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

: Medical to Dental Referral Note (example) - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Composition;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "Med-2-Dental-Referral"];
  fhir:Resource.meta [
     fhir:Meta.versionId [ fhir:value "19" ];
     fhir:Meta.lastUpdated [ fhir:value "2020-08-06T17:04:22.397+00:00"^^xsd:dateTime ];
     fhir:Meta.source [ fhir:value "#pDdMEGNjxgvU2m7d" ];
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note>     ], [
       fhir:value "http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referralnote";
       fhir:index 1;
       fhir:link <http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referralnote>     ]
  ];
  fhir:Resource.language [ fhir:value "en-US"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.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 --&gt; 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>"
  ];
  fhir:Composition.identifier [
     fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ];
     fhir:Identifier.value [ fhir:value "http://any.org/1" ]
  ];
  fhir:Composition.status [ fhir:value "final"];
  fhir:Composition.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       a loinc:57133-1;
       fhir:Coding.system [ fhir:value "http://loinc.org" ];
       fhir:Coding.code [ fhir:value "57133-1" ];
       fhir:Coding.display [ fhir:value "Referral Note" ]     ]
  ];
  fhir:Composition.subject [
     fhir:Reference.reference [ fhir:value "Patient/example-dental" ];
     fhir:Reference.display [ fhir:value "Patient A" ]
  ];
  fhir:Composition.encounter [
     fhir:Reference.reference [ fhir:value "Encounter/Med-visit-1" ];
     fhir:Reference.display [ fhir:value "PCP visit" ]
  ];
  fhir:Composition.date [ fhir:value "2020-01-14T03:10:14Z"^^xsd:dateTime];
  fhir:Composition.author [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "PractitionerRole/PractitionerRole-M" ];
     fhir:Reference.display [ fhir:value "Dr. John M, MD" ]
  ];
  fhir:Composition.title [ fhir:value "Referral Note"];
  fhir:Composition.attester [
     fhir:index 0;
     fhir:Composition.attester.mode [ fhir:value "legal" ];
     fhir:Composition.attester.time [ fhir:value "2020-03-14T09:10:14Z"^^xsd:dateTime ];
     fhir:Composition.attester.party [
       fhir:Reference.reference [ fhir:value "PractitionerRole/PractitionerRole-M" ];
       fhir:Reference.display [ fhir:value "Dr. John M, MD" ]     ]
  ];
  fhir:Composition.custodian [
     fhir:Reference.reference [ fhir:value "Organization/GHC-organization" ];
     fhir:Reference.display [ fhir:value "Good Health Clinic" ]
  ];
  fhir:Composition.section [
     fhir:index 0;
     fhir:Composition.section.title [ fhir:value "Allergies and Intolerances Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:48765-2;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "48765-2" ];
         fhir:Coding.display [ fhir:value "Allergies and adverse reactions Document" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "AllergyIntolerance/Allergy-example-dental" ]     ]
  ], [
     fhir:index 1;
     fhir:Composition.section.title [ fhir:value "Medication Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:10160-0;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "10160-0" ];
         fhir:Coding.display [ fhir:value "History of Medication use Narrative" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "MedicationRequest/Lisinopril-medreq" ]     ]
  ], [
     fhir:index 2;
     fhir:Composition.section.title [ fhir:value "Problem Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:11450-4;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "11450-4" ];
         fhir:Coding.display [ fhir:value "Problem list - Reported" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Condition/HTN-example" ]     ], [
       fhir:index 1;
       fhir:Reference.reference [ fhir:value "Condition/DM1-example" ]     ], [
       fhir:index 2;
       fhir:Reference.reference [ fhir:value "Condition/Dental-plaque-example" ]     ], [
       fhir:index 3;
       fhir:Reference.reference [ fhir:value "Condition/toothache-example" ]     ], [
       fhir:index 4;
       fhir:Reference.reference [ fhir:value "Condition/Swollen-gums-example" ]     ], [
       fhir:index 5;
       fhir:Reference.reference [ fhir:value "Condition/Bleeding-gums-example" ]     ], [
       fhir:index 6;
       fhir:Reference.reference [ fhir:value "Condition/Chronic-periodontitis-example" ]     ], [
       fhir:index 7;
       fhir:Reference.reference [ fhir:value "Condition/Caries-risk" ]     ]
  ], [
     fhir:index 3;
     fhir:Composition.section.title [ fhir:value "Reason for Referral Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:42349-1;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "42349-1" ];
         fhir:Coding.display [ fhir:value "Reason for referral (narrative)" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Toothache</p><p>Left lower quadrant pain</p><p>Bleeding gums</p></div>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "ServiceRequest/example-dental-referral-1" ]     ]
  ], [
     fhir:index 4;
     fhir:Composition.section.title [ fhir:value "Plan of Treatment Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:18776-5;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "18776-5" ];
         fhir:Coding.display [ fhir:value "Plan of care note" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>D0150 - Comprehensive Oral Evaluation</p></div>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Encounter/Comp-oral-eval" ]     ]
  ], [
     fhir:index 5;
