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 
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/owl#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <Composition/ccda-consultation-note-composition-example> a fhir:Composition; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "ccda-consultation-note-composition-example"]; fhir:Resource.meta [ fhir:Meta.versionId [ fhir:value "1" ]; fhir:Meta.lastUpdated [ fhir:value "2016-06-15T08:16:14Z"^^xsd:dateTime ]; fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/StructureDefinition/ccda-consultation-note-composition"; fhir:index 0 ] ]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Consultation Note document for Henry Jones</p>\n <p>Managed by Community Health and Hospitals</p>\n </div>" ]; fhir:extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension" ]; fhir:Extension.valueUri [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497" ] ], [ fhir:index 1; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension" ]; fhir:Extension.valueUri [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497" ] ], [ fhir:index 2; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension" ]; fhir:Extension.valueUri [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497" ] ], [ fhir:index 3; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension" ]; fhir:Extension.valueUri [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466" ] ], [ fhir:index 4; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension" ]; fhir:Extension.valueUri [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497" ] ], [ fhir:index 5; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension" ]; fhir:Extension.valueUri [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent" ] ]; fhir:Composition.identifier [ fhir:Identifier.system [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/ccda-consultation-note-composition" ]; fhir:Identifier.value [ fhir:value "1" ] ]; fhir:Composition.date [ fhir:value "2016-02-28T09:10:14Z"^^xsd:dateTime]; fhir:Composition.type [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:11488-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11488-4" ]; fhir:Coding.display [ fhir:value "Consult Note" ] ] ]; fhir:Composition.title [ fhir:value "Consultation Note"]; fhir:Composition.status [ fhir:value "preliminary"]; fhir:Composition.confidentiality [ fhir:value "N"]; fhir:Composition.subject [ fhir:link <http://fhirtest.uhn.ca/baseDstu3/Patient/117467>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Patient/117467" ]; fhir:Reference.display [ fhir:value "Henry Jones" ] ]; fhir:Composition.author [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497" ]; fhir:Reference.display [ fhir:value "Adam Everyman, MD" ] ]; fhir:Composition.attester [ fhir:index 0; fhir:Composition.attester.mode [ fhir:value "legal"; fhir:index 0 ]; fhir:Composition.attester.time [ fhir:value "2012-01-04T09:10:14Z"^^xsd:dateTime ]; fhir:Composition.attester.party [ fhir:link <http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497" ]; fhir:Reference.display [ fhir:value "Adam Everyman, MD" ] ] ]; fhir:Composition.custodian [ fhir:link <http://fhirtest.uhn.ca/baseDstu3/Organization/117471>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Organization/117471" ]; fhir:Reference.display [ fhir:value "Community Health and Hospitals" ] ]; fhir:Composition.event [ fhir:index 0; fhir:Composition.event.code [ fhir:index 0; fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/v3/ActClass" ]; fhir:Coding.code [ fhir:value "PCPR" ]; fhir:Coding.display [ fhir:value "Care Provision" ] ] ]; fhir:Composition.event.period [ fhir:Period.start [ fhir:value "2015-11-18"^^xsd:date ]; fhir:Period.end [ fhir:value "2015-12-12"^^xsd:date ] ] ]; fhir:Composition.encounter [ fhir:link <http://fhirtest.uhn.ca/baseDstu3/Encounter/117630>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Encounter/117630" ] ]; fhir:Composition.section [ fhir:index 0; fhir:Composition.section.title [ fhir:value "Advance Directives Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:42348-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "42348-3" ]; fhir:Coding.display [ fhir:value "Advance directives" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Name</b>\n </td>\n <td>\n <b>Applies Period</b>\n </td>\n </tr>\n <tr>\n <td>Resuscitation</td>\n <td>2015/01/01 - 2016/12/31</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 1; fhir:Composition.section.title [ fhir:value "Allergies and Intolerances Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:48765-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "48765-2" ]; fhir:Coding.display [ fhir:value "Allergies and adverse reactions" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Substance</b>\n </td>\n <td>\n <b>Overall Severity</b>\n </td>\n <td>\n <b>Reaction</b>\n </td>\n <td>\n <b>Reaction