HL7.FHIR.US.DENTAL-DATA-EXCHANGE\Medical to Dental Referral Note (example) - XML Representation

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

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<Composition xmlns="http://hl7.org/fhir">
  <id value="Med-2-Dental-Referral"/>
  <meta>
    <versionId value="19"/>
    <lastUpdated value="2020-08-06T17:04:22.397+00:00"/>
    <source value="#pDdMEGNjxgvU2m7d"/>
    <profile
             value="http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note"/>
    <profile
             value="http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referralnote"/>
  </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>: 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>
  </text>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="http://any.org/1"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="57133-1"/>
      <display value="Referral Note"/>
    </coding>
  </type>
  <subject>
    <reference value="Patient/example-dental"/>
    <display value="Patient A"/>
  </subject>
  <encounter>
    <reference value="Encounter/Med-visit-1"/>
    <display value="PCP visit"/>
  </encounter>
  <date value="2020-01-14T03:10:14Z"/>
  <author>
    <reference value="PractitionerRole/PractitionerRole-M"/>
    <display value="Dr. John M, MD"/>
  </author>
  <title value="Referral Note"/>
  <attester>
    <mode value="legal"/>
    <time value="2020-03-14T09:10:14Z"/>
    <party>
      <reference value="PractitionerRole/PractitionerRole-M"/>
      <display value="Dr. John M, MD"/>
    </party>
  </attester>
  <custodian>
    <reference value="Organization/GHC-organization"/>
    <display value="Good Health Clinic"/>
  </custodian>
  <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>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>
    </text>
    <entry>
      <reference value="AllergyIntolerance/Allergy-example-dental"/>
    </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>Lisinopril 10 mg tab</td><td>1 tab once/day</td><td/><td>Active</td><td/><td>Generic substitution allowed</td></tr></table></div>
    </text>
    <entry>
      <reference value="MedicationRequest/Lisinopril-medreq"/>
    </entry>
  </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> 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>
    </text>
    <entry>
      <reference value="Condition/HTN-example"/>
    </entry>
    <entry>
      <reference value="Condition/DM1-example"/>
    </entry>
    <entry>
      <reference value="Condition/Dental-plaque-example"/>
    </entry>
    <entry>
      <reference value="Condition/toothache-example"/>
    </entry>
    <entry>
      <reference value="Condition/Swollen-gums-example"/>
    </entry>
    <entry>
      <reference value="Condition/Bleeding-gums-example"/>
    </entry>
    <entry>
      <reference value="Condition/Chronic-periodontitis-example"/>
    </entry>
    <entry>
      <reference value="Condition/Caries-risk"/>
    </entry>
  </section>
  <section>
    <title value="Reason for Referral Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="42349-1"/>
        <display value="Reason for referral (narrative)"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>Toothache</p><p>Left lower quadrant pain</p><p>Bleeding gums</p></div>
    </text>
    <entry>
      <reference value="ServiceRequest/example-dental-referral-1"/>
    </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"><p>D0150 - Comprehensive Oral Evaluation</p></div>
    </text>
    <entry>
      <reference value="Encounter/Comp-oral-eval"/>
    </entry>
  </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"><p>Results text</p></div>
    </text>
  </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>Assessment Section text</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>The patient has not visited a dentist or received flouride treatments in the past 4 years while away at college</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>    <!-- 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>
    </text>
    <entry>
      <reference value="Procedure/Insulin-pump-insertion"/>
    </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"><p>No Procedures performed</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</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>
    </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><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>
    </text>
    <entry>
      <reference value="Observation/body-temperature"/>
    </entry>
    <entry>
      <reference value="Observation/heart-rate"/>
    </entry>
    <entry>
      <reference value="Observation/respiratory-rate"/>
    </entry>
  </section>
  <section>
    <title value="Goals Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="61146-7"/>
        <display value="Goals"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>No soda/sugary drinks/energy drinks</p><p>Use fluoride toothpaste</p></div>
    </text>
  </section>
  <section>
    <title value="Health Concerns Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="75310-3"/>
        <display value="Health concerns Document"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>Neuropathy due to diabetes mellitus</p></div>
    </text>
  </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>Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride
          toothpaste, floss</p></div>
    </text>
    <entry>
      <reference value="Communication/dental-education"/>
    </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"><p>No Information</p></div>
    </text>
  </section>
</Composition>