FHIR IG analytics| Package | fhir.virtually.healthcare |
| Resource Type | Composition |
| Id | Composition-ab2539ee-fd55-4abc-9898-d4c1520dd2ba.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: Composition ab2539ee-fd55-4abc-9898-d4c1520dd2ba
Profile: ConsulationNote
identifier: URI/81397bc1-609d-4534-bba2-4892d575553e (use: usual, )
status: Final
type: Clinical note
date: 2024-11-08 15:51:00+0000
author: Dr HealthOnline Test
title: Clinical note
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "ab2539ee-fd55-4abc-9898-d4c1520dd2ba",
"meta": {
"profile": [
"https://fhir.virtually.healthcare/StructureDefinition/ConsulationNote"
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"use": "usual",
"system": "urn:ietf:rfc:3986",
"value": "81397bc1-609d-4534-bba2-4892d575553e",
"assigner": {
"identifier": {
"system": "https://fhir.nhs.uk/Id/ods-organization-code",
"value": "F83004"
}
}
},
"status": "final",
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "823651000000106",
"display": "Clinical note"
}
]
},
"subject": {
"reference": "urn:uuid:335bf7ee-47c8-4fe7-bfce-831db4d3b769",
"type": "Patient"
},
"encounter": {
"reference": "urn:uuid:ab2539ee-fd55-4abc-9898-d4c1520dd2ba",
"identifier": {
"system": "https://emis.com/Id/Consultation/GUID",
"value": "ab2539ee-fd55-4abc-9898-d4c1520dd2ba",
"assigner": {
"identifier": {
"system": "https://fhir.nhs.uk/Id/ods-organization-code",
"value": "F83004"
}
}
}
},
"date": "2024-11-08T15:51:00+00:00",
"author": [
{
"reference": "urn:uuid:a716058c-f9d5-4537-b1e7-d021bd2185a3",
"type": "Practitioner",
"identifier": {
"system": "https://fhir.hl7.org.uk/Id/professional-code",
"value": "25825845"
},
"display": "Dr HealthOnline Test"
}
],
"title": "Clinical note",
"section": [
{
"title": "Result",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data Narrative"
}
],
"text": "Result"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Serum TSH (thyroid stimulating hormone) level, 12 mU/L <i>Added some lines of text</i></p></div>"
},
"entry": [
{
"reference": "urn:uuid:5fa04e13-3d6e-4ccd-99df-3d3ecdcb264b",
"type": "Observation",
"display": "Serum TSH (thyroid stimulating hormone) level, 12 mU/L"
}
]
},
{
"title": "Examination",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61149-1",
"display": "Objective Narrative"
}
],
"text": "Examination"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Body weight, 79 kg</p><p>Standing height, 179 cm</p><p>Body mass index, 24.66 kg/m2</p></div>"
},
"entry": [
{
"reference": "urn:uuid:d3adf58c-bd92-4d45-b598-d76e2210a4a5",
"type": "Observation",
"display": "Body weight, 79 kg"
},
{
"reference": "urn:uuid:f859d2b0-a68f-4ff5-aa5d-44ebeff18505",
"type": "Observation",
"display": "Standing height, 179 cm"
},
{
"reference": "urn:uuid:9f8e11e9-381e-434c-b9da-a309ee669f83",
"type": "Observation",
"display": "Body mass index, 24.66 kg/m2"
}
]
},
{
"title": "Procedure",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Procedure"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Physical therapy procedure</p><p> <i>getting hip pain</i></p></div>"
},
"entry": [
{
"reference": "urn:uuid:d7c55283-f991-4854-85f5-e6def3cc82be",
"type": "Observation",
"display": "Physical therapy procedure"
}
]
},
{
"title": "Referral",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Referral"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Refer for thyroid test</p></div>"
},
"entry": [
{
"reference": "urn:uuid:71f58a26-5daa-491d-b85f-cf60fbe90236",
"type": "ServiceRequest"
}
]
},
{
"title": "Document",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Document"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Referral Letter (08-Nov-2024) <i>for Refer for thyroid test</i></p><p>Discharge summary report <i>Discharge summary report from Gynaecologist at EMIS PCS Test Surgery 2 (08-Nov-2024)</i></p></div>"
},
"entry": [
{
"reference": "urn:uuid:900566b1-a93d-4cb1-998a-a5141e2127bf",
