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
Formats: XML Example or JSON Example or Turtle Example.
The narrative from the above example:
Discharge Summary document for Henry Jones
Managed by Community Health and Hospitals
Substance | Overall Severity | Reaction | Reaction Severity | Status |
Cashew Nut | Severe | Anaphylactic reaction | Mild | Active |
Cramping, bloating, and constipation.
Dark Stools
Tenderness of lower abdomen
Appendicitis
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 |
Problem Name | Type | Onset Date | Abatement Date | Status |
Fever | Condition | 2016-04-01 | 2016-04-14 | Complete |
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 .... ........
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.
Relationship | Diagnosis | Age at Onset |
Father | Myocardial Infarction(cause of Death) | 57 |
Father | Diabetes | 40 |
Social History Element | Description | Effective Dates |
Smoking | 1 pack tobacco per day | 2005/05/01 - 2010/02/28 |
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 |
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.
listType="ordered"
Gastroenterology
Cardiology
Dietitian
Planned Activity | Period | Status |
Colonoscopy | 2010/08/16 - 2010/08/16 | Completed |
Recommendation to Exercise | 2015/10/29 | Ongoing |
Problem Name | Type | Onset Date | Abatement Date | Status |
Fever | Condition | 2016-04-01 | 2016-04-14 | Complete |
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 |
Diverticula of intestine
Medication | Directions | Start Date | Status | Indications | Fill Instructions |
Proventil HFA | Inhalant solution - 2 puffs QID PRN wheezing | 20151029 | Active | Pneumonia | Generic substitution allowed |
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 |
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.
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.
Laboratory Information | Chemistries and drug levels |
---|---|
Potasium | 4.0 |
NA (135-145meq/l) | 140 |
Other Tests | Results |
---|---|
EKG | Sinus rhythm without acute changes. |
Vaccine | Date | Status |
Fluvax (Influenza) | 2016-04-05 | Completed |
Date | Nutritional Status | Diet |
2005/12/29 | Well nourished | Low sodium diet, excessive carbohydrate |
2010/05/26 | Slight dehydration | High protein, low fibre |
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.