# Example: Transitions of Care Clinical Document - PACIO Transitions of Care Implementation Guide v1.0.0

* [**Table of Contents**](toc.md)
* [**FHIR Artifacts**](artifacts.md)
* **Example: Transitions of Care Clinical Document**

## Example Composition: Example: Transitions of Care Clinical Document

| |
| :--- |
| *Page standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) |

Language: en-US

Profile: [Transition of Care Composition](StructureDefinition-TOC-Composition.md)

**identifier**: `http://example.org/GoodHealthClinic/id`/76053988-543c-4681-9a90-2f2eb9a7836c-CCDA-CCD

**status**: Final

**type**: Physician Discharge summary

**date**: 2024-05-10 08:49:58-0400

**author**: [Practitioner Jen Cadbury](Practitioner-Example-JenCadbury.md)

**title**: Transitions of Care Document for Betsy Smith-Johnson

**custodian**: [Organization Happy Nursing Facility](Organization-org-SNF-Happy-Nursing-Facility.md)



## Resource Content

```json
{
  "resourceType" : "Composition",
  "id" : "BSJ-TOCComposition",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/pacio-toc/StructureDefinition/TOC-Composition"]
  },
  "language" : "en-US",
  "identifier" : {
    "system" : "http://example.org/GoodHealthClinic/id",
    "value" : "76053988-543c-4681-9a90-2f2eb9a7836c-CCDA-CCD"
  },
  "status" : "final",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "11490-0",
      "display" : "Physician Discharge summary"
    }]
  },
  "subject" : {
    "reference" : "Patient/Example-Smith-Johnson-Patient1"
  },
  "date" : "2024-05-10T08:49:58.313-04:00",
  "author" : [{
    "reference" : "Practitioner/Example-JenCadbury"
  }],
  "title" : "Transitions of Care Document for Betsy Smith-Johnson",
  "custodian" : {
    "reference" : "Organization/org-SNF-Happy-Nursing-Facility"
  },
  "section" : [{
    "title" : "Advance directives for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "42348-3"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Advance directives for Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "notasked"
      }]
    }
  },
  {
    "title" : "List of allergies for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "48765-2"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Allergies for Betsy Smith-Johnson</div>"
    },
    "entry" : [{
      "reference" : "AllergyIntolerance/BSJ-AllergyACE"
    }]
  },
  {
    "title" : "Behavioral health information for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/pacio-toc/CodeSystem/toc-temp-cs",
        "code" : "behavioral_health_summary"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Behavioral health information for Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "withheld"
      }]
    }
  },
  {
    "title" : "Functional status of Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "47420-5"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Functional status of Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "nilknown"
      }]
    }
  },
  {
    "title" : "List of immunizations for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11369-6"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">List of immunizations for Betsy Smith-Johnson</div>"
    },
    "entry" : [{
      "reference" : "Immunization/BSJ-Immunization-PCV20"
    },
    {
      "reference" : "Immunization/BSJ-Immunization-Fluzone"
    }]
  },
  {
    "title" : "Discharge instructions for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "69730-0"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Discharge instructions for Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "nilknown"
      }]
    }
  },
  {
    "title" : "List of medical equipment needed by Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "46264-8"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">List of medical equipment needed by Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "nilknown"
      }]
    }
  },
  {
    "title" : "List of medications prescribed for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "10160-0"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">List of medications prescribed for Betsy Smith-Johnson</div>"
    },
    "entry" : [{
      "reference" : "List/BSJ-SMPMedList"
    }]
  },
  {
    "title" : "Discharge care plan for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "18776-5"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Discharge care plan for Betsy Smith-Johnson</div>"
    },
    "entry" : [{
      "reference" : "CarePlan/BSJ-SNFDischargeCarePlan"
    }]
  },
  {
    "title" : "List of problem conditions and observations for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11450-4"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">List of problem conditions and observations for Betsy Smith-Johnson</div>"
    },
    "entry" : [{
      "reference" : "Condition/BSJ-DressingConcern"
    },
    {
      "reference" : "Condition/BSJ-HeartDiseaseDiagnosis"
    },
    {
      "reference" : "Condition/BSJ-HemiparesisDiagnosis"
    },
    {
      "reference" : "Condition/BSJ-HyperlipidemiaDiagnosis"
    },
    {
      "reference" : "Condition/BSJ-HypertensionDiagnosis"
    },
    {
      "reference" : "Condition/BSJ-StrokeDiagnosis"
    },
    {
      "reference" : "Condition/OT-ProblemList-RightWeak"
    }]
  },
  {
    "title" : "List of procedures prescribed for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "47519-4"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">List of procedures prescribed for Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "nilknown"
      }]
    }
  },
  {
    "title" : "Reason for referring Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "42349-1"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Reason for referring Betsy Smith-Johnson</div>"
    },
    "entry" : [{
      "reference" : "Encounter/BSJ-Encounter"
    }]
  },
  {
    "title" : "List of test results for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "30954-2"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">List of test results for Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "nilknown"
      }]
    }
  },
  {
    "title" : "Social history for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "29762-2"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Social history for Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "nilknown"
      }]
    }
  },
  {
    "title" : "Vital signs for Betsy Smith-Johnson",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8716-3"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Vital signs for Betsy Smith-Johnson</div>"
    },
    "emptyReason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
        "code" : "nilknown"
      }]
    }
  }]
}

```
