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-discharge-summary-composition-example

Formats: XML Example or JSON Example or Turtle Example.

The narrative from the above example:

Discharge Summary(CCoF)

Discharge Summary document for Henry Jones

Managed by Community Health and Hospitals

Subject Details

Allergies and Intolerances Section

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

Chief Complaint and Reason for Visit Section

Cramping, bloating, and constipation.

Chief Complaint Section

Dark Stools

Reason for Visit Section

Tenderness of lower abdomen

Admission Diagnosis Section

Appendicitis

Admission Medications Section

Medication Directions Start Date Status Indications Fill Instructions
Pepcid Complete (MAGNESIUM HYDROXIDE0 Chew one tablet completely and swallow as needed 20151029 Active Bloating Generic substitution allowed

History of Past Illness Section

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

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 .... ........

Review of Systems Section

Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.

Family History Section

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

Social History Section

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

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

Hospital Course Section

Following a colonoscopy, the patient was admitted and started on Lovenox and nitroglycerin paste. The patient had serial cardiac enzymes and was ruled out for myocardial infarction. The patient underwent a dual isotope stress test. There was no evidence of reversible ischemia on the Cardiolite scan. The patient has been ambulated. The patient had a Holter monitor placed but the report is not available at this time. The patient has remained hemodynamically stable. Will discharge.

Hospital Consultations Section

listType="ordered"

Gastroenterology

Cardiology

Dietitian

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

Discharge Diagnosis Section

Diverticula of intestine

Discharge Medications Section (entries optional)

Medication Directions Start Date Status Indications Fill Instructions
Proventil HFA Inhalant solution - 2 puffs QID PRN wheezing 20151029 Active Pneumonia Generic substitution allowed

Discharge Medications Section (entries required)

Medication Directions Start Date Status Indications Fill Instructions
Acetaminophen Tab 325 mg Take 2 tablet(s) every four hours if needed 20151029 Active Pain management Generic substitution allowed

Hospital Discharge Instructions Section

Take all of your prescription medication as directed.

Make an appointment with your doctor to be seen two weeks from the date of your procedure.

You may feel slightly bloated after the procedure because of air that was introduced during the examination.

Call your physician if you notice:
Bleeding or black stools.
Abdominal pain.
Fever or chills.
Nausea or vomiting.
Any unusual pain or problem.
Pain or redness at the site where the intravenous needle was placed.

Do not drink alcohol for 24 hours. Alcohol amplifies the effect of the sedatives given.

Do not drive or operate machinery for 24 hours.

Hospital Discharge Physical Section

GENERAL: Well-developed, slightly obese man.

NECK: Supple, with no jugular venous distension.

HEART: Intermittent tachycardia without murmurs or gallops.

PULMONARY: Decreased breath sounds, but no clear-cut rales or wheezes.

EXTREMITIES: Free of edema.

Hospital Discharge Studies Section

Laboratory Information Chemistries and drug levels
Potasium 4.0
NA (135-145meq/l) 140

Other Tests Results
EKG Sinus rhythm without acute changes.

Immunizations Section

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

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

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.