C-CDA on FHIR
1.2.0 - STU 1
C-CDA on FHIR
1.2.0 - STU 1
This page is part of the C-CDA on FHIR Implementation Guide (v1.2.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
<Composition xmlns="http://hl7.org/fhir">
<id value="Consultation-Note-Example"/>
<meta>
<versionId value="4"/>
<lastUpdated value="2020-08-12T21:30:19.090+00:00"/>
<source value="#csn482LCsnDWyxbW"/>
<profile
value="http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US">
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Id</span>
</td>
<td class="td_header_role_value">12345</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Created:</span>
</td>
<td class="td_header_role_value">June 15, 2016, 16:14, PST </td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Care Provision</span>
</td>
<td class="td_header_role_value">Consultation for Amy Shaw</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Performer </span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Author</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Id</span>
</td>
<td class="td_header_role_value">9937012
2.16.840.1.113883.19</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Type</span>
</td>
<td class="td_header_role_value">Consultation</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Date</span>
</td>
<td class="td_header_role_value"> From June 15, 2016, 16:20 to
June 15, 2016, 18:20 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Location</span>
</td>
<td class="td_header_role_value">Ambulatory Care at Community
Health and Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Responsible party</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Assigned entity</span>
</td>
<td class="td_header_role_value">Community Health and Hospitals
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Emergency contact</span>
</td>
<td class="td_header_role_value">Michael Shaw
<br/>
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1212
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Care giver</span>
</td>
<td class="td_header_role_value">Mrs. Lillian White
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Entered by</span>
</td>
<td class="td_header_role_value">Sally Jones</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Signed </span>
</td>
<td class="td_header_role_value">Ronald Boone at June 15, 2016
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Informant</span>
</td>
<td class="td_header_role_value">Henry Vincent, CPh</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1007 Pharmacy Drive
<br/>Portland, OR 99123, US
<br/>Tel: +1(555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Information recipient:</span>
</td>
<td class="td_header_role_value">Primary Physician, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1005 St. Clair Avenue
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1666
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Legal authenticator</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD signed at June
15, 2016 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document maintained by</span>
</td>
<td class="td_header_role_value">Community Health and
Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
</div>
</text>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:e28fefc8-5aac-427c-93d7-f0bc7d633a9a"/>
</identifier>
<status value="preliminary"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="11488-4"/>
<display value="Consult Note"/>
</coding>
</type>
<subject>🔗
<reference value="Patient/example"/>
<display value="Amy V. Shaw"/>
</subject>
<encounter>🔗
<reference value="Encounter/encounter-1"/>
<display value="Encounter with patient Amy V. Shaw"/>
</encounter>
<date value="2016-02-28T09:10:14Z"/>
<author>🔗
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
<display value="Ronald Bone, MD"/>
</author>
<title value="Consultation Note"/>
<attester>
<mode value="legal"/>
<time value="2012-01-04T09:10:14Z"/>
<party>🔗
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
<display value="Ronald Boone, MD"/>
</party>
</attester>
<custodian>🔗
<reference value="Organization/acme-lab"/>
<display value="Acme Labs"/>
</custodian>
<event>
<code>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActClass"/>
<code value="PCPR"/>
<display value="Care Provision"/>
</coding>
</code>
<period>
<start value="2015-11-18"/>
<end value="2015-12-12"/>
</period>
</event>
<section>
<title value="Advance Directives Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42348-3"/>
<display value="Advance directives"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Name</b>
</td>
<td>
<b>Applies Period</b>
</td>
</tr>
<tr>
<td>Resuscitation</td>
<td>2015/01/01 - 2016/12/31</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Allergies and Intolerances Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
<display value="Allergies and adverse reactions Document"/>
</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>
<entry>🔗
<reference value="AllergyIntolerance/allergy-intolerance"/>
</entry>
</section>
<section>
<title value="Assessment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="51848-0"/>
<display value="Evaluation note"/>
</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>
<section>
<title value="Assessment and Plan Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="51847-2"/>
<display value="Evaluation + Plan note"/>
</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>
<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+Reason for visit Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Cramping, bloating, and constipation.</p>
</div>
</text>
</section>
<section>
<title value="Chief Complaint Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10154-3"/>
