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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 
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/owl#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix sct: <http://snomed.info/id/> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <Composition/CCDA-on-FHIR-Operative-Note-Example> a fhir:Composition; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "CCDA-on-FHIR-Operative-Note-Example"]; fhir:Resource.meta [ fhir:Meta.versionId [ fhir:value "1" ]; fhir:Meta.lastUpdated [ fhir:value "2016-06-15T08:16:14Z"^^xsd:dateTime ]; fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Operative-Note"; fhir:index 0 ] ]; fhir:Resource.language [ fhir:value "en-US"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Operative Note document for Henry Jones</p>\n <p>Managed by Community Health and Hospitals</p>\n </div>" ]; fhir:Composition.identifier [ fhir:Identifier.system [ fhir:value "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Operative-Note" ]; fhir:Identifier.value [ fhir:value "1" ] ]; fhir:Composition.date [ fhir:value "2016-03-22T09:10:14Z"^^xsd:dateTime]; fhir:Composition.type [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:11504-8; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11504-8" ]; fhir:Coding.display [ fhir:value "Provider-unspecified Operation Note" ] ] ]; fhir:Composition.title [ fhir:value "Operative Note"]; fhir:Composition.status [ fhir:value "preliminary"]; fhir:Composition.confidentiality [ fhir:value "N"]; fhir:Composition.subject [ fhir:link <http://fhir3.healthintersections.com.au/open/Patient/c493f2f2-28d5-49ab-90e8-9e8be341f7>; fhir:Reference.reference [ fhir:value "http://fhir3.healthintersections.com.au/open/Patient/c493f2f2-28d5-49ab-90e8-9e8be341f7" ]; fhir:Reference.display [ fhir:value "Henry Jones" ] ]; fhir:Composition.author [ fhir:index 0; fhir:link <http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500>; fhir:Reference.reference [ fhir:value "http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500" ]; fhir:Reference.display [ fhir:value "Adam Everyman, MD" ] ]; fhir:Composition.attester [ fhir:index 0; fhir:Composition.attester.mode [ fhir:value "legal"; fhir:index 0 ]; fhir:Composition.attester.time [ fhir:value "2012-01-04T09:10:14Z"^^xsd:dateTime ]; fhir:Composition.attester.party [ fhir:link <http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500>; fhir:Reference.reference [ fhir:value "http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500" ]; fhir:Reference.display [ fhir:value "Adam Everyman, MD" ] ] ]; fhir:Composition.custodian [ fhir:link <http://fhir3.healthintersections.com.au/open/Organization/1213e1ae-afc2-4a7c-8ed3-43b7a4e3d7>; fhir:Reference.reference [ fhir:value "http://fhir3.healthintersections.com.au/open/Organization/1213e1ae-afc2-4a7c-8ed3-43b7a4e3d7" ]; fhir:Reference.display [ fhir:value "Community Health and Hospitals" ] ]; fhir:Composition.event [ fhir:index 0; fhir:Composition.event.code [ fhir:index 0; fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept sct:73761001; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ]; fhir:Coding.code [ fhir:value "73761001" ]; fhir:Coding.display [ fhir:value "Colonoscopy" ] ] ]; fhir:Composition.event.period [ fhir:Period.start [ fhir:value "2015-11-18"^^xsd:date ]; fhir:Period.end [ fhir:value "2015-12-12"^^xsd:date ] ] ]; fhir:Composition.encounter [ fhir:link <http://fhirtest.uhn.ca/baseDstu3/Encounter/117630>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Encounter/117630" ] ]; fhir:Composition.section [ fhir:index 0; fhir:Composition.section.title [ fhir:value "Allergies and Intolerances Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:48765-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "48765-2" ]; fhir:Coding.display [ fhir:value "Allergies and adverse reactions" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Substance</b>\n </td>\n <td>\n <b>Overall Severity</b>\n </td>\n <td>\n <b>Reaction</b>\n </td>\n <td>\n <b>Reaction Severity</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Cashew Nut</td>\n <td>Severe</td>\n <td>Anaphylactic reaction</td>\n <td>Mild</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.mode [ fhir:value "snapshot" ]; fhir:Composition.section.orderedBy [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/list-order" ]; fhir:Coding.code [ fhir:value "event-date" ]; fhir:Coding.display [ fhir:value "Sorted by Event Date" ] ] ] ], [ fhir:index 1; fhir:Composition.section.title [ fhir:value "Anesthesia Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59774-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59774-0" ]; fhir:Coding.display [ fhir:value "Anesthesia" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Conscious sedation with propofol 200 mg IV</p>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhir3.healthintersections.com.au/open/Medication/73bdc4a1-736c-4d79-8f42-620a19a367>; fhir:Reference.reference [ fhir:value "http://fhir3.healthintersections.com.au/open/Medication/73bdc4a1-736c-4d79-8f42-620a19a367" ] ] ], [ fhir:index 2; fhir:Composition.section.title [ fhir:value " Assessment Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:51848-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "51848-0" ]; fhir:Coding.display [ fhir:value "Assessment (evaluation)" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Obesity.</p>\n <p>Uncontrolled brittle Type II diabetic.</p>\n <p>Shortness of breath, mild wheezing.</p>\n <p>Pressure ulder on left knee.</p>\n </div>" ] ], [ fhir:index 3; fhir:Composition.section.title [ fhir:value "Assessment and Plan Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:51847-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "51847-2" ]; fhir:Coding.display [ fhir:value "Assessment (evaluation) and plan" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Recurrent GI bleed of unknown etiology; hypotension perhaps\n secondary to this but as likely secondary to polypharmacy</p>\n <p>Acute on chronic anemia secondary to #1.</p>\n <p>Azotemia, acute renal failure with volume loss secondary tom#1.</p>\n <p>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</p>\n <p>Other chronic diagnoses as noted above, currently stable.