Dental Data Exchange
0.1.0 - STU1 Ballot
Dental Data Exchange
0.1.0 - STU1 Ballot
This page is part of the Dental Data Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
<Composition xmlns="http://hl7.org/fhir"> <id value="Dental-2-Med-Consult"/> <meta> <versionId value="18"/> <lastUpdated value="2020-08-06T17:04:22.341+00:00"/> <source value="#SVm0tHbmHoKOA68J"/> <profile value="http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note"/> <profile value="http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult"/> </meta> <language value="en-US"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative</b></p><p><b>id</b>: Dental-2-Med-Consult</p><p><b>meta</b>: </p><p><b>language</b>: en-US</p><p><b>identifier</b>: id: urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b</p><p><b>status</b>: final</p><p><b>type</b>: <span title="Codes: {http://loinc.org 11488-4}">Consult Note</span></p><p><b>encounter</b>: <a href="Encounter-Dental-encounter.html">Dental Referral with patient A. Generated Summary: id: Dental-encounter; status: finished; <span title="{http://terminology.hl7.org/CodeSystem/v3-ActCode AMB}">ambulatory</span>; <span title="Codes: {http://snomed.info/sct 185347001}">Encounter for problem (procedure)</span>; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ActPriority R}">routine</span>; period: Feb 16, 2020 8:00:14 PM --> Feb 16, 2020 8:30:14 PM</a></p><p><b>date</b>: Feb 16, 2020 9:10:14 AM</p><p><b>author</b>: <a href="Practitioner-practitioner-D.html">Dentist D, DMD. Generated Summary: id: practitioner-D; id: 1234560000; John D ; ph: 720-555-6443(WORK); gender: male; birthDate: 1990-06-09</a></p><p><b>title</b>: Consultation Note</p><h3>Attesters</h3><table class="grid"><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>legal</td><td>Mar 28, 2020 9:10:14 AM</td><td><a href="Practitioner-practitioner-D.html">Dentist Dentist D, DMD. Generated Summary: id: practitioner-D; id: 1234560000; John D ; ph: 720-555-6443(WORK); gender: male; birthDate: 1990-06-09</a></td></tr></table><p><b>custodian</b>: <a href="Organization-GOHC-organization.html">Good Oral Health Clinic. Generated Summary: id: GOHC-organization; id: 2316452725; active; <span title="Codes: {http://terminology.hl7.org/CodeSystem/organization-type prov}">Healthcare Provider</span>; name: Good Oral Health Clinic; ph: (+1) 720-677-7777, customer2-service@GHclinic.org</a></p><h3>Events</h3><table class="grid"><tr><td>-</td><td><b>Code</b></td><td><b>Period</b></td></tr><tr><td>*</td><td><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ActClass PCPR}">Care Provision</span></td><td>2020-02-16 --> 2020-02-16</td></tr></table></div> </text> <extension url="http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension"> <valueReference> <reference value="ServiceRequest/example-dental-referral-1"/> <display value="Dental Referral"/> </valueReference> </extension> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b"/> </identifier> <status value="final"/> <type> <coding> <system value="http://loinc.org"/> <code value="11488-4"/> <display value="Consult Note"/> </coding> </type> <subject> <reference value="Patient/example-dental"/> <display value="Patient A"/> </subject> <encounter> <reference value="Encounter/Dental-encounter"/> <display value="Dental Referral with patient A"/> </encounter> <date value="2020-02-16T09:10:14Z"/> <author> <reference value="Practitioner/practitioner-D"/> <display value="Dentist D, DMD"/> </author> <title value="Consultation Note"/> <attester> <mode value="legal"/> <time value="2020-03-28T09:10:14Z"/> <party> <reference value="Practitioner/practitioner-D"/> <display value="Dentist Dentist D, DMD"/> </party> </attester> <custodian> <reference value="Organization/GOHC-organization"/> <display value="Good Oral Health Clinic"/> </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="2020-02-16"/> <end value="2020-02-16"/> </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>Penicillin