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="Procedure-Note-Example"/>
<meta>
<versionId value="4"/>
<lastUpdated value="2020-08-12T21:30:12.894+00:00"/>
<source value="#csn482LCsnDWyxbW"/>
<profile
value="http://hl7.org/fhir/us/ccda/StructureDefinition/Procedure-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">Procedure Note 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">Event Type</span>
</td>
<td class="td_header_role_value">Outpatient Procedure</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">Event 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">Perioperative Department 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>
<extension
url="http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension">
<valueReference>🔗
<reference value="ServiceRequest/colonoscopy"/>
<display value="Colonoscopy"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension">
<valueReference>🔗
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension">
<valueReference>🔗
<reference value="Practitioner/practitioner-1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension">
<valueReference>🔗
<reference value="Practitioner/practitioner-1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension">
<valueReference>🔗
<reference value="Practitioner/practitioner-1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension">
<valueReference>🔗
<reference value="Consent/consent-example-basic"/>
</valueReference>
</extension>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:ef152c04-068f-461e-82c0-654b7460259e"/>
</identifier>
<status value="preliminary"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="28570-0"/>
<display value="Procedure note"/>
</coding>
</type>
<subject>🔗
<reference value="Patient/example"/>
<display value="Amy V. Shaw"/>
</subject>
<date value="2016-02-28T09:10:14Z"/>
<author>🔗
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
<display value="Ronald Bone, MD"/>
</author>
<title value="Procedure 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/organization-1"/>
<display value="Community Health and Hospitals"/>
</custodian>
<event>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="73761001"/>
<display value="Colonoscopy"/>
</coding>
</code>
<period>
<start value="2016-06-15"/>
<end value="2016-06-15"/>
</period>
</event>
<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="Anesthesia Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59774-0"/>
<display value="Anesthesia"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Conscious sedation with propofol 200 mg IV</p>
</div>
</text>
<entry>🔗
<reference value="Procedure/procedure-rehab"/>
</entry>
<entry>🔗
<reference value="MedicationStatement/medication-statement"/>
</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="Procedure Description Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29554-3"/>
<display value="Procedure Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>The patient was brought to the operating room, placed in the supine
position, and general anesthesia was induced. A detailed technical
narrative of a laparoscopic appendectomy from initial incision to
placement of any dressings follows. </p>
</div>
</text>
</section>
<section>
<title value="Procedure Indications Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59768-2"/>
<display value="Procedure indications [Interpretation] Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>The procedure is performed for screening in a low risk
individual.</p>
</div>
</text>
</section>
<section>
<title value="Planned Procedure Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59772-4"/>
<display value="Planned procedure"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Colonoscopy</p>
</div>
</text>
</section>
<section>
<title value="Procedure Disposition Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59775-7"/>
<display value="Procedure disposition Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>The patient was taken to the Endoscopy Recovery Unit in stable
condition.</p>
</div>
</text>
</section>
<section>
<title value="Procedure Estimated Blood Loss Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59770-8"/>
<display value="Procedure estimated blood loss Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Minimal</p>
</div>
</text>
</section>
<section>
<title value="Procedure Findings Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59776-5"/>
<display value="Procedure findings Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>A 6 mm sessile polyp was found in the ascending colon and removed by
snare, no cautery. Bleeding was controlled. Moderate diverticulosis
and hemorrhoids were incidentally noted.</p>
</div>
</text>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="Procedure Implants Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59771-6"/>
<display value="Procedure implants Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>No implants were placed.</p>
</div>
</text>
</section>
<section>
<title value="Procedure Specimens Taken Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59773-2"/>
<display value="Procedure specimens taken Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Ascending colon polyp</p>
</div>
</text>
</section>
<section>
<title value="Postprocedure Diagnosis Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59769-0"/>
<display value="Postprocedure diagnosis Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Sigmoid diverticulosis, moderate</p>
<p>Internal hemorrhoids</p>
<p>Colon polyp, 6mm, ascending colon</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>
<!--
<entry>
<reference value="Observation/observation-smoker"/>
</entry>
-->
<section>
<title value="Complications Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="55109-3"/>
<display value="Complications Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Asthmatic symptoms while under general anesthesia.</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="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">
<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>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
</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="Medical (General) History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11329-0"/>
<display value="History general Narrative - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Stomach cramps</p>
</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="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="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>20160615</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="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>
<!--
<entry>
<reference value="Observation/observation-smoker"/>
</entry>
-->
<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>
</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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