</p>\n </div>" ] ], [ fhir:index 4; fhir:Composition.section.title [ fhir:value "Complications Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:55109-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "55109-3" ]; fhir:Coding.display [ fhir:value "Complications" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Asthmatic symptoms while under general anesthesia.</p>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link <http://fhirtest.uhn.ca/baseDstu3/Condition/117648>; fhir:Reference.reference [ fhir:value "http://fhirtest.uhn.ca/baseDstu3/Condition/117648" ] ] ], [ fhir:index 5; fhir:Composition.section.title [ fhir:value "Preoperative Diagnosis Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10219-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10219-4" ]; fhir:Coding.display [ fhir:value "Preoperative Diagnosis" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis</p>\n </div>" ] ], [ fhir:index 6; fhir:Composition.section.title [ fhir:value "Operative Note Surgical Procedure Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10223-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10223-6" ]; fhir:Coding.display [ fhir:value "Operative Note Surgical Procedure" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Laparoscopic Appendectomy</p>\n </div>" ] ], [ fhir:index 7; fhir:Composition.section.title [ fhir:value "Planned Procedure Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59772-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59772-4" ]; fhir:Coding.display [ fhir:value "Planned procedure" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Colonoscopy</p>\n </div>" ] ], [ fhir:index 8; fhir:Composition.section.title [ fhir:value "Procedure Indications Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59768-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59768-2" ]; fhir:Coding.display [ fhir:value "Procedure indications" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The procedure is performed for screening in a low risk individual.</p>\n </div>" ] ], [ fhir:index 9; fhir:Composition.section.title [ fhir:value "Procedure Description Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:29554-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "29554-3" ]; fhir:Coding.display [ fhir:value "Procedure description" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was brought to the operating room, placed in the supine position, and\n general anesthesia was induced. A detailed technical narrative of a laparoscopic\n appendectomy from initial incision to placement of any dressings follows. </p>\n </div>" ] ], [ fhir:index 10; fhir:Composition.section.title [ fhir:value "Procedure Estimated Blood Loss Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59770-8; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59770-8" ]; fhir:Coding.display [ fhir:value "Procedure Estimated Blood Loss" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Minimal</p>\n </div>" ] ], [ fhir:index 11; fhir:Composition.section.title [ fhir:value "Procedure Findings Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59776-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59776-5" ]; fhir:Coding.display [ fhir:value "Procedure findings" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>A 6 mm sessile polyp was found in the ascending colon and \n removed by snare, no cautery. Bleeding was controlled. \n Moderate diverticulosis and hemorrhoids were incidentally noted.</p>\n </div>" ] ], [ fhir:index 12; fhir:Composition.section.title [ fhir:value "Procedure Specimens Taken Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59773-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59773-2" ]; fhir:Coding.display [ fhir:value "Procedure specimens taken" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Ascending colon polyp</p>\n </div>" ] ], [ fhir:index 13; fhir:Composition.section.title [ fhir:value "Operative Note Fluids Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10216-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10216-0" ]; fhir:Coding.display [ fhir:value "Operative Note Fluids" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>250 ML Ringers Lactate</p>\n </div>" ] ], [ fhir:index 14; fhir:Composition.section.title [ fhir:value "Surgical Drains Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:11537-8; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11537-8" ]; fhir:Coding.display [ fhir:value "Surgical Drains" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Penrose drain placed</p>\n </div>" ] ], [ fhir:index 15; fhir:Composition.section.title [ fhir:value "Procedure Implants Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59771-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59771-6" ]; fhir:Coding.display [ fhir:value "Procedure implants" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No implants were placed.</p>\n </div>" ] ], [ fhir:index 16; fhir:Composition.section.title [ fhir:value "Procedure Disposition Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:59775-7; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "59775-7" ]; fhir:Coding.display [ fhir:value "Procedure disposition" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was taken to the Endoscopy Recovery Unit in stable condition.</p>\n </div>" ] ], [ fhir:index 17; fhir:Composition.section.title [ fhir:value "Postoperative Diagnosis Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:10218-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10218-6" ]; fhir:Coding.display [ fhir:value "Postoperative Diagnosis" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis with periappendiceal abscess</p>\n </div>" ] ], [ fhir:index 18; fhir:Composition.section.title [ fhir:value "Plan of Treatment Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:concept loinc:18776-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "18776-5" ]; fhir:Coding.display [ fhir:value "Plan of treatment" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Planned Activity</b>\n </td>\n <td>\n <b>Period</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Colonoscopy</td>\n <td>2010/08/16 - 2010/08/16</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2015/10/29</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>" ] ].
© HL7.org 2011+. FHIR STU3 Candidate (v1.8.0-10514) generated on Thu, Dec 8, 2016 06:39+1100. QA Page
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