G (Ingredient)</td><td>Mild</td><td>Skin rash</td><td>Mild</td><td>Active</td></tr></table></div> </text> <entry> <reference value="AllergyIntolerance/Allergy-example-dental"/> </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>The patient has not visited a dentist or received fluoride treatments in the past four years while away at college</p></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"><p>Mild, Hypertension</p><p>Type 1 diabetes</p><p>Dental caries</p><p>Unable to chew</p><p>Teeth covered in plague</p><p>Toothache</p><p>Chronic periodontitis</p><p>Infection of tooth</p><p>At high risk for dental caries (finding)</p></div> </text> <entry> <reference value="Condition/HTN-example"/> </entry> <entry> <reference value="Condition/DM1-example"/> </entry> <entry> <reference value="Condition/Dental-caries"/> </entry> <entry> <reference value="Condition/no-chew"/> </entry> <entry> <reference value="Condition/Dental-plaque-example"/> </entry> <entry> <reference value="Condition/toothache-example"/> </entry> <entry> <reference value="Condition/Chronic-periodontitis-example"/> </entry> <entry> <reference value="Condition/Tooth-infection"/> </entry> <entry> <reference value="Condition/Caries-risk"/> </entry> </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>erythromycin 500 mg</td><td>Take 1 tablet every six hours X10 days</td><td/><td>Active</td><td/><td/></tr><tr><td>ibuprofen (OTC) 200 mg tab</td><td>Take 2-3 tablets every 8 hours as needed for pain</td><td>Take 2-3 tablets every 8 hours as needed for pain</td><td/><td>Active</td><td/><td/></tr><tr><td>acetaminophen (OTC) 325 mg</td><td>Take 2 tablets every 4-6 hours as needed for pain</td><td/><td>Active</td><td/><td/></tr><tr><td>Lisinopril 10 mg tab</td><td>1 tab once a day</td><td/><td>Active</td><td/><td/></tr></table></div> </text> <entry> <reference value="MedicationRequest/erythromycin-medreq-2"/> </entry> <entry> <reference value="MedicationRequest/Ibuprofen-medreq-2"/> </entry> <entry> <reference value="MedicationRequest/Tylenol-med-dental"/> </entry> <entry> <reference value="MedicationRequest/Lisinopril-medreq"/> </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> Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment </p><p> Significant decay on the left lower second molar (tooth #18) with signs of infection </p><p> Early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7) </p><p> Recommend an extraction of the left lower second molar(tooth #18) and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion </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 border="1" width="100%"><thead><tr><th>Vaccine</th><th>Date</th><th>Status</th></tr></thead><tbody><tr><td> Hepatitis B vaccine </td><td>January 4, 2020</td><td>Completed</td></tr></tbody></table></div> </text> <entry> <reference value="Immunization/imm-1"/> </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 border="1" width="100%"><thead><tr><th>Device Type</th><th>Procedure</th><th>Implant Date</th></tr></thead><tbody><tr><td>Insulin Pump</td><td>Insertion of insulin pump (procedure)</td><td>November 3, 2013</td></tr></tbody></table></div> </text> <entry> <reference value="Procedure/Insulin-pump-insertion"/> </entry> </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 border="1" width="100%"><thead><tr><th>Date</th><th>Code</th><th>Description</th><th>Mouth Location</th></tr></thead><tbody><tr><td>Feb 23, 2020</td><td>D7140</td><td>Extraction, erupted tooth or exposed root (elevation and/or forceps removal)</td><td>Tooth #18</td></tr><tr><td>Mar 3, 2020</td><td>D1352</td><td>Preventive resin restoration in a moderate to high caries risk patient-permanent tooth</td><td>Tooth #7</td></tr><tr><td>Mar 10, 2020</td><td>D0150</td><td>comprehensive oral evaluation - new or established patient</td><td>N/A</td></tr><tr><td>Mar 10, 2020</td><td>D1110</td><td>Prophylaxis - Adult</td><td>N/A</td></tr><tr><td>Mar 