<display value="Chief complaint Narrative - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Dark Stools</p>
</div>
</text>
</section>
<section>
<title value="Family History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10157-6"/>
<display value="History of family member diseases Narrative"/>
</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>
<section>
<title value="Functional Status Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47420-5"/>
<display value="Functional status assessment note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Functional or Cognitive Finding</b>
</td>
<td>
<b>Observation</b>
</td>
<td>
<b>Observation Date</b>
</td>
<td>
<b>Condition Status</b>
</td>
</tr>
<tr>
<td>Ambulation (Dependent to Independent</td>
<td>Independently able</td>
<td>2010/03/11</td>
<td>Active</td>
</tr>
<tr>
<td>Finding of Functional Performance and Activity</td>
<td>Dyspnea</td>
<td>2008/02/16</td>
<td>Active</td>
</tr>
<tr>
<td>Cognitive Function Finding</td>
<td>Memory Impairment</td>
<td>2014/04/29</td>
<td>Active</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="General Status Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10210-3"/>
<display value="Physical findings of General status Narrative"/>
</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>
<section>
<title value="Past Medical History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11348-0"/>
<display value="History of Past illness Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>See History of Present Illness</p>
</div>
</text>
</section>
<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 Narrative"/>
</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>
<section>
<title value="Immunizations Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11369-6"/>
<display value="History of Immunization Narrative"/>
</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>
<entry>🔗
<reference value="Immunization/immunization"/>
</entry>
</section>
<section>
<title value="Medical Equipment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46264-8"/>
<display value="History of medical device use"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Supply/Device</b>
</td>
<td>
<b>Date Supplied</b>
</td>
</tr>
<tr>
<td>Automatic Implantable cardioverter/defbrillator</td>
<td>2008/11/16</td>
</tr>
<tr>
<td>Wheelchair</td>
<td>1999/12/01</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Medication Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10160-0"/>
<display value="History of Medication use Narrative"/>
</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>
<entry>🔗
<reference value="MedicationStatement/medication-statement"/>
</entry>
</section>
<section>
<title value="Mental Status Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10190-7"/>
<display value="Mental status"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table border="1" width="100%">
<thead>
<tr>
<td>
<b>Mental Status Findings</b>
</td>
<td>
<b>Effective Dates</b>
</td>
<td>
<b>Condition Status</b>
</td>
</tr>
</thead>
<tr>
<td>Mental Function</td>
<td>July 31, 2013</td>
<td>Impaired</td>
</tr>
<tr>
<td>Cognitive Abilities</td>
<td>July 31, 2013</td>
<td>Judgement, Intact</td>
</tr>
<tr>
<td>Cognitive Function</td>
<td>July 31, 2013</td>
<td>Aggressive Behavior</td>
</tr>
<tr>
<td>Cognitive Function</td>
<td>July 31, 2013</td>
<td>Difficulty understanding own emotions</td>
</tr>
<tr>
<td>Cognitive Function</td>
<td>July 31, 2013</td>
<td>Difficulty communicating Thoughts </td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Nutrition Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61144-2"/>
<display value="Diet and nutrition Narrative"/>
</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>
<section>
<title value="Physical Exam Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29545-1"/>
<display value="Physical findings Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="Plan of Treatment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
<display value="Plan of care note"/>
</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>
<section>
<title value="Problem Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11450-4"/>
<display value="Problem list - Reported"/>
</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>Liveborn born in hospital</td>
<td>Condition</td>
<td/>
<td/>
<td>Complete</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="Procedures Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47519-4"/>
<display value="History of Procedures Document"/>
</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>
<entry>🔗
<reference value="Procedure/procedure-rehab"/>
</entry>
</section>
<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>
<section>
<title value="Results Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="30954-2"/>
<display value="Relevant diagnostic tests/laboratory data Narrative"/>
</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>
<entry>🔗
<reference value="Observation/observation-lab-urine"/>
</entry>
</section>
<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>
<section>
<title value="Social History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29762-2"/>
<display value="Social history Narrative"/>
</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>
<entry>🔗
<reference value="Observation/observation-smoker"/>
</entry>
</section>
<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>
<entry>🔗
<reference value="Observation/observation-vitals-temp"/>
</entry>
</section>
</Composition>
IG © 2020+ HL7 International / Cross-Group Projects. Package hl7.fhir.us.ccda#1.2.0 based on FHIR 4.0.1. Generated 2024-03-12
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