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 
{
"resourceType" : "Composition",
"id" : "Med-2-Dental-Referral",
"meta" : {
"versionId" : "19",
"lastUpdated" : "2020-08-06T17:04:22.397+00:00",
"source" : "#pDdMEGNjxgvU2m7d",
"profile" : [
"http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note",
"http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referralnote"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<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>: Med-2-Dental-Referral</p><p><b>meta</b>: </p><p><b>language</b>: en-US</p><p><b>identifier</b>: id: http://any.org/1</p><p><b>status</b>: final</p><p><b>type</b>: <span title=\"Codes: {http://loinc.org 57133-1}\">Referral Note</span></p><p><b>encounter</b>: <a href=\"Encounter-Med-visit-1.html\">PCP visit. Generated Summary: id: Med-visit-1; status: finished; <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode AMB}\">ambulatory</span>; <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99201}\">Office Visit</span>; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ActPriority R}\">routine</span>; period: Feb 14, 2020 8:00:14 PM --> Feb 14, 2020 8:30:14 PM</a></p><p><b>date</b>: Jan 14, 2020 3:10:14 AM</p><p><b>author</b>: <a href=\"PractitionerRole-PractitionerRole-M.html\">Dr. John M, MD. Generated Summary: id: PractitionerRole-M; <span title=\"Codes: {http://snomed.info/sct 394814009}\">General practice (specialty)</span>; ph: 5555557777</a></p><p><b>title</b>: Referral 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 14, 2020 9:10:14 AM</td><td><a href=\"PractitionerRole-PractitionerRole-M.html\">Dr. John M, MD. Generated Summary: id: PractitionerRole-M; <span title=\"Codes: {http://snomed.info/sct 394814009}\">General practice (specialty)</span>; ph: 5555557777</a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-GHC-organization.html\">Good Health Clinic. Generated Summary: id: GHC-organization; id: 1316452725; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span>; name: Good Health Clinic; ph: (+1) 555-677-7777, customer-service@GHclinic.org</a></p></div>"
},
"identifier" : {
"system" : "urn:ietf:rfc:3986",
"value" : "http://any.org/1"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "57133-1",
"display" : "Referral Note"
}
]
},
"subject" : {
"reference" : "Patient/example-dental",
"display" : "Patient A"
},
"encounter" : {
"reference" : "Encounter/Med-visit-1",
"display" : "PCP visit"
},
"date" : "2020-01-14T03:10:14Z",
"author" : [
{
"reference" : "PractitionerRole/PractitionerRole-M",
"display" : "Dr. John M, MD"
}
],
"title" : "Referral Note",
"attester" : [
{
"mode" : "legal",
"time" : "2020-03-14T09:10:14Z",
"party" : {
"reference" : "PractitionerRole/PractitionerRole-M",
"display" : "Dr. John M, MD"
}
}
],
"custodian" : {
"reference" : "Organization/GHC-organization",
"display" : "Good Health Clinic"
},
"section" : [
{
"title" : "Allergies and Intolerances Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48765-2",
"display" : "Allergies and adverse reactions Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tr><td><b>Allergen</b></td><td><b>Code</b></td><td><b>Manifestation</b></td><td><b>Severity</b></td></tr><tr><td>Penicillin G</td><td>7908</td><td>Skin rash</td><td>mild</td></tr></table></div>"
},
"entry" : [
{
"reference" : "AllergyIntolerance/Allergy-example-dental"
}
]
},
{
"title" : "Medication Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10160-0",
"display" : "History of Medication use Narrative"
}
]
},
"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>Lisinopril 10 mg tab</td><td>1 tab once/day</td><td/><td>Active</td><td/><td>Generic substitution allowed</td></tr></table></div>"
},
"entry" : [
{
"reference" : "MedicationRequest/Lisinopril-medreq"
}
]
},
{
"title" : "Problem Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11450-4",
"display" : "Problem list - Reported"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p> Mild, Hypertension</p><p> Type 1 diabetes</p><p> Teeth covered in plague</p><p> Toothache</p><p> Swollen Gums</p><p> Bleeding Gums</p><p> Chronic periodontitis</p><p> At high risk for dental carries</p></div>"
},
"entry" : [
{
"reference" : "Condition/HTN-example"
},
{
"reference" : "Condition/DM1-example"
},
{
"reference" : "Condition/Dental-plaque-example"
},
{
"reference" : "Condition/toothache-example"
},
{
"reference" : "Condition/Swollen-gums-example"
},
{
"reference" : "Condition/Bleeding-gums-example"
},
{
"reference" : "Condition/Chronic-periodontitis-example"
},
{
"reference" : "Condition/Caries-risk"
}
]
},
{
"title" : "Reason for Referral Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "42349-1",