Severity</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Cashew Nut</td>\n <td>Severe</td>\n <td>Anaphylactic reaction</td>\n <td>Mild</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.mode [ fhir:value "snapshot" ]; fhir:Composition.section.orderedBy [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/list-order" ]; fhir:Coding.code [ fhir:value "event-date" ]; fhir:Coding.display [ fhir:value "Sorted by Event Date" ] ] ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632" ] ] ], [ fhir:index 2; fhir:Composition.section.title [ fhir:value " Assessment Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:51848-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "51848-0" ]; fhir:Coding.display [ fhir:value "Assessment (evaluation)" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Obesity.</p>\n <p>Uncontrolled brittle Type II diabetic.</p>\n <p>Shortness of breath, mild wheezing.</p>\n <p>Pressure ulder on left knee.</p>\n </div>" ] ], [ fhir:index 3; fhir:Composition.section.title [ fhir:value "Assessment and Plan Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:51847-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "51847-2" ]; fhir:Coding.display [ fhir:value "Assessment (evaluation) and plan" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Recurrent GI bleed of unknown etiology; hypotension perhaps\n secondary to this but as likely secondary to polypharmacy</p>\n <p>Acute on chronic anemia secondary to #1.</p>\n <p>Azotemia, acute renal failure with volume loss secondary tom#1.</p>\n <p>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</p>\n <p>Other chronic diagnoses as noted above, currently stable.</p>\n </div>" ] ], [ fhir:index 4; fhir:Composition.section.title [ fhir:value "Chief Complaint and Reason for Visit Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:46239-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "46239-0" ]; fhir:Coding.display [ fhir:value "Chief complaint and reason for visit" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Cramping, bloating, and constipation.</p>\n </div>" ] ], [ fhir:index 5; fhir:Composition.section.title [ fhir:value "Chief Complaint Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10154-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10154-3" ]; fhir:Coding.display [ fhir:value "Chief complaint" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Dark Stools</p>\n </div>" ] ], [ fhir:index 6; fhir:Composition.section.title [ fhir:value "Family History Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10157-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10157-6" ]; fhir:Coding.display [ fhir:value "History of family member diseases" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Relationship</b>\n </td>\n <td>\n <b>Diagnosis</b>\n </td>\n <td>\n <b>Age at Onset</b>\n </td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Myocardial Infarction(cause of Death)</td>\n <td>57</td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Diabetes</td>\n <td>40</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652" ] ] ], [ fhir:index 7; fhir:Composition.section.title [ fhir:value "Functional Status Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:47420-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "47420-5" ]; fhir:Coding.display [ fhir:value "Functional status" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Functional or Cognitive Finding</b>\n </td>\n <td>\n <b>Observation</b>\n </td>\n <td>\n <b>Observation Date</b>\n </td>\n <td>\n <b>Condition Status</b>\n </td>\n </tr>\n <tr>\n <td>Ambulation (Dependent to Independent</td>\n <td>Independently able</td>\n <td>2010/03/11</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Finding of Functional Performance and Activity</td>\n <td>Dyspnea</td>\n <td>2008/02/16</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Cognitive Function Finding</td>\n <td>Memory Impairment</td>\n <td>2014/04/29</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 8; fhir:Composition.section.title [ fhir:value " General Status Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10210-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10210-3" ]; fhir:Coding.display [ fhir:value "Physical findings of General status" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Alert and in good spirits, no acute distress.</p>\n </div>" ] ], [ fhir:index 9; fhir:Composition.section.title [ fhir:value "History of Past Illness Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:11348-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11348-0" ]; fhir:Coding.display [ fhir:value "History of past illness" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>See History of Present Illness</p>\n </div>" ] ], [ fhir:index 10; fhir:Composition.section.title [ fhir:value "History of Present Illness Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10164-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10164-2" ]; fhir:Coding.display [ fhir:value "History of present illness" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>This patient was only recently discharged for a recurrent GI bleed as described below. </p>\n <p>He presented to the ER today c/o a dark stool yesterday but a normal brown\n stool today. On exam he was hypotensive in the 80?s resolved after .... .... .... </p>\n <p>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal.