FHIR IG analytics

Resources that use this resource

No resources found

Resources that this resource uses

No resources found

Narrative

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

Source1

{
  "resourceType": "Composition",
  "id": "composition-ed-note-example",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "18842-5",
        "display": "Discharge summary"
      }
    ],
    "text": "ED Clinical Note"
  },
  "subject": {
    "reference": "Patient/patient-acs-example"
  },
  "encounter": {
    "reference": "Encounter/encounter-ed-example"
  },
  "date": "2026-06-12T10:30:00+08:00",
  "author": [
    {
      "reference": "Practitioner/practitioner-ed-example"
    }
  ],
  "title": "Emergency Department Clinical Note — Acute Coronary Syndrome",
  "confidentiality": "N",
  "attester": [
    {
      "mode": "legal",
      "time": "2026-06-12T10:30:00+08:00",
      "party": {
        "reference": "Practitioner/practitioner-ed-example"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/organization-pgh-example"
  },
  "section": [
    {
      "title": "Chief Complaint",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10154-3",
            "display": "Chief complaint Reported"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>45-year-old male with 2-hour history of crushing substernal chest pain radiating to left arm, associated with dyspnea and diaphoresis.</p></div>"
      },
      "entry": [
        {
          "reference": "Condition/condition-acs-example"
        }
      ]
    },
    {
      "title": "History of Present Illness",
      "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>Patient Juan Dela Cruz, 45M, Filipino, presented to PGH ED at 08:30 with acute chest pain. Pain described as crushing, 8/10 severity, substernal with radiation to left arm. Associated with shortness of breath and sweating. No relief with rest. Known T2DM since 2020. Current smoker (1 pack/day x 20 years).</p></div>"
      }
    },
    {
      "title": "Vital Signs",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "8716-3",
            "display": "Vital signs note"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><ul><li>BP: 160/95 mmHg (elevated)</li><li>HR: 110 bpm (tachycardic)</li><li>RR: 24/min (tachypneic)</li><li>SpO2: 92% RA (hypoxemic)</li><li>Temp: 37.2°C</li><li>Pain: 8/10</li></ul></div>"
      },
      "entry": [
        {
          "reference": "Observation/observation-bp-acs"
        },
        {
          "reference": "Observation/observation-hr-acs"
        },
        {
          "reference": "Observation/observation-rr-acs"
        },
        {
          "reference": "Observation/observation-spo2-acs"
        },
        {
          "reference": "Observation/observation-temp-acs"
        },
        {
          "reference": "Observation/observation-pain-acs"
        }
      ]
    },
    {
      "title": "Assessment and Plan",
      "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><strong>Assessment:</strong> Acute Coronary Syndrome — Anterior STEMI (ST-elevation V1-V4 on ECG, elevated troponin 2.5 ng/mL).</p><p><strong>Plan:</strong> 1) Aspirin 325mg chewed, Clopidogrel 600mg loading, Metoprolol 25mg PO. 2) Cardiology consult for emergent PCI. 3) Admit to CCU post-PCI.</p></div>"
      },
      "entry": [
        {
          "reference": "Condition/condition-acs-example"
        }
      ]
    },
    {
      "title": "Active Conditions",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "11493-4",
            "display": "Hospital discharge studies summary Narrative"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><ul><li>Type 2 Diabetes Mellitus (diagnosed 2020, on Metformin)</li><li>Acute Coronary Syndrome — Anterior STEMI (diagnosed today)</li></ul></div>"
      },
      "entry": [
        {
          "reference": "Condition/condition-t2dm-example"
        },
        {
          "reference": "Condition/condition-acs-example"
        }
      ]
    }
  ]
}