"type": "DocumentReference"
},
{
"reference": "urn:uuid:4a838ced-3568-4839-b247-316fabef3163",
"type": "DocumentReference"
}
]
},
{
"title": "Allergy",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Allergy"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Adverse reaction to drug <i>aspirin</i></p><p>Allergy to drug</p><p>Allergy to aspirin</p></div>"
},
"entry": [
{
"reference": "urn:uuid:b795e488-21eb-49cb-9360-d4cb7a02dc6e",
"type": "AllergyIntolerance",
"display": "Adverse reaction to drug"
},
{
"reference": "urn:uuid:6a18b33e-23f7-4fab-9899-232e494267c7",
"type": "AllergyIntolerance",
"display": "Allergy to drug"
},
{
"reference": "urn:uuid:6e1a1654-a02b-4638-bad1-c64b65fd09f3",
"type": "AllergyIntolerance",
"display": "Allergy to aspirin"
}
]
},
{
"title": "History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11329-0",
"display": "History general Narrative - Reported"
}
],
"text": "History"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Family history of alcohol misuse (Aunt)</p></div>"
},
"entry": [
{
"reference": "urn:uuid:552182f3-208a-479f-ad28-bca5a82e312e",
"type": "Observation",
"display": "Family history of alcohol misuse (Aunt)"
}
]
},
{
"title": "Test Request",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data Narrative"
}
],
"text": "Test Request"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Venous blood specimen</p></div>"
},
"entry": [
{
"reference": "urn:uuid:3fe68913-6016-46b1-a20a-fb97fd125ea1",
"type": "Observation",
"display": "Venous blood specimen"
}
]
},
{
"title": "Comment",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48767-8",
"display": "Annotation comment [Interpretation] Narrative"
}
],
"text": "Comment"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p> <i>this is a comment. steps. weight</i></p></div>"
}
},
{
"title": "Follow up",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Plan of care note"
}
],
"text": "Follow up"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Medication review 08/12/2024</p></div>"
},
"entry": [
{
"reference": "urn:uuid:70efbefb-9985-4579-90ed-fc1b36ef2905",
"type": "Task",
"display": "Medication review 08/12/2024"
}
]
},
{
"title": "Family History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Family History"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No family history diabetes <i>some test</i></p><p>Family history of breast cancer (Uncle)</p></div>"
},
"entry": [
{
"reference": "urn:uuid:603260f4-3d90-4418-925b-4766f96f8575",
"type": "Observation",
"display": "No family history diabetes"
},
{
"reference": "urn:uuid:0242b574-fa7b-4614-9e7d-2a5736b58eda",
"type": "Observation",
"display": "Family history of breast cancer (Uncle)"
}
]
},
{
"title": "Medication",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10160-0",
"display": "History of Medication use Narrative"
}
],
"text": "Medication"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Aspirin 75mg dispersible tablets</p></div>"
},
"entry": [
{
"reference": "urn:uuid:da40f003-7178-474b-b14a-ac143d2be49f",
"type": "MedicationRequest"
}
]
},
{
"title": "Problem",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10154-3",
"display": "Chief complaint Narrative - Reported"
}
],
"text": "Problem"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Current non-smoker</p><p>Essential hypertension</p></div>"
},
"entry": [
{
"reference": "urn:uuid:9c58bbb7-7211-48fc-8368-1b88d04fc6cf",
"type": "Observation",
"display": "Current non-smoker"
},
{
"reference": "urn:uuid:27201baa-56c6-40b2-b1b5-9dc709b50f89",
"type": "Observation",
"display": "Essential hypertension"
}
]
},
{
"title": "Assessment",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Assessment"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Hypertension monitoring</p><p>Hypertension six month review</p><p>Medication review done</p></div>"
},
"entry": [
{
"reference": "urn:uuid:0abe00a