\n H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC\n 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1,\n PTT 40. </p>\n <p>He was transfused with 6 units of packed red blood cells with .... .... .... </p>\n <p>GI evaluation 12 September: Colonoscopy showed single red clot in .... ........ </p>\n </div>" ] ], [ fhir:index 11; fhir:Composition.section.title [ fhir:value "Immunizations Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:11369-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11369-6" ]; fhir:Coding.display [ fhir:value "History of immunization" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vaccine</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fluvax (Influenza)</td>\n <td>2016-04-05</td>\n <td>Completed</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Immunization/117678>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Immunization/117678" ] ] ], [ fhir:index 12; fhir:Composition.section.title [ fhir:value "Medical Equipment Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:46264-8; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "46264-8" ]; fhir:Coding.display [ fhir:value "Medical equipment" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Supply/Device</b>\n </td>\n <td>\n <b>Date Supplied</b>\n </td>\n </tr>\n <tr>\n <td>Automatic Implantable cardioverter/defbrillator</td>\n <td>2008/11/16</td>\n </tr>\n <tr>\n <td>Wheelchair</td>\n <td>1999/12/01</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 13; fhir:Composition.section.title [ fhir:value "Medication Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10160-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10160-0" ]; fhir:Coding.display [ fhir:value "History of Medication Use" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Amoxicillin</td>\n <td>Amoxicillin Powder, for Suspension 250mg/5ml</td>\n <td>20160401</td>\n <td>Active</td>\n <td>Pneumonia</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Medication/117679>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Medication/117679" ] ] ], [ fhir:index 14; fhir:Composition.section.title [ fhir:value "Mental Status Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10190-7; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10190-7" ]; fhir:Coding.display [ fhir:value "Mental status" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <td>\n <b>Mental Status Findings</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n <td>\n <b>Condition Status</b>\n </td>\n </tr>\n </thead>\n <tr>\n <td>Mental Function</td>\n <td>July 31, 2013</td>\n <td>Impaired</td>\n </tr>\n <tr>\n <td>Cognitive Abilities</td>\n <td>July 31, 2013</td>\n <td>Judgement, Intact</td>\n </tr>\n <tr>\n <td>Cognitive Function</td>\n <td>July 31, 2013</td>\n <td>Aggressive Behavior</td>\n </tr>\n <tr>\n <td>Cognitive Function</td>\n <td>July 31, 2013</td>\n <td>Difficulty understanding own emotions</td>\n </tr>\n <tr>\n <td>Cognitive Function</td>\n <td>July 31, 2013</td>\n <td>Difficulty communicating Thoughts </td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 15; fhir:Composition.section.title [ fhir:value " Nutrition Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:61144-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "61144-2" ]; fhir:Coding.display [ fhir:value "Diet and nutrition" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Nutritional Status</b>\n </td>\n <td>\n <b>Diet</b>\n </td>\n </tr>\n <tr>\n <td>2005/12/29</td>\n <td>Well nourished</td>\n <td>Low sodium diet, excessive carbohydrate</td>\n </tr>\n <tr>\n <td>2010/05/26</td>\n <td>Slight dehydration</td>\n <td>High protein, low fibre</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 16; fhir:Composition.section.title [ fhir:value "Physical Exam Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:29545-1; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "29545-1" ]; fhir:Coding.display [ fhir:value "Physical findings" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>HEENT: All normal to examination.</p>\n <p>>HEART: RRR, no murmur.</p>\n <p>THORAX & LUNGS: Clear without rhonchi or wheeze.</p>\n <p>ABDOMEN: Marked distension and tenderness, slightly obese, pos bowelsounds.</p>\n <p>BACK: Normal to inspection and palpation, without tenderness; no presacral edema.</p>\n <p>EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.