10, 2020</td><td>D0210</td><td>Full mouth radiographic survey</td><td>N/A</td></tr></tbody></table></div> </text> <entry> <reference value="ServiceRequest/Dental-extraction-example"/> </entry> <entry> <reference value="ServiceRequest/Resin-restore-example"/> </entry> <entry> <reference value="Encounter/Comp-oral-eval"/> </entry> <entry> <reference value="Encounter/Dentist-followup-prophylaxis"/> </entry> <entry> <reference value="ServiceRequest/Radiograph-survey"/> </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 border="1" width="100%"><thead><tr><th>Date</th><th>Code</th><th>Description</th><th>Mouth Location</th></tr></thead><tbody><tr><td>Feb 16, 2020</td><td>D1206</td><td>topical application of fluoride varnish</td><td>N/A</td></tr></tbody></table></div> </text> <entry> <reference value="Procedure/Dental-flouride-tx-example"/> </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>Patient referred for evaluation and treatment for toothache lower left</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 Status - Meaningful Use</td><td>Never smoked tobacco</td><td>Feb 14, 2020</td></tr><tr><td>Highest Education Level</td><td>College Education</td><td>2005/05/01 - 2010/02/28</td></tr><tr><td>Employment</td><td>Accountaint, Full Time</td><td>2005/05/01 - 2010/02/28</td></tr></table></div> </text> <entry> <reference value="Observation/Smoker-obs-example-dental"/> </entry> <entry> <reference value="Observation/Education-level-example-dental"/> </entry> <entry> <reference value="Observation/Present-job-example-dental"/> </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 border="1" width="100%"><thead><tr><th>Observation Type</th><th>Value</th><th>Units</th></tr></thead><tbody><tr><td>Body Temperature</td><td>99</td><td>[degF]</td></tr><tr><td>Heart Rate</td><td>82</td><td>/min</td></tr><tr><td>Blood Pressure - Diastolic</td><td>80</td><td>mmHg</td></tr><tr><td>Blood Pressure - Systolic</td><td>120</td><td>mmHg</td></tr></tbody></table></div> </text> <entry> <reference value="Observation/body-temperature"/> </entry> <entry> <reference value="Observation/heart-rate"/> </entry> <entry> <reference value="Observation/blood-pressure"/> </entry> </section> <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 educated on the benefits of using a fluoride toothpaste, daily flossing, and bi-annual routine dental cleaning visits.</p></div> </text> <entry> <reference value="Communication/dental-education2"/> </entry> </section> <section> <title value="Payers Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="48768-6"/> <display value="Payment sources Document"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p>Aetna Comprehensive Medical /Dental Insurance</p></div> </text> <entry> <reference value="Coverage/Dental-Aetna"/> </entry> </section> <section> <title value="Dental Findings Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="8704-9"/> <display value="Physical findings of Mouth and Throat and Teeth"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><table border="1" width="100%"><thead><tr><th>Finding Type</th><th>Value</th><th>Location</th></tr></thead><tbody><tr><td>Problem</td><td>Dental Caries</td><td>Tooth #18</td></tr><tr><td>Problem</td><td>Infection of Tooth</td><td>Tooth #18</td></tr><tr><td>Problem</td><td>Dental Caries</td><td>Tooth #7</td></tr><tr><td>Result</td><td>Overjet</td><td>3mm</td></tr></tbody></table></div> </text> <entry> <reference value="Condition/Mandibular-perm18-example"/> </entry> <entry> <reference value="Condition/Tooth-infection18"/> </entry> <entry> <reference value="Condition/Maxillary-perm7-example"/> </entry> <entry> <reference value="Observation/Overjet"/> </entry> </section> </Composition>
IG © 2020+ Payer/Provider Information Exchange Work Group. Package hl7.fhir.us.dental-data-exchange#0.1.0 based on FHIR 4.0.1. Generated 2020-08-10
Links: Table of Contents |
QA Report | Search
| Version History |
|
Propose a change