This page is part of the C-CDA on FHIR Implementation Guide (v1.8.0: STU 1 Ballot 2) based on FHIR v1.8.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

{title?}

<Composition xmlns="http://hl7.org/fhir">
  <id value="CCDA-on-FHIR-History-and-Physical-Example"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2016-06-15T08:16:14Z"/>
    <profile
             value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
            <p>History and Physical 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://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></extension><extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension"><valueUri value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></extension><extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension"><valueUri value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></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://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></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-on-FHIR-History-and-Physical"/>
    <value value="1"/>
  </identifier>
  <date value="2016-02-28T09:10:14Z"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="34117-2"/>
      <display value="History and Physical Note"/>
    </coding>
  </type>
  <title value="History and Physical"/>
  <status value="preliminary"/>
  <confidentiality value="N"/>
<!--   Patient Resource  -->
  <subject>
    <reference
               value="http://fhir3.healthintersections.com.au/open/Patient/c493f2f2-28d5-49ab-90e8-9e8be341f7"/>
    <display value="Henry Jones"/>
  </subject>
<!--   Practitioner Resource  -->
  <author>
    <reference
               value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/>
    <display value="Adam Everyman, MD"/>
  </author>
  <attester>
    <mode value="legal"/>
    <time value="2012-01-04T09:10:14Z"/>
    <party>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/>
      <display value="Adam Everyman, MD"/>
    </party>
  </attester>
<!--   Organization Resource  -->
  <custodian>
    <reference
               value="http://fhir3.healthintersections.com.au/open/Organization/1213e1ae-afc2-4a7c-8ed3-43b7a4e3d7"/>
    <display value="Community Health and Hospitals"/>
  </custodian>
  <event>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/v3/ActClass"/>
        <code value="PCPR"/>
        <display value="Care Provision"/>
      </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  -->
<!--   Allergies and Intolerances Section Resource  -->
<!--  <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632"/></entry> -->
  <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>
  </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>
<!--   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>
<!--   Family History Section Narrative  -->
<!--   Family History Section Resource  -->
<!--  <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652"/></entry> -->
  <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>
  </section>
<!--   General Status Section Narrative  -->
  <section>
    <title value=" General Status Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10210-3"/>
        <display value="Physical findings of General status"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <p>Alert and in good spirits, no acute distress.</p>
            </div>
    </text>
  </section>
<!--   History of Past Illness Section Narrative  -->
<!--   History of Past Illness Section Condition Resource -->
<!--   <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/></entry> -->
  <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>
  </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>
<!--   Immunizations Section Narrative  -->
  <section>
    <title value="Immunizations Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11369-6"/>
        <display value="History of immunization"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  <!--   Immunization Section Resource  -->
    <entry>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Immunization/de43e197-62fb-4337-81bd-8523b9a8af"/>
    </entry>
  </section>
<!--   Instructions Section Narrative  -->
  <section>
    <title value="Instructions Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="69730-0"/>
        <display value=" Instructions"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <p>Patient may have low grade fever, mild joint pain and injection area tenderness.</p>
            </div>
    </text>
  </section>
<!--   Medication 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>
  <!--   Medication Section Resource  -->
    <entry>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Medication/73bdc4a1-736c-4d79-8f42-620a19a367"/>
    </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>
<!--   Problem Section Narrative  -->
<!--   Problem Section Condition Resource  -->
<!--   <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/></entry> -->
  <section>
    <title value="Problem Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11450-4"/>
        <display value="Problem list"/>
      </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>
  </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://fhir3.healthintersections.com.au/open/Procedure/62735e39-bc54-4636-b47e-9e3e5709ae"/>
    </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>
<!--   Results Section Narrative  -->
  <section>
    <title value="Results Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="30954-2"/>
        <display value="Relevant diagnostic tests and laboratory data"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Result Type</b>
                        </td>
                        <td>
                            <b>Quantity Value</b>
                        </td>
                        <td>
                            <b>Date</b>
                        </td>
                        <td>
                            <b>Status</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Glucose [Moles/volume] in Blood</td>
                        <td>6.3 mmol/l</td>
                        <td>2016/04/01</td>
                        <td>Final</td>
                    </tr>
                </table>
            </div>
    </text>
  <!--   Result Section Observation Resource  -->
    <entry>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Observation/dce96908-11fc-49e0-9d55-7442b0eff9"/>
    </entry>
  </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://fhir3.healthintersections.com.au/open/Observation/4d0aba77-8fc0-4739-9ea6-b958c63378"/>
    </entry>
  </section>
<!--   Vital Signs Section Narrative  -->
  <section>
    <title value="Vital Signs Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8716-3"/>
        <display value="Vital signs"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  <!--   Vital Signs Section Observation Resource  -->
    <entry>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Observation/bc96946f-c13f-4a7c-a396-92f8523763"/>
    </entry>
  </section>
</Composition>