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
<Composition xmlns="http://hl7.org/fhir"> <id value="ccda-ccd-composition-example"/> <meta> <versionId value="1"/> <lastUpdated value="2016-06-15T08:16:14Z"/> <profile value="http://hl7.org/fhir/StructureDefinition/ccda-ccd-composition"/> </meta> <text> <status value="generated"/> <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> </div> </text> <extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension"> <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/> </extension> <extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension"> <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/> </extension> <extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension"> <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/> </extension> <extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension"> <valueUri value="http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"/> </extension> <extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension"> <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/> </extension> <extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension"> <valueUri value="http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent"/> </extension> <identifier> <system value="http://hl7.org/fhir/ccda/StructureDefinition/ccda-ccd-composition"/> <value value="1"/> </identifier> <date value="2016-02-14T09:10:14Z"/> <type> <coding> <system value="http://loinc.org"/> <code value="34133-9"/> <display value="Summary of episode note"/> </coding> </type> <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> <reference value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/> <display value="Adam Everyman, MD"/> </party> </attester> <!-- Organization Resource --> <custodian> <reference value="http://fhirtest.uhn.ca/baseDstu3/Organization/117471"/> <display value="Community Health and Hospitals"/> </custodian> <event> <code> <coding> <system value="http://hl7.org/fhir/v3/ActClass"/> <code value="PCPR"/> <display value="Care Provision"/> </coding> </code> <period> <start value="2015-11-18"/> <end value="2015-12-12"/> </period> </event> <!-- Encounter Resource --> <encounter> <reference value="http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"/> </encounter> <!-- Allergies and Intolerances Section Narrative --> <section> <title value="Allergies and Intolerances Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="48765-2"/> <display value="Allergies and adverse reactions"/> </coding> </code> <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> <mode value="snapshot"/> <orderedBy> <coding> <system value="http://hl7.org/fhir/list-order"/> <code value="event-date"/> <display value="Sorted by Event Date"/> </coding> </orderedBy> <!-- 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"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Medication</b> </td> <td> <b>Directions</b> </td> <td> <b>Start Date</b> </td> <td> <b>Status</b> </td> <td> <b>Indications</b> </td> <td> <b>Fill Instructions</b> </td> </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"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Problem Name</b> </td> <td> <b>Type</b> </td> <td> <b>Onset Date</b> </td> <td> <b>Abatement Date</b> </td> <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> </tr> </table> </div> </text> <!-- Problem Section Condition Resource --> <entry> <reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/> </entry> </section> <!-- Procedures Section Narrative --> <section> <title value="Procedures Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="47519-4"/> <display value="History of procedures"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Procedure Name</b> </td> <td> <b>Body Site</b> </td> <td> <b>Performer</b> </td> <td> <b>Date Performed</b> </td> <td> <b>Reason</b> </td> </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"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <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 --> <section> <title value="Advance Directives Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="42348-3"/> <display value="Advance directives"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <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> </text> </section> <!-- Encounters Section Narrative --> <section> <title value="Encounters Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="46240-8"/> <display value="Encounters"/> </coding> </code> <text> <status value="generated"/> <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> </code> <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 --> <section> <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> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <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> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <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>