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-procedure-note-composition-example

Formats: XML Example or JSON Example or Turtle Example.

The narrative from the above example:

Procedure Note

Procedure Note 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

Anesthesia Section

Conscious sedation with propofol 200 mg IV

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.

Procedure Description Section

The patient was brought to the operating room, placed in the supine position, and general anesthesia was induced. A detailed technical narrative of a laparoscopic appendectomy from initial incision to placement of any dressings follows.

Procedure Indications Section

The procedure is performed for screening in a low risk individual.

Planned Procedure Section

Colonoscopy

Procedure Disposition Section

The patient was taken to the Endoscopy Recovery Unit in stable condition.

Procedure Estimated Blood Loss Section

Minimal

Procedure Findings Section

A 6 mm sessile polyp was found in the ascending colon and removed by snare, no cautery. Bleeding was controlled. Moderate diverticulosis and hemorrhoids were incidentally noted.

Procedure Implants Section

No implants were placed.

Procedure Specimens Taken Section

Ascending colon polyp

Postprocedure Diagnosis Section

Sigmoid diverticulosis, moderate

Internal hemorrhoids

Colon polyp, 6mm, ascending colon

Chief Complaint and Reason for Visit Section

Cramping, bloating, and constipation.

Chief Complaint Section

Dark Stools

Complications Section

Asthmatic symptoms while under general anesthesia.

Family History Section

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

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

Medical (General) History Section

Stomach cramps

Medication Section

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

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

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

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

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.