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

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  <id value="ccda-procedure-note-composition-example"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2016-06-15T08:16:14Z"/>
    <profile
             value="http://hl7.org/fhir/StructureDefinition/ccda-procedure-note-composition"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p>Procedure Note document for Henry Jones</p>
      <p>Managed by Community Health and Hospitals</p>
    </div>
  </text>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension">
    <valueUri value="http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent"/>
  </extension>
  <identifier>
    <system
            value="http://hl7.org/fhir/ccda/StructureDefinition/ccda-procedure-note-composition"/>
    <value value="1"/>
  </identifier>
  <date value="2016-03-10T09:10:14Z"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="28570-0"/>
      <display value="Procedure Note"/>
    </coding>
  </type>
  <title value="Procedure Note"/>
  <status value="preliminary"/>
  <confidentiality value="N"/>
<!--   Patient Resource  -->
  <subject>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Patient/117467"/>
    <display value="Henry Jones"/>
  </subject>
<!--   Practitioner Resource  -->
  <author>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
    <display value="Adam Everyman, MD"/>
  </author>
  <attester>
    <mode value="legal"/>
    <time value="2012-01-04T09:10:14Z"/>
    <party>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
      <display value="Adam Everyman, MD"/>
    </party>
  </attester>
<!--   Organization Resource  -->
  <custodian>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Organization/117471"/>
    <display value="Community Health and Hospitals"/>
  </custodian>
  <event>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="73761001"/>
        <display value="Colonoscopy"/>
      </coding>
    </code>
    <period>
      <start value="2015-11-18"/>
      <end value="2015-12-12"/>
    </period>
  </event>
<!--   Encounter Resource  -->
  <encounter>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"/>
  </encounter>
<!--   Allergies and Intolerances Section Narrative  -->
  <section>
    <title value="Allergies and Intolerances Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48765-2"/>
        <display value="Allergies and adverse reactions"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
    <mode value="snapshot"/>
    <orderedBy>
      <coding>
        <system value="http://hl7.org/fhir/list-order"/>
        <code value="event-date"/>
        <display value="Sorted by Event Date"/>
      </coding>
    </orderedBy>
  <!--   Allergy and Intolerances Section Resource  -->
    <entry>
      <reference
                 value="http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632"/>
    </entry>
  </section>
<!--   Anesthesia Section Narrative  -->
  <section>
    <title value="Anesthesia Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59774-0"/>
        <display value="Anesthesia"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Conscious sedation with propofol 200 mg IV</p>
      </div>
    </text>
  <!--   Anesthesia Section Procedure Resource -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Procedure/117687"/>
    </entry>
  <!--   Anesthesia Section Medication  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Medication/117679"/>
    </entry>
  </section>
<!--   Assessment Section Narrative  -->
  <section>
    <title value=" Assessment Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="51848-0"/>
        <display value="Assessment (evaluation)"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Obesity.</p>
        <p>Uncontrolled brittle Type II diabetic.</p>
        <p>Shortness of breath, mild wheezing.</p>
        <p>Pressure ulder on left knee.</p>
      </div>
    </text>
  </section>
<!--   Assessment and Plan Section Narrative  -->
  <section>
    <title value="Assessment and Plan Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="51847-2"/>
        <display value="Assessment (evaluation) and plan"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Recurrent GI bleed of unknown etiology; hypotension perhaps
                    secondary to this but as likely secondary to polypharmacy</p>
        <p>Acute on chronic anemia secondary to #1.</p>
        <p>Azotemia, acute renal failure with volume loss secondary tom#1.</p>
        <p>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</p>
        <p>Other chronic diagnoses as noted above, currently stable.</p>
      </div>
    </text>
  </section>
<!--   Procedure Description Section Narrative  -->
  <section>
    <title value="Procedure Description Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29554-3"/>
        <display value="Procedure description"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>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.  </p>
      </div>
    </text>
  </section>
<!--   Procedure Indications Section Narrative  -->
  <section>
    <title value="Procedure Indications Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59768-2"/>
        <display value="Procedure indications"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>The procedure is performed for screening in a low risk individual.</p>
      </div>
    </text>
  </section>
<!--   Planned Procedure Section Narrative  -->
  <section>
    <title value="Planned Procedure Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59772-4"/>
        <display value="Planned procedure"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Colonoscopy</p>
      </div>
    </text>
  </section>
<!--   Procedure Disposition Section Narrative  -->
  <section>
    <title value="Procedure Disposition Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59775-7"/>
        <display value="Procedure disposition"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>The patient was taken to the Endoscopy Recovery Unit in stable condition.</p>
      </div>
    </text>
  </section>
<!--   Procedure Estimated Blood Loss Section Narrative  -->
  <section>
    <title value="Procedure Estimated Blood Loss Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59770-8"/>
        <display value="Procedure estimated blood loss"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Minimal</p>
      </div>
    </text>
  </section>
<!--   Procedure Findings Section Narrative  -->
  <section>
    <title value="Procedure Findings Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59776-5"/>
        <display value="Procedure findings"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>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.</p>
      </div>
    </text>
  <!--   Procedure Findings Section Condition Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/>