</p>\n </div>" ] ], [ fhir:index 17; fhir:Composition.section.title [ fhir:value "Plan of Treatment Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:18776-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "18776-5" ]; fhir:Coding.display [ fhir:value "Plan of treatment" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Planned Activity</b>\n </td>\n <td>\n <b>Period</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Colonoscopy</td>\n <td>2010/08/16 - 2010/08/16</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2015/10/29</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 18; fhir:Composition.section.title [ fhir:value "Problem Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:11450-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11450-4" ]; fhir:Coding.display [ fhir:value "Problem list" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Problem Name</b>\n </td>\n <td>\n <b>Type</b>\n </td>\n <td>\n <b>Onset Date</b>\n </td>\n <td>\n <b>Abatement Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fever</td>\n <td>Condition</td>\n <td>2016-04-01</td>\n <td>2016-04-14</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Condition/117648>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Condition/117648" ] ] ], [ fhir:index 19; fhir:Composition.section.title [ fhir:value "Procedures Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:47519-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "47519-4" ]; fhir:Coding.display [ fhir:value "History of procedures" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Procedure Name</b>\n </td>\n <td>\n <b>Body Site</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Date Performed</b>\n </td>\n <td>\n <b>Reason</b>\n </td>\n </tr>\n <tr>\n <td>Appendectomy (Procedure)</td>\n <td>Abdomen</td>\n <td>Dr. Adam Everyman</td>\n <td>20160405</td>\n <td>Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Procedure/117687>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Procedure/117687" ] ] ], [ fhir:index 20; fhir:Composition.section.title [ fhir:value "Reason for Visit Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:29299-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "29299-5" ]; fhir:Coding.display [ fhir:value "Reason for visit" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Tenderness of lower abdomen</p>\n </div>" ] ], [ fhir:index 21; fhir:Composition.section.title [ fhir:value "Results Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:30954-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "30954-2" ]; fhir:Coding.display [ fhir:value "Relevant diagnostic tests and laboratory data" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Result Type</b>\n </td>\n <td>\n <b>Quantity Value</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Glucose [Moles/volume] in Blood</td>\n <td>6.3 mmol/l</td>\n <td>2016/04/01</td>\n <td>Final</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Observation/117685>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Observation/117685" ] ] ], [ fhir:index 22; fhir:Composition.section.title [ fhir:value "Review of Systems Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10187-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10187-3" ]; fhir:Coding.display [ fhir:value "Review of systems" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient denies recent history of fever or malaise. Positive for weakness and\n shortness of breath. Several episodes of abdominal tenderness. No recent headaches. \n Positive for osteoarthritis in hips, knees and hands. </p>\n </div>" ] ], [ fhir:index 23; fhir:Composition.section.title [ fhir:value "Social History Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:29762-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "29762-2" ]; fhir:Coding.display [ fhir:value "Social history" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Social History Element</b>\n </td>\n <td>\n <b>Description</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n </tr>\n <tr>\n <td>Smoking</td>\n <td>1 pack tobacco per day</td>\n <td>2005/05/01 - 2010/02/28</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Observation/117688>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Observation/117688" ] ] ], [ fhir:index 24; fhir:Composition.section.title [ fhir:value "Vital Signs Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:8716-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "8716-3" ]; fhir:Coding.display [ fhir:value "Vital signs" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vital Sign</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Value</b>\n </td>\n </tr>\n <tr>\n <td>Temperature</td>\n <td>2016/04/05</td>\n <td>39 Degrees Celcius</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Observation/117689>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Observation/117689" ] ] ].
© HL7.org 2011+. CCDA on FHIR STU 1 Ballot (v1.6.0-9635) generated on Thu, Aug 11, 2016 21:16+1000. QA Page
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