"display" : "Reason for referral (narrative)"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Toothache</p><p>Left lower quadrant pain</p><p>Bleeding gums</p></div>"
},
"entry" : [
{
"reference" : "ServiceRequest/example-dental-referral-1"
}
]
},
{
"title" : "Plan of Treatment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Plan of care note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>D0150 - Comprehensive Oral Evaluation</p></div>"
},
"entry" : [
{
"reference" : "Encounter/Comp-oral-eval"
}
]
},
{
"title" : "Results Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "30954-2",
"display" : "Relevant diagnostic tests/laboratory data Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Results text</p></div>"
}
},
{
"title" : "Assessment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "51848-0",
"display" : "Evaluation note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Assessment Section text</p></div>"
}
},
{
"title" : "History of Present Illness Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10164-2",
"display" : "History of Present illness Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>The patient has not visited a dentist or received flouride treatments in the past 4 years while away at college</p></div>"
}
},
{
"title" : "Immunizations Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11369-6",
"display" : "History of Immunization Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<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>\n Hepatitis B vaccine\n </td><td>January 4, 2020</td><td>Completed</td></tr></tbody></table></div>"
},
"entry" : [
{
"reference" : "Immunization/imm-1"
}
]
},
{
"title" : "Medical Equipment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "46264-8",
"display" : "History of medical device use"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table border=\"1\" width=\"100%\"><thead><tr><th>Device Type</th> <!-- This is the generic name of the device. --><th>Procedure</th><th>Implant Date</th> <!-- separated out implant date --></tr></thead><tbody><tr><td>Insulin Pump</td><td>Insertion of insulin pump (procedure)</td><td>November 3, 2013</td></tr></tbody></table></div>"
},
"entry" : [
{
"reference" : "Procedure/Insulin-pump-insertion"
}
]
},
{
"title" : "Procedures Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "47519-4",
"display" : "History of Procedures Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No Procedures performed</p></div>"
}
},
{
"title" : "Social History Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29762-2",
"display" : "Social history Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<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</td><td>NA</td><td>2005/05/01 - 2020/03/28</td></tr><tr><td>Highest Education Received</td><td>Collect Education</td><td>2010/05/01 - 2014/03/28</td></tr><tr><td>Employment</td><td>Full-time accountant</td><td>2015/05/01 - current</td></tr></table></div>"
},
"entry" : [
{
"reference" : "Observation/Smoker-obs-example-dental"
},
{
"reference" : "Observation/Education-level-example-dental"
},
{
"reference" : "Observation/Present-job-example-dental"
}
]
},
{
"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>2020/04/15</td><td>98.5</td></tr><tr><td>Pulse</td><td>2020/04/15</td><td>78</td></tr><tr><td>Respiration</td><td>2020/04/15</td><td>20</td></tr></table></div>"
},
"entry" : [
{
"reference" : "Observation/body-temperature"
},
{
"reference" : "Observation/heart-rate"
},
{
"reference" : "Observation/respiratory-rate"
}
]
},
{
"title" : "Goals Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "61146-7",
"display" : "Goals"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No soda/sugary drinks/energy drinks</p><p>Use fluoride toothpaste</p></div>"
}
},
{
"title" : "Health Concerns Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "75310-3",
"display" : "Health concerns Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Neuropathy due to diabetes mellitus</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>Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride\n toothpaste, floss</p></div>"
},
"entry" : [
{
"reference" : "Communication/dental-education"
}
]
},
{
"title" : "Payers Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48768-6",
"display" : "Payment sources Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Aetna Comprehensive Medical /Dental Insurance</p></div>"
},
"entry" : [
{
"reference" : "Coverage/Dental-Aetna"
}
]
},
{
"title" : "Dental Findings Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8704-9",
"display" : "Physical findings of Mouth and Throat and Teeth"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No Information</p></div>"
}
}
]
}
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
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