    </entry>
  </section>
<!--   Procedure Implants Section Narrative  -->
  <section>
    <title value="Procedure Implants Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59771-6"/>
        <display value="Procedure implants"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>No implants were placed.</p>
      </div>
    </text>
  </section>
<!--   Procedure Specimens Taken Section Narrative  -->
  <section>
    <title value="Procedure Specimens Taken Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59773-2"/>
        <display value="Procedure specimens taken"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Ascending colon polyp</p>
      </div>
    </text>
  </section>
<!--   Post Procedure Diagnosis Section Narrative  -->
  <section>
    <title value="Postprocedure Diagnosis Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="59769-0"/>
        <display value="Postprocedure diagnosis"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Sigmoid diverticulosis, moderate</p>
        <p>Internal hemorrhoids</p>
        <p>Colon polyp, 6mm, ascending colon</p>
      </div>
    </text>
  </section>
<!--   Chief Complaint and Reason for Visit Section Narrative  -->
  <section>
    <title value="Chief Complaint and Reason for Visit Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="46239-0"/>
        <display value="Chief complaint and reason for visit"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Cramping, bloating, and constipation.</p>
      </div>
    </text>
  </section>
<!--   Chief Complaint Section Narrative  -->
  <section>
    <title value="Chief Complaint Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10154-3"/>
        <display value="Chief complaint"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Dark Stools</p>
      </div>
    </text>
  </section>
<!--   Complications Section Narrative  -->
  <section>
    <title value="Complications Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="55109-3"/>
        <display value="Complications"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Asthmatic symptoms while under general anesthesia.</p>
      </div>
    </text>
  <!--   Complications Section Condition Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/>
    </entry>
  </section>
<!--   Family History Section Narrative  -->
  <section>
    <title value="Family History Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10157-6"/>
        <display value="History of family member diseases"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  <!--   Family History Section Resource  -->
    <entry>
      <reference
                 value="http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652"/>
    </entry>
  </section>
<!--   History of Past Illness Section Narrative  -->
  <section>
    <title value="History of Past Illness Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11348-0"/>
        <display value="History of past illness"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  <!--   History of Past Illness Section Condition Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/>
    </entry>
  </section>
<!--   History of Present Illness Section Narrative  -->
  <section>
    <title value="History of Present Illness Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10164-2"/>
        <display value="History of present illness"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
<!--   Medical History Section Narrative  -->
  <section>
    <title value="Medical (General) History Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11329-0"/>
        <display value="Medical (general) history"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Stomach cramps</p>
      </div>
    </text>
  </section>
<!--   Medications Section Narrative  -->
  <section>
    <title value="Medication Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10160-0"/>
        <display value="History of Medication Use"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>Amoxicillin</td>
            <td>Amoxicillin Powder, for Suspension 250mg/5ml</td>
            <td>20160401</td>
            <td>Active</td>
            <td>Pneumonia</td>
            <td>Generic substitution allowed</td>
          </tr>
        </table>
      </div>
    </text>
  <!--   Medications Section Resource -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Medication/117679"/>
    </entry>
  </section>
<!--   Physical Exam Section Narrative  -->
  <section>
    <title value="Physical Exam Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29545-1"/>
        <display value="Physical findings"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>HEENT: All normal to examination.</p>
        <p>&gt;HEART: RRR, no murmur.</p>
        <p>THORAX &amp; LUNGS: Clear without rhonchi or wheeze.</p>
        <p>ABDOMEN: Marked distension and tenderness, slightly obese, pos bowelsounds.</p>
        <p>BACK: Normal to inspection and palpation, without tenderness; no presacral edema.</p>
        <p>EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.</p>
      </div>
    </text>
  </section>
<!--   Plan of Treatment Section Narrative  -->
  <section>
    <title value="Plan of Treatment Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
        <display value="Plan of treatment"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
<!--   Procedures Section Narrative  -->
  <section>
    <title value="Procedures Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="47519-4"/>
        <display value="History of procedures"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  <!--   Procedures Section Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Procedure/117687"/>
    </entry>
  </section>
<!--   Reason for Visit Section Narrative  -->
  <section>
    <title value="Reason for Visit Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29299-5"/>
        <display value="Reason for visit"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Tenderness of lower abdomen</p>
      </div>
    </text>
  </section>
<!--   Review of Systems Section Narrative  -->
  <section>
    <title value="Review of Systems Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10187-3"/>
        <display value="Review of systems"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>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. </p>
      </div>
    </text>
  </section>
<!--   Social History Section Narrative  -->
  <section>
    <title value="Social History Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29762-2"/>
        <display value="Social history"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  <!--   Social History Section Observation Resource  -->
    <entry>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Observation/117688"/>
    </entry>
  </section>
</Composition>