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-Progress-Note-Example"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2016-06-15T08:16:14Z"/>
    <profile
             value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Progress-Note"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <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>
  </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-Progress-Note"/>
    <value value="1"/>
  </identifier>
  <date value="2016-03-22T09:10:14Z"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="11506-3"/>
      <display value="Provider-unspecified Progress note"/>
    </coding>
  </type>
  <title value="Progress Note"/>
  <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 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>
<!--   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>
<!--   Interventions Section Narrative  -->
  <section>
    <title value="Interventions Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="62387-6"/>
        <display value="Interventions provided"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
<!--   Nutrition Section Narrative  -->
  <section>
    <title value=" Nutrition Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="61144-2"/>
        <display value="Diet and nutrition"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </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>
<!--   Objective Section Narrative  -->
  <section>
    <title value="Objective Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="61149-1"/>
        <display value="Objective"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
<!--   Subjective Section Narrative  -->
  <section>
    <title value="Subjective Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="61150-9"/>
        <display value="Subjective"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </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>
<!--   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>
<!--   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>
<!--   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>
  <!--  Results Section Observation Resource  -->
    <entry>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Observation/dce96908-11fc-49e0-9d55-7442b0eff9"/>
    </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>