STU 1 Ballot

This page is part of the C-CDA on FHIR Implementation Guide (v1.6.0: STU 1 Ballot 1) based on FHIR v1.6.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions


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  <text>
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    <div xmlns="http://www.w3.org/1999/xhtml">
      <p>Continuity of Care document for Henry Jones</p>
      <p>Managed by Community Health and Hospitals</p>
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    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"/>
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  <extension
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    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
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  <date value="2016-02-14T09:10:14Z"/>
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  <title value="Continuity of Care Document"/>
  <status value="preliminary"/>
  <confidentiality value="N"/>
<!--   Patient Resource   -->
  <subject>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Patient/117467"/>
    <display value="Henry Jones"/>
  </subject>
<!--   Practitioner Resource   -->
  <author>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
    <display value="Adam Everyman, MD"/>
  </author>
  <attester>
    <mode value="legal"/>
    <time value="2012-01-04T09:10:14Z"/>
    <party>
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<!--   Organization Resource   -->
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  <event>
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    <period>
      <start value="2015-11-18"/>
      <end value="2015-12-12"/>
    </period>
  </event>
<!--   Encounter Resource  -->
  <encounter>
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<!--   Allergies and Intolerances Section Narrative  -->
  <section>
    <title value="Allergies and Intolerances Section"/>
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      <coding>
        <system value="http://loinc.org"/>
        <code value="48765-2"/>
        <display value="Allergies and adverse reactions"/>
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    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Substance</b>
            </td>
            <td>
              <b>Overall Severity</b>
            </td>
            <td>
              <b>Reaction</b>
            </td>
            <td>
              <b>Reaction Severity</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Cashew Nut</td>
            <td>Severe</td>
            <td>Anaphylactic reaction</td>
            <td>Mild</td>
            <td>Active</td>
          </tr>
        </table>
      </div>
    </text>
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  <!--   Allergy and Intolerance Section Resource  -->
    <entry>
      <reference
                 value="http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632"/>
    </entry>
  </section>
<!--   Medication Section Narrative  -->
  <section>
    <title value="Medication Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10160-0"/>
        <display value="History of Medication Use"/>
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    <text>
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      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Medication</b>
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            <td>
              <b>Directions</b>
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            <td>
              <b>Start Date</b>
            </td>
            <td>
              <b>Status</b>
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            <td>
              <b>Indications</b>
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            <td>
              <b>Fill Instructions</b>
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          </tr>
          <tr>
            <td>Amoxicillin</td>
            <td>Amoxicillin Powder, for Suspension 250mg/5ml</td>
            <td>20160401</td>
            <td>Active</td>
            <td>Pneumonia</td>
            <td>Generic substitution allowed</td>
          </tr>
        </table>
      </div>
    </text>
  <!--   Medication Section Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Medication/117679"/>
    </entry>
  </section>
<!--   Problem Section Narrative   -->
  <section>
    <title value="Problem Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11450-4"/>
        <display value="Problem list"/>
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        <table>
          <tr>
            <td>
              <b>Problem Name</b>
            </td>
            <td>
              <b>Type</b>
            </td>
            <td>
              <b>Onset Date</b>
            </td>
            <td>
              <b>Abatement Date</b>
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            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Fever</td>
            <td>Condition</td>
            <td>2016-04-01</td>
            <td>2016-04-14</td>
            <td>Complete</td>
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        </table>
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  <!--   Problem Section Condition Resource   -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/>
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<!--   Procedures Section Narrative   -->
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    <title value="Procedures Section"/>
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    <text>
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        <table>
          <tr>
            <td>
