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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 
{
"resourceType" : "Composition",
"id" : "CCDA-on-FHIR-Progress-Note-Example",
"meta" : {
"versionId" : "1",
"lastUpdated" : "2016-06-15T08:16:14Z",
"profile" : [
"http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Progress-Note"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Progress Note document for Henry Jones</p>
<p>Managed by Community Health and Hospitals</p>
</div>"
},
"identifier" : {
"system" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Progress-Note",
"value" : "1"
},
"date" : "2016-03-22T09:10:14Z",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11506-3",
"display" : "Provider-unspecified Progress note"
}
]
},
"title" : "Progress Note",
"status" : "preliminary",
"confidentiality" : "N",
"subject" : {
"reference" : "http://fhir3.healthintersections.com.au/open/Patient/c493f2f2-28d5-49ab-90e8-9e8be341f7",
"display" : "Henry Jones"
},
"author" : [
{
"reference" : "http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500",
"display" : "Adam Everyman, MD"
}
],
"attester" : [
{
"mode" : [
"legal"
],
"time" : "2012-01-04T09:10:14Z",
"party" : {
"reference" : "http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500",
"display" : "Adam Everyman, MD"
}
}
],
"custodian" : {
"reference" : "http://fhir3.healthintersections.com.au/open/Organization/1213e1ae-afc2-4a7c-8ed3-43b7a4e3d7",
"display" : "Community Health and Hospitals"
},
"event" : [
{
"code" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/v3/ActClass",
"code" : "PCPR",
"display" : "Care Provision"
}
]
}
],
"period" : {
"start" : "2015-11-18",
"end" : "2015-12-12"
}
}
],
"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"
}
]
}
},
{
"title" : " Assessment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "51848-0",
"display" : "Assessment (evaluation)"
}
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
}
},
{
"title" : "Assessment and Plan Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "51847-2",
"display" : "Assessment (evaluation) and plan"
}
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
}
},
{
"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" : "Instructions Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "69730-0",
"display" : " Instructions"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Patient may have low grade fever, mild joint pain and injection area tenderness.</p>
</div>"
}
},
{
"title" : "Interventions Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "62387-6",
"display" : "Interventions provided"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Planned Intervention</b>
</td>
<td>
<b>Status</b>
</td>
<td>
<b>Date</b>
</td>
</tr>
<tr>
<td>Elevate head of bed</td>
<td>active</td>
<td>September 2, 2015</td>
</tr>
<tr>
<td>Oxygen administration by nasal cannula</td>
<td>active</td>
<td>September 1, 2015</td>
</tr>
<tr>
<td>pulse oximetry monitoring</td>
<td>active</td>
<td>September 3, 2015</td>
</tr>
</table>
</div>"
}
},
{
"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" : "Physical Exam Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29545-1",
"display" : "Physical findings"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>HEENT: All normal to examination.</p>
<p>>HEART: RRR, no murmur.</p>
<p>THORAX & 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>"
}
},
{
"title" : "Objective Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "61149-1",
"display" : "Objective"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Chest: clear to ausc. No rales, normal breath sounds</p>
<p>Heart: RR, PMI in normal location and no heave or evidence ofcardiomegaly,normal heart sounds, no murm or gallop</p>
</div>"
}
},
{
"title" : "Subjective Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "61150-9",
"display" : "Subjective"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml">
<p>Complaints of rectal bleeding, fatigue and a change in bowel patterns.</p>
<p>Has several days of constipation alternating with diarrhea.</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. Several episodes of abdominal tenderness. No recent headaches.
Positive for osteoarthritis in hips, knees and hands. </p>
</div>"
}
},
{
"title" : "Medication Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10160-0",
"display" : "History of Medication Use"
}
]
},
"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>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>"
},
"entry" : [
{
"reference" : "http://fhir3.healthintersections.com.au/open/Medication/73bdc4a1-736c-4d79-8f42-620a19a367"
}
]
},
{
"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>"
}
},
{
"title" : "Results Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "30954-2",
"display" : "Relevant diagnostic tests and laboratory data"
}
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
"reference" : "http://fhir3.healthintersections.com.au/open/Observation/dce96908-11fc-49e0-9d55-7442b0eff9"
}
]
},
{
"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://fhir3.healthintersections.com.au/open/Observation/bc96946f-c13f-4a7c-a396-92f8523763"
}
]
}
]
}
© 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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