Consolidated CDA (C-CDA)
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This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example Binary: History Of Present Illness Example

This content is an example of the History of Present Illness Section Logical Model and is not a FHIR Resource

    
<section xmlns="urn:hl7-org:v3">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>
  <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" 
        code="10164-2" 
        displayName="HISTORY OF PRESENT ILLNESS"/>
  <title>HISTORY OF PRESENT ILLNESS</title>
  <text>
    <paragraph>This patient was only recently discharged for a recurrent 
        GI bleed as described below.</paragraph>
    <paragraph>He presented to the ER today c/o a dark stool yesterday 
        but a normal brown stool today. On exam he was hypotensive in the 
        80s resolved after .... .... .... </paragraph>
    <paragraph>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, 
        electrolytes normal. H. pylori antibody pending. Admission 
        hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet 
        count 256,000. Urinalysis normal. Urine culture: No growth. INR 
        1.1, PTT 40.</paragraph>
    <paragraph>He was transfused with 6 units of packed red blood cells 
        with .... .... ....</paragraph>
    <paragraph>GI evaluation 12 September: Colonoscopy showed single red 
       clot in .... .... ....</paragraph>
  </text>
</section>