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 
{
"resourceType" : "Composition",
"id" : "ccda-discharge-summary-composition-example",
"meta" : {
"versionId" : "1",
"lastUpdated" : "2016-06-15T08:16:14Z",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/ccda-discharge-summary-composition"
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Discharge Summary document for Henry Jones</p>
<p>Managed by Community Health and Hospitals</p>
</div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension",
"valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
},
{
"url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension",
"valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
},
{
"url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension",
"valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
},
{
"url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension",
"valueUri" : "http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"
},
{
"url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension",
"valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
},
{
"url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension",
"valueUri" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent"
}
},
"identifier" : {
"system" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-discharge-summary-composition",
"value" : "1"
},
"date" : "2016-02-14T09:10:14Z",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18842-5",
"display" : "Discharge Summary"
}
}
},
"title" : "Discharge Summary(CCoF)",
"status" : "preliminary",
"confidentiality" : "N",
"subject" : {
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Patient/117467",
"display" : "Henry Jones"
},
"author" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497",
"display" : "Adam Everyman, MD"
}
},
"custodian" : {
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Organization/117471",
"display" : "Community Health and Hospitals"
},
"encounter" : {
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"
},
"section" : [
{
"title" : "Allergies and Intolerances Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48765-2",
"display" : "Allergies and adverse reactions"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"mode" : "snapshot",
"orderedBy" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/list-order",
"code" : "event-date",
"display" : "Sorted by Event Date"
}
}
},
"entry" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632"
}
}
},
{
"title" : "Chief Complaint and Reason for Visit Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "46239-0",
"display" : "Chief complaint and reason for visit"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Cramping, bloating, and constipation.</p>
</div>"
}
},
{
"title" : "Chief Complaint Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10154-3",
"display" : "Chief complaint"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Dark Stools</p>
</div>"
}
},
{
"title" : "Reason for Visit Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29299-5",
"display" : "Reason for visit"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Tenderness of lower abdomen</p>
</div>"
}
},
{
"title" : "Admission Diagnosis Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "46241-6",
"display" : "Hospital admission diagnosis"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Appendicitis</p>
</div>"
}
},
{
"title" : "Admission Medications Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "42346-7",
"display" : "Medications on admission"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>Pepcid Complete (MAGNESIUM HYDROXIDE0</td>
<td>Chew one tablet completely and swallow as needed </td>
<td>20151029</td>
<td>Active</td>
<td>Bloating</td>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>"
}
},
{
"title" : "History of Past Illness Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11348-0",
"display" : "History of past illness"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Condition/117648"
}
}
},
{
"title" : "History of Present Illness Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10164-2",
"display" : "History of present illness"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>This patient was only recently discharged for a recurrent GI bleed as described below. </p>
<p>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 .... .... .... </p>
<p>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. </p>
<p>He was transfused with 6 units of packed red blood cells with .... .... .... </p>
<p>GI evaluation 12 September: Colonoscopy showed single red clot in .... ........ </p>
</div>"
}
},
{
"title" : "Review of Systems Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10187-3",
"display" : "Review of systems"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>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. </p>
</div>"
}
},
{
"title" : "Family History Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10157-6",
"display" : "History of family member diseases"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652"
}
}
},
{
"title" : "Social History Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29762-2",
"display" : "Social history"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Observation/117688"
}
}
},
{
"title" : "Functional Status Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "47420-5",
"display" : "Functional status"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
}
},
{
"title" : "Hospital Course Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8648-8",
"display" : "Hospital course"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>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.</p>
</div>"
}
},
{
"title" : "Hospital Consultations Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18841-7",
"display" : "Hospital consultations"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>listType="ordered"</p>
<p>Gastroenterology</p>
<p>Cardiology</p>
<p>Dietitian</p>
</div>"
}
},
{
"title" : "Plan of Treatment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Plan of treatment"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
}
},
{
"title" : "Problem Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11450-4",
"display" : "Problem list"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Condition/117648"
}
}
},
{
"title" : "Procedures Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "47519-4",
"display" : "History of procedures"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Procedure/117687"
}
}
},
{
"title" : "Discharge Diagnosis Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11535-2",
"display" : " Hospital discharge diagnosis"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Diverticula of intestine</p>
</div>"
}
},
{
"title" : "Discharge Medications Section (entries optional)",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10183-2",
"display" : "Hospital discharge medications"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>Proventil HFA</td>
<td>Inhalant solution - 2 puffs QID PRN wheezing</td>
<td>20151029</td>
<td>Active</td>
<td>Pneumonia</td>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>"
}
},
{
"title" : "Discharge Medications Section (entries required)",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10183-2",
"display" : "Hospital discharge medications"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>Acetaminophen Tab 325 mg</td>
<td>Take 2 tablet(s) every four hours if needed</td>
<td>20151029</td>
<td>Active</td>
<td>Pain management</td>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>"
}
},
{
"title" : "Hospital Discharge Instructions Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8653-8",
"display" : "Hospital discharge instructions"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Take all of your prescription medication as directed. </p>
<p>Make an appointment with your doctor to be seen two weeks from the date of your procedure. </p>
<p>You may feel slightly bloated after the procedure because of air that was
introduced during the examination. </p>
<p> Call your physician if you notice: <br/> Bleeding or black stools. <br/>
Abdominal pain. <br/> Fever or chills. <br/> Nausea or vomiting. <br/> Any unusual
pain or problem. <br/> Pain or redness at the site where the intravenous needle was
placed. <br/>
</p>
<p>Do not drink alcohol for 24 hours. Alcohol amplifies the effect of the sedatives given. </p>
<p>Do not drive or operate machinery for 24 hours.</p>
</div>"
}
},
{
"title" : "Hospital Discharge Physical Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10184-0",
"display" : "Hospital discharge physical"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>GENERAL: Well-developed, slightly obese man. </p>
<p>NECK: Supple, with no jugular venous distension.</p>
<p>HEART: Intermittent tachycardia without murmurs or gallops. </p>
<p>PULMONARY: Decreased breath sounds, but no clear-cut rales or wheezes.</p>
<p>EXTREMITIES: Free of edema.</p>
</div>"
}
},
{
"title" : "Hospital Discharge Studies Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11493-4",
"display" : "Hospital discharge studies summary"
}
}
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<table border="1" width="100%">
<thead>
<tr>
<th>Laboratory Information</th>
<th>Chemistries and drug levels</th>
</tr>
</thead>
<tbody>
<tr>
<td>Potasium</td>
<td>4.0</td>
</tr>
<tr>
<td>NA (135-145meq/l)</td>
<td>140</td>
</tr>
</tbody>
</table>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>Other Tests</th>
<th>Results</th>
</tr>
</thead>
<tbody>
<tr>
<td>EKG</td>
<td>Sinus rhythm without acute changes.</td>
</tr>
</tbody>
</table>
</div>"
}
},
{
"title" : "Immunizations Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11369-6",
"display" : "History of immunization"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "http://fhirtest.uhn.ca/baseDstu3/Immunization/117678"
}
}
},
{
"title" : " Nutrition Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "61144-2",
"display" : "Diet and nutrition"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
}
},
{
"title" : "Vital Signs Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8716-3",
"display" : "Vital signs"
}
}
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "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
Links: Search |
Version History |
Table of Contents |
|
Propose a change