              <b>Procedure Name</b>
            </td>
            <td>
              <b>Body Site</b>
            </td>
            <td>
              <b>Performer</b>
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            <td>
              <b>Date Performed</b>
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            <td>
              <b>Reason</b>
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          </tr>
          <tr>
            <td>Appendectomy (Procedure)</td>
            <td>Abdomen</td>
            <td>Dr. Adam Everyman</td>
            <td>20160405</td>
            <td>Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding</td>
          </tr>
        </table>
      </div>
    </text>
  <!--   Procedures Section Resource   -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Procedure/117687"/>
    </entry>
  </section>
<!--   Results Section Narrative  -->
  <section>
    <title value="Results Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="30954-2"/>
        <display value="Relevant diagnostic tests and laboratory data"/>
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    <text>
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        <table>
          <tr>
            <td>
              <b>Result Type</b>
            </td>
            <td>
              <b>Quantity Value</b>
            </td>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Glucose [Moles/volume] in Blood</td>
            <td>6.3 mmol/l</td>
            <td>2016/04/01</td>
            <td>Final</td>
          </tr>
        </table>
      </div>
    </text>
  <!--   Result Section Observation Resource   -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Observation/117685"/>
    </entry>
  </section>
<!--   Advance Directive Section Narrative  -->
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    <title value="Advance Directives Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="42348-3"/>
        <display value="Advance directives"/>
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    <text>
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        <table>
          <tr>
            <td>
              <b>Name</b>
            </td>
            <td>
              <b>Applies Period</b>
            </td>
          </tr>
          <tr>
            <td>Resuscitation</td>
            <td>2015/01/01 - 2016/12/31</td>
          </tr>
        </table>
      </div>
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  </section>
<!--   Encounters Section Narrative  -->
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    <title value="Encounters Section"/>
    <code>
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        <system value="http://loinc.org"/>
        <code value="46240-8"/>
        <display value="Encounters"/>
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      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Encounter</b>
            </td>
            <td>
              <b>Performer</b>
            </td>
            <td>
              <b>Location</b>
            </td>
            <td>
              <b>Date</b>
            </td>
          </tr>
          <tr>
            <td>Checkup Examination</td>
            <td>Dr. S. Steene</td>
            <td>Community Urgent Care Center</td>
            <td>2015/09/26</td>
          </tr>
        </table>
      </div>
    </text>
  </section>
<!--   Family History Section Narrative  -->
  <section>
    <title value="Family History Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10157-6"/>
        <display value="History of family member diseases"/>
      </coding>
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    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Relationship</b>
            </td>
            <td>
              <b>Diagnosis</b>
            </td>
            <td>
              <b>Age at Onset</b>
            </td>
          </tr>
          <tr>
            <td>Father</td>
            <td>Myocardial Infarction(cause of Death)</td>
            <td>57</td>
          </tr>
          <tr>
            <td>Father</td>
            <td>Diabetes</td>
            <td>40</td>
          </tr>
        </table>
      </div>
    </text>
  <!--   Family History Section Resource  -->
    <entry>
      <reference
                 value="http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652"/>
    </entry>
  </section>
<!--   Functional Status Section Narrative  -->
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    <title value="Functional Status Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="47420-5"/>
        <display value="Functional status assessment"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Functional or Cognitive Finding</b>
            </td>
            <td>
              <b>Observation</b>
            </td>
            <td>
              <b>Observation Date</b>
            </td>
            <td>
              <b>Condition Status</b>
            </td>
          </tr>
          <tr>
            <td>Ambulation (Dependent to Independent</td>
            <td>Independently able</td>
            <td>2010/03/11</td>
            <td>Active</td>
          </tr>
          <tr>
            <td>Finding of Functional Performance and Activity</td>
            <td>Dyspnea</td>
            <td>2008/02/16</td>
            <td>Active</td>
          </tr>
          <tr>
            <td>Cognitive Function Finding</td>
            <td>Memory Impairment</td>
            <td>2014/04/29</td>
            <td>Active</td>
          </tr>
        </table>
      </div>
    </text>
  </section>
<!--   Immunization Section Narrative   -->
  <section>
