
  )
- http://snomed.info/sct

code

Zika RT-PCR
- Zika virus envelope E gene [Presence] in Serum by NAA with probe detection
  (
  80825-3
  )
- http://loinc.org

subject

Eve Everywoman

performer

Acme Labs

section

title

Pregnancy Section

code

- Pregnancy summary Document
  (
  90767-5
  )
- http://loinc.org

entry

eICR Pregnancy Status Example

observation-pregnancy-status-eve-everywoman

meta

versionId	13
lastUpdated	2019-10-05T03:15:42.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/pregnancy-status-observation

date-recorded-extension

2017-10-01

date-determined-extension

2017-10-01

status

final

code

- Pregnancy Status
  (
  82810-3
  )
- http://loinc.org

subject

Eve Everywoman

effectivePeriod

start

2017-08-26

valueCodeableConcept

- Pregnant (finding)
  (
  77386006
  )
- http://snomed.info/sct

method

- Diagnostic ultrasonography (procedure)
  (
  16310003
  )
- http://snomed.info/sct

component

date-determined-extension	2017-10-01
code	Gestational age Estimated from patient reported estimated date of conception ( 53691-2 ) http://loinc.org
valueQuantity	143 d

component

date-determined-extension	2017-10-01
code	Delivery date Estimated from date fundal height reaches umb ( 57064-8 ) http://loinc.org
valueDateTime	2018-05-01