     fhir:Composition.section.title [ fhir:value "Results Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:30954-2;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "30954-2" ];
         fhir:Coding.display [ fhir:value "Relevant diagnostic tests/laboratory data Narrative" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Results text</p></div>"     ]
  ], [
     fhir:index 6;
     fhir:Composition.section.title [ fhir:value "Assessment Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:51848-0;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "51848-0" ];
         fhir:Coding.display [ fhir:value "Evaluation note" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Assessment Section text</p></div>"     ]
  ], [
     fhir:index 7;
     fhir:Composition.section.title [ fhir:value "History of Present Illness Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:10164-2;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "10164-2" ];
         fhir:Coding.display [ fhir:value "History of Present illness Narrative" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ]
  ], [
     fhir:index 8;
     fhir:Composition.section.title [ fhir:value "Immunizations Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:11369-6;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "11369-6" ];
         fhir:Coding.display [ fhir:value "History of Immunization Narrative" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Immunization/imm-1" ]     ]
  ], [
     fhir:index 9;
     fhir:Composition.section.title [ fhir:value "Medical Equipment Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:46264-8;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "46264-8" ];
         fhir:Coding.display [ fhir:value "History of medical device use" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Procedure/Insulin-pump-insertion" ]     ]
  ], [
     fhir:index 10;
     fhir:Composition.section.title [ fhir:value "Procedures Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:47519-4;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "47519-4" ];
         fhir:Coding.display [ fhir:value "History of Procedures Document" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No Procedures performed</p></div>"     ]
  ], [
     fhir:index 11;
     fhir:Composition.section.title [ fhir:value "Social History Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:29762-2;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "29762-2" ];
         fhir:Coding.display [ fhir:value "Social history Narrative" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Observation/Smoker-obs-example-dental" ]     ], [
       fhir:index 1;
       fhir:Reference.reference [ fhir:value "Observation/Education-level-example-dental" ]     ], [
       fhir:index 2;
       fhir:Reference.reference [ fhir:value "Observation/Present-job-example-dental" ]     ]
  ], [
     fhir:index 12;
     fhir:Composition.section.title [ fhir:value "Vital Signs Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:8716-3;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "8716-3" ];
         fhir:Coding.display [ fhir:value "Vital signs" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Observation/body-temperature" ]     ], [
       fhir:index 1;
       fhir:Reference.reference [ fhir:value "Observation/heart-rate" ]     ], [
       fhir:index 2;
       fhir:Reference.reference [ fhir:value "Observation/respiratory-rate" ]     ]
  ], [
     fhir:index 13;
     fhir:Composition.section.title [ fhir:value "Goals Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:61146-7;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "61146-7" ];
         fhir:Coding.display [ fhir:value "Goals" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No soda/sugary drinks/energy drinks</p><p>Use fluoride toothpaste</p></div>"     ]
  ], [
     fhir:index 14;
     fhir:Composition.section.title [ fhir:value "Health Concerns Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:75310-3;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "75310-3" ];
         fhir:Coding.display [ fhir:value "Health concerns Document" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Neuropathy due to diabetes mellitus</p></div>"     ]
  ], [
     fhir:index 15;
     fhir:Composition.section.title [ fhir:value "Instructions Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:69730-0;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "69730-0" ];
         fhir:Coding.display [ fhir:value "Instructions" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.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>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Communication/dental-education" ]     ]
  ], [
     fhir:index 16;
     fhir:Composition.section.title [ fhir:value "Payers Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:48768-6;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "48768-6" ];
         fhir:Coding.display [ fhir:value "Payment sources Document" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Aetna Comprehensive Medical /Dental Insurance</p></div>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Coverage/Dental-Aetna" ]     ]
  ], [
     fhir:index 17;
     fhir:Composition.section.title [ fhir:value "Dental Findings Section" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:8704-9;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "8704-9" ];
         fhir:Coding.display [ fhir:value "Physical findings of Mouth and Throat and Teeth" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No Information</p></div>"     ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.