This page is part of the Making EHR Data MOre available for Research and Public Health (MedMorph) Healthcare Surveys Reporting Content IG (v2.0.0-ballot: STU 2 Ballot) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 1.0.0. For a full list of available versions, see the Directory of published versions
Page standards status: Informative |
{
"resourceType" : "Composition",
"id" : "hcs-composition-example",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/health-care-surveys-reporting/StructureDefinition/hcs-composition"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition hcs-composition-example</b></p><a name=\"hcs-composition-example\"> </a><a name=\"hchcs-composition-example\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-hcs-composition.html\">Health Care Survey Report Composition</a></p></div><p><b>identifier</b>: c03eab8c-11e8-4d0c-ad2a-b385395e27db</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 75619-7}\">National Health Care Surveys report</span></p><p><b>encounter</b>: <a href=\"Encounter-encounter-ambulatory.html\">Ambulatory Office Visit</a></p><p><b>date</b>: 2023-01-02 22:13:23+0000</p><p><b>author</b>: <a href=\"Practitioner-practitioner-1.html\">Nicholas Joseph</a></p><p><b>title</b>: National Health Care Surveys report</p></div>"
},
"identifier" : {
"value" : "c03eab8c-11e8-4d0c-ad2a-b385395e27db"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "75619-7"
}
]
},
"subject" : {
🔗 "reference" : "Patient/patient-ledner",
"display" : "Amy Shaw"
},
"encounter" : {
🔗 "reference" : "Encounter/encounter-ambulatory",
"display" : "Ambulatory Office Visit"
},
"date" : "2023-01-02T22:13:23Z",
"author" : [
{
🔗 "reference" : "Practitioner/practitioner-1",
"display" : "Nicholas Joseph"
}
],
"title" : "National Health Care Surveys report",
"section" : [
{
"title" : "Reason for Visit Section",
"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\"><p>Reason for Visit: Bad cough</p></div>"
}
},
{
"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\"><p>Single liveborn, born in hospital</p><p>Acute bronchitis</p></div>"
},
"entry" : [
{
🔗 "reference" : "Condition/condition-problem"
},
{
🔗 "reference" : "Condition/condition-encounter-diagnosis"
}
]
},
{
"title" : "Allergies Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48765-2",
"display" : "Allergies and adverse reactions Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Allergy to Sulfonide</p></div>"
},
"entry" : [
{
🔗 "reference" : "AllergyIntolerance/allergyintolerance-sulfonamide"
}
]
},
{
"title" : "Medications Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10160-0",
"display" : "History of Medication use Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Taking Lantus</div>"
},
"entry" : [
{
🔗 "reference" : "MedicationAdministration/medicationadministrationone-example"
},
{
🔗 "reference" : "MedicationRequest/hcs-MedicationRequestone-example"
}
]
},
{
"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>CBC Results: WBC 6.8, RBC 4.2, Hgb 14.0, Hct 41.0, Plt 210</p><p>CMP Results: Glucose 98, BUN 14, Cr 0.8, Na 140, K 3.8, Cl 102</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-clinical-example"
},
{
🔗 "reference" : "DiagnosticReport/diagnosticreport-lab-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "28650-0",
"display" : "Clinical notes and chart sections Set"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Patient presented with one week history of cough and low-grade fever. Lungs clear on examination. No lymphadenopathy.</p></div>"
},
"entry" : [
{
🔗 "reference" : "DocumentReference/documentreference-example"
},
{
🔗 "reference" : "DiagnosticReport/diagnosticreport-note-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "51847-2",
"display" : "Evaluation + Plan note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><ul><li>Referral to social worker for housing assistance</li></ul></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-screening-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Plan of care note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Continue symptomatic treatment. Return if symptoms worsen or fail to improve within 5 days.</p></div>"
},
"entry" : [
{
🔗 "reference" : "ServiceRequest/servicerequest-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11369-6",
"display" : "History of Immunization Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Influenza vaccine administered 10/15/2024</p><p>COVID-19 vaccine: Last dose received 06/20/2024</p></div>"
},
"entry" : [
{
🔗 "reference" : "Immunization/immunization-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "47519-4",
"display" : "History of Procedures Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Appendectomy (1995)</p><p>Colonoscopy (2020)</p></div>"
},
"entry" : [
{
🔗 "reference" : "Procedure/procedure-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8716-3",
"display" : "Vital signs"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>BP: 120/80 mmHg</p><p>HR: 70 bpm</p><p>Temp: 37.0 C</p><p>RR: 16</p><p>SpO2: 98%</p><p>Weight: 68 kg</p><p>Height: 170 cm</p><p>BMI: 23.5 kg/m²</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-bp-example"
},
{
🔗 "reference" : "Observation/observation-weight-example"
},
{
🔗 "reference" : "Observation/observation-height-example"
},
{
🔗 "reference" : "Observation/observation-heartrate-example"
},
{
🔗 "reference" : "Observation/observation-oximetry-example"
},
{
🔗 "reference" : "Observation/observation-bmi-example"
},
{
🔗 "reference" : "Observation/observation-temperature-example"
},
{
🔗 "reference" : "Observation/observation-resprate-example"
}
]
},
{
"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\"><p>Patient is a non-smoker</p><p>Occupation: Teacher</p><p>Lives with spouse and two children</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-smoking-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "46264-8",
"display" : "History of medical device use"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No implantable devices</p></div>"
},
"entry" : [
{
🔗 "reference" : "Device/device-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "85847-2",
"display" : "Patient Care team information"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Primary Care Provider: Dr. Nicholas Joseph</p><p>Pulmonologist: Dr. Sarah Chen</p></div>"
},
"entry" : [
{
🔗 "reference" : "CareTeam/careteam-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "61146-7",
"display" : "Goals"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Resolve acute bronchitis</p><p>Improve sleep quality</p></div>"
},
"entry" : [
{
🔗 "reference" : "Goal/goal-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "90767-5",
"display" : "Pregnancy summary Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Patient is not currently pregnant</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/observation-pregnancy-status-example"
},
{
🔗 "reference" : "Observation/observation-pregnancy-intent-example"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48768-6",
"display" : "Payment sources Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Primary Insurance: Blue Cross Blue Shield</p><p>ID: XYZ123456789</p><p>Group: ABC987</p></div>"
},
"entry" : [
{
🔗 "reference" : "Coverage/coverage-example"
}
]
}
]
}