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 |
<Composition xmlns="http://hl7.org/fhir">
<id value="hcs-composition-example"/>
<meta>
<profile
value="http://hl7.org/fhir/us/health-care-surveys-reporting/StructureDefinition/hcs-composition"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<value value="c03eab8c-11e8-4d0c-ad2a-b385395e27db"/>
</identifier>
<status value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="75619-7"/>
</coding>
</type>
<subject>🔗
<reference value="Patient/patient-ledner"/>
<display value="Amy Shaw"/>
</subject>
<encounter>🔗
<reference value="Encounter/encounter-ambulatory"/>
<display value="Ambulatory Office Visit"/>
</encounter>
<date value="2023-01-02T22:13:23Z"/>
<author>🔗
<reference value="Practitioner/practitioner-1"/>
<display value="Nicholas Joseph"/>
</author>
<title value="National Health Care Surveys report"/>
<section>
<title value="Reason for Visit Section"/>
<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"><p>Reason for Visit: Bad cough</p></div>
</text>
</section>
<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"><p>Single liveborn, born in hospital</p><p>Acute bronchitis</p></div>
</text>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
<entry>🔗
<reference value="Condition/condition-encounter-diagnosis"/>
</entry>
</section>
<section>
<title value="Allergies Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
<display value="Allergies and adverse reactions Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>Allergy to Sulfonide</p></div>
</text>
<entry>🔗
<reference value="AllergyIntolerance/allergyintolerance-sulfonamide"/>
</entry>
</section>
<section>
<title value="Medications Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10160-0"/>
<display value="History of Medication use Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Taking Lantus</div>
</text>
<entry>🔗
<reference
value="MedicationAdministration/medicationadministrationone-example"/>
</entry>
<entry>🔗
<reference value="MedicationRequest/hcs-MedicationRequestone-example"/>
</entry>
</section>
<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>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>
</text>
<entry>🔗
<reference value="Observation/observation-clinical-example"/>
</entry>
<entry>🔗
<reference value="DiagnosticReport/diagnosticreport-lab-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="28650-0"/>
<display value="Clinical notes and chart sections Set"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>🔗
<reference value="DocumentReference/documentreference-example"/>
</entry>
<entry>🔗
<reference value="DiagnosticReport/diagnosticreport-note-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="51847-2"/>
<display value="Evaluation + Plan note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><ul><li>Referral to social worker for housing assistance</li></ul></div>
</text>
<entry>🔗
<reference value="Observation/observation-screening-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
<display value="Plan of care note"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>🔗
<reference value="ServiceRequest/servicerequest-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11369-6"/>
<display value="History of Immunization Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>🔗
<reference value="Immunization/immunization-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47519-4"/>
<display value="History of Procedures Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>Appendectomy (1995)</p><p>Colonoscopy (2020)</p></div>
</text>
<entry>🔗
<reference value="Procedure/procedure-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8716-3"/>
<display value="Vital signs"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>🔗
<reference value="Observation/observation-bp-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-weight-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-height-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-heartrate-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-oximetry-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-bmi-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-temperature-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-resprate-example"/>
</entry>
</section>
<section>
<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"><p>Patient is a non-smoker</p><p>Occupation: Teacher</p><p>Lives with spouse and two children</p></div>
</text>
<entry>🔗
<reference value="Observation/observation-smoking-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46264-8"/>
<display value="History of medical device use"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>No implantable devices</p></div>
</text>
<entry>🔗
<reference value="Device/device-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="85847-2"/>
<display value="Patient Care team information"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>Primary Care Provider: Dr. Nicholas Joseph</p><p>Pulmonologist: Dr. Sarah Chen</p></div>
</text>
<entry>🔗
<reference value="CareTeam/careteam-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61146-7"/>
<display value="Goals"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>Resolve acute bronchitis</p><p>Improve sleep quality</p></div>
</text>
<entry>🔗
<reference value="Goal/goal-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="90767-5"/>
<display value="Pregnancy summary Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>Patient is not currently pregnant</p></div>
</text>
<entry>🔗
<reference value="Observation/observation-pregnancy-status-example"/>
</entry>
<entry>🔗
<reference value="Observation/observation-pregnancy-intent-example"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48768-6"/>
<display value="Payment sources Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>🔗
<reference value="Coverage/coverage-example"/>
</entry>
</section>
</Composition>