    <title value="Immunizations Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11369-6"/>
        <display value="History of immunization"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Vaccine</b>
            </td>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Fluvax (Influenza)</td>
            <td>2016-04-05</td>
            <td>Completed</td>
          </tr>
        </table>
      </div>
    </text>
  <!--   Immunization Section Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Immunization/117678"/>
    </entry>
  </section>
<!--   Nutrition Section Narrative  -->
  <section>
    <title value=" Nutrition Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="61144-2"/>
        <display value="Diet and nutrition"/>
      </coding>
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    <text>
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        <table>
          <tr>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Nutritional Status</b>
            </td>
            <td>
              <b>Diet</b>
            </td>
          </tr>
          <tr>
            <td>2005/12/29</td>
            <td>Well nourished</td>
            <td>Low sodium diet, excessive carbohydrate</td>
          </tr>
          <tr>
            <td>2010/05/26</td>
            <td>Slight dehydration</td>
            <td>High protein, low fibre</td>
          </tr>
        </table>
      </div>
    </text>
  </section>
<!--   Mental Status Section Narrative  -->
  <section>
    <title value="Mental Status Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10190-7"/>
        <display value="Mental status"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Mental Status</b>
            </td>
            <td>
              <b>Support System</b>
            </td>
          </tr>
          <tr>
            <td>2005/06/21</td>
            <td>Good</td>
            <td>Not required</td>
          </tr>
          <tr>
            <td>2015/12/29</td>
            <td>Dimentia</td>
            <td>Daily Home Care</td>
          </tr>
        </table>
      </div>
    </text>
  </section>
<!--   Social History Section Narrative  -->
  <section>
    <title value="Social History Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29762-2"/>
        <display value="Social history"/>
      </coding>
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        <table>
          <tr>
            <td>
              <b>Social History Element</b>
            </td>
            <td>
              <b>Description</b>
            </td>
            <td>
              <b>Effective Dates</b>
            </td>
          </tr>
          <tr>
            <td>Smoking</td>
            <td>1 pack tobacco per day</td>
            <td>2005/05/01 - 2010/02/28</td>
          </tr>
        </table>
      </div>
    </text>
    <entry>
    <!--   Social History Section Observation Resource  -->
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Observation/117688"/>
    </entry>
  </section>
<!--   Plan of Treatment Section Narrative  -->
  <section>
    <title value="Plan of Treatment Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
        <display value="Plan of treatment"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Planned Activity</b>
            </td>
            <td>
              <b>Period</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Colonoscopy</td>
            <td>2010/08/16 - 2010/08/16</td>
            <td>Completed</td>
          </tr>
          <tr>
            <td>Recommendation to Exercise</td>
            <td>2015/10/29</td>
            <td>Ongoing</td>
          </tr>
        </table>
      </div>
    </text>
  </section>
<!--   Payers Section Narrative  -->
  <section>
    <title value="Payers Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48768-6"/>
        <display value="Payers"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Payer Name</b>
            </td>
            <td>
              <b>Policy ID</b>
            </td>
            <td>
              <b>Policy Holder</b>
            </td>
          </tr>
          <tr>
            <td>United Healthcare</td>
            <td>12341</td>
            <td>Self</td>
          </tr>
          <tr>
            <td>Cigna</td>
            <td>53123</td>
            <td>Spouse</td>
          </tr>
        </table>
      </div>
    </text>
  </section>
<!--   Medication Equipment Section Narrative  -->
  <section>
    <title value="Medical Equipment Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="46264-8"/>
        <display value="Medical equipment"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Supply/Device</b>
            </td>
            <td>
              <b>Date Supplied</b>
            </td>
          </tr>
          <tr>
            <td>Automatic Implantable cardioverter/defbrillator</td>
            <td>2008/11/16</td>
          </tr>
          <tr>
            <td>Wheelchair</td>
            <td>1999/12/01</td>
          </tr>
        </table>
      </div>
    </text>
  </section>
<!--   Vital Signs Section Narrative  -->
  <section>
    <title value="Vital Signs 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">
        <table>
          <tr>
            <td>
              <b>Vital Sign</b>
            </td>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Value</b>
            </td>
          </tr>
          <tr>
            <td>Temperature</td>
            <td>2016/04/05</td>
            <td>39 Degrees Celcius</td>
          </tr>
        </table>
      </div>
    </text>
  <!--   Vital Signs Section Observation Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Observation/117689"/>
    </entry>
  </section>
</Composition>