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Packagefhir.paciosampledata
Resource TypeComposition
IdComposition-BSJ1-composition-CCDA-dischargeSummary-01.json
FHIR VersionR4

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Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: Composition BSJ1-composition-CCDA-dischargeSummary-01

identifier: Uniform Resource Identifier (URI)/urn:uuid:03d0f89e-b0ac-482b-a400-c436df8055e3

status: Preliminary

type: Discharge Summary

date: 2025-05-04 15:15:00+0000

author: Priya Sarkar, MD

title: Betsy Smith-Johnson Discharge Summary

custodian: Metro Hospital Emergency Department


Source1

{
  "resourceType": "Composition",
  "id": "BSJ1-composition-CCDA-dischargeSummary-01",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary|2.0.0-ballot"
    ]
  },
  "language": "en-US",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": {
    "system": "urn:ietf:rfc:3986",
    "value": "urn:uuid:03d0f89e-b0ac-482b-a400-c436df8055e3"
  },
  "status": "preliminary",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "18842-5",
        "display": "Discharge Summary"
      }
    ]
  },
  "subject": {
    "reference": "Patient/patient-betsysmith-johnson01",
    "display": "Betsy Smith-Johnson"
  },
  "date": "2025-05-04T15:15:00.000+00:00",
  "author": [
    {
      "reference": "PractitionerRole/PractitionerRole-Physician-PriyaSarkar",
      "display": "Priya Sarkar, MD"
    }
  ],
  "title": "Betsy Smith-Johnson Discharge Summary",
  "custodian": {
    "reference": "Organization/org-ED-Metro-Hospital",
    "display": "Metro Hospital Emergency Department"
  },
  "section": [
    {
      "title": "Allergies and Intolerances Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "48765-2",
            "display": "Allergies and adverse reactions Document"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Allergies for Betsy Smith Johnson</div>"
      },
      "entry": [
        {
          "reference": "AllergyIntolerance/betsysmith-johnson01-AllergyACE"
        }
      ]
    },
    {
      "title": "Chief Complaint and Reason for Visit Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "46239-0",
            "display": "Chief complaint+Reason for visit Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Chief complaint and reason for visit for Betsy Smith Johnson</div>"
      },
      "entry": [
        {
          "reference": "DocumentReference/BSJ1-documentReference-ED-AdminAssessment-01"
        }
      ]
    },
    {
      "title": "Chief Complaint Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10154-3",
            "display": "Chief complaint Narrative - Reported"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Chief complaint for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Reason for Visit Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "29299-5",
            "display": "Reason for visit"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Reason for visit for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Admission Diagnosis Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "46241-6",
            "display": "Hospital admission diagnosis Narrative - Reported"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Admission diagnosis for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Admission Medications Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "42346-7",
            "display": "Medications on admission (narrative)"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Medications on admission for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Past Medical History Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "11348-0",
            "display": "History of Past illness Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Past Medical History for Betsy Smith Johnson</div>"
      },
      "entry": [
        {
          "reference": "Condition/betsysmith-johnson01-Condition-BreastCancer-01",
          "display": "Breast Cancer"
        }
      ]
    },
    {
      "title": "History of Present Illness Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10164-2",
            "display": "History of Present illness Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">History of present illness for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Review of Systems Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10187-3",
            "display": "Review of systems"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Review of systems for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Family History Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10157-6",
            "display": "History of family member diseases Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Family history for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Social History Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "29762-2",
            "display": "Social history Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Social history for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Functional Status Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "47420-5",
            "display": "Functional status assessment note"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Functional status assessment for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Hospital Course Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "8648-8",
            "display": "Hospital course"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital course for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Hospital Consultations Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "18841-7",
            "display": "Hospital consultations Document"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital consultations for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Plan of Treatment Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "18776-5",
            "display": "Plan of care note"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Plan of treatment for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Problem Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "11450-4",
            "display": "Problem list - Reported"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Problem list for Betsy Smith Johnson</div>"
      },
      "entry": [
        {
          "reference": "Condition/betsysmith-johnson01-Condition-Hemiparesis-01",
          "display": "Hemiparesis"
        },
        {
          "reference": "Condition/betsysmith-johnson01-Condition-Diabetes-01",
          "display": "Diabetes"
        },
        {
          "reference": "Condition/betsysmith-johnson01-Condition-Hypertension-01",
          "display": "Hypertension"
        },
        {
          "reference": "Condition/betsysmith-johnson01-Condition-Hyperlipidemia-01",
          "display": "Hyperlipidemia"
        },
        {
          "reference": "Condition/betsysmith-johnson01-Condition-Depression-01",
          "display": "Depression"
        },
        {
          "reference": "Condition/betsysmith-johnson01-Condition-KidneyDisease-01",
          "display": "Kidney Disease"
        },
        {
          "reference": "Condition/betsysmith-johnson01-Condition-Osteoarthritis-01",
          "display": "Osteoarthritis"
        },
        {
          "reference": "Condition/betsysmith-johnson01-Condition-Osteopenia-01",
          "display": "Osteopenia"
        },
        {
          "reference": "Condition/betsysmith-johnson01-condition-IschemicStrokeDiagnosis-01",
          "display": "Ischemic Stroke"
        }
      ]
    },
    {
      "title": "Procedures Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "47519-4",
            "display": "History of Procedures Document"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Procedures for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Discharge Diagnosis Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "11535-2",
            "display": "Hospital discharge Dx Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Discharge diagnosis for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Discharge Medications Section (entries required)",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10183-2",
            "display": "Hospital discharge medications"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Discharge medications for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Hospital Discharge Instructions Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "8653-8",
            "display": "Hospital discharge instructions"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital discharge instructions for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Hospital Discharge Physical Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10184-0",
            "display": "Hospital discharge physical findings Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital discharge physical findings for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Hospital Discharge Studies Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "11493-4",
            "display": "Hospital discharge studies summary"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital discharge studies for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Immunizations Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "11369-6",
            "display": "History of Immunization Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Immunizations for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Nutrition Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "61144-2",
            "display": "Diet and nutrition Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Nutrition for Betsy Smith Johnson</div>"
      }
    },
    {
      "title": "Vital Signs Section",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "8716-3",
            "display": "Vital signs"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Vital signs for Betsy Smith Johnson</div>"
      },
      "entry": [
        {
          "reference": "Observation/betsysmith-johnson01-observation-bodyweight-01"
        },
        {
          "reference": "Observation/betsysmith-johnson01-observation-bodyheight-01"
        },
        {
          "reference": "Observation/betsysmith-johnson01-observation-bmi-01"
        },
        {
          "reference": "Observation/betsysmith-johnson01-observation-bp-01"
        },
        {
          "reference": "Observation/betsysmith-johnson01-observation-heartrate-01"
        },
        {
          "reference": "Observation/betsysmith-johnson01-observation-respirationrate-01"
        },
        {
          "reference": "Observation/betsysmith-johnson01-observation-bodytemp-01"
        },
        {
          "reference": "Observation/betsysmith-johnson01-observation-oxygensat-01"
        }
      ]
    }
  ]
}