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

C-CDA on FHIR: ccda-consultation-note-composition-example

Formats: XML Example or JSON Example or Turtle Example.

The narrative from the above example:

Consultation Note

Consultation Note document for Henry Jones

Managed by Community Health and Hospitals

Subject Details

Advance Directives Section

Name Applies Period
Resuscitation 2015/01/01 - 2016/12/31

Allergies and Intolerances Section

Substance Overall Severity Reaction Reaction Severity Status
Cashew Nut Severe Anaphylactic reaction Mild Active

Assessment Section

Obesity.

Uncontrolled brittle Type II diabetic.

Shortness of breath, mild wheezing.

Pressure ulder on left knee.

Assessment and Plan Section

Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy

Acute on chronic anemia secondary to #1.

Azotemia, acute renal failure with volume loss secondary tom#1.

Hyperkalemia secondary to #3 and on ACE and K+ supplement.

Other chronic diagnoses as noted above, currently stable.

Chief Complaint and Reason for Visit Section

Cramping, bloating, and constipation.

Chief Complaint Section

Dark Stools

Family History Section

Relationship Diagnosis Age at Onset
Father Myocardial Infarction(cause of Death) 57
Father Diabetes 40

Functional Status Section

Functional or Cognitive Finding Observation Observation Date Condition Status
Ambulation (Dependent to Independent Independently able 2010/03/11 Active
Finding of Functional Performance and Activity Dyspnea 2008/02/16 Active
Cognitive Function Finding Memory Impairment 2014/04/29 Active

General Status Section

Alert and in good spirits, no acute distress.

History of Past Illness Section

See History of Present Illness

History of Present Illness Section

This patient was only recently discharged for a recurrent GI bleed as described below.

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 80?s resolved after .... .... ....

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.

He was transfused with 6 units of packed red blood cells with .... .... ....

GI evaluation 12 September: Colonoscopy showed single red clot in .... ........

Immunizations Section

Vaccine Date Status
Fluvax (Influenza) 2016-04-05 Completed

Medical Equipment Section

Supply/Device Date Supplied
Automatic Implantable cardioverter/defbrillator 2008/11/16
Wheelchair 1999/12/01

Medication Section

Medication Directions Start Date Status Indications Fill Instructions
Amoxicillin Amoxicillin Powder, for Suspension 250mg/5ml 20160401 Active Pneumonia Generic substitution allowed

Mental Status Section

Mental Status Findings Effective Dates Condition Status
Mental Function July 31, 2013 Impaired
Cognitive Abilities July 31, 2013 Judgement, Intact
Cognitive Function July 31, 2013 Aggressive Behavior
Cognitive Function July 31, 2013 Difficulty understanding own emotions
Cognitive Function July 31, 2013 Difficulty communicating Thoughts

Nutrition Section

Date Nutritional Status Diet
2005/12/29 Well nourished Low sodium diet, excessive carbohydrate
2010/05/26 Slight dehydration High protein, low fibre

Physical Exam Section

HEENT: All normal to examination.

>HEART: RRR, no murmur.

THORAX & LUNGS: Clear without rhonchi or wheeze.

ABDOMEN: Marked distension and tenderness, slightly obese, pos bowelsounds.

BACK: Normal to inspection and palpation, without tenderness; no presacral edema.

EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.

Plan of Treatment Section

Planned Activity Period Status
Colonoscopy 2010/08/16 - 2010/08/16 Completed
Recommendation to Exercise 2015/10/29 Ongoing

Problem Section

Problem Name Type Onset Date Abatement Date Status
Fever Condition 2016-04-01 2016-04-14 Complete

Procedures Section

Procedure Name Body Site Performer Date Performed Reason
Appendectomy (Procedure) Abdomen Dr. Adam Everyman 20160405 Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding

Reason for Visit Section

Tenderness of lower abdomen

Results Section

Result Type Quantity Value Date Status
Glucose [Moles/volume] in Blood 6.3 mmol/l 2016/04/01 Final

Review of Systems Section

Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. Several episodes of abdominal tenderness. No recent headaches. Positive for osteoarthritis in hips, knees and hands.

Social History Section

Social History Element Description Effective Dates
Smoking 1 pack tobacco per day 2005/05/01 - 2010/02/28

Vital Signs Section

Vital Sign Date Value
Temperature 2016/04/05 39 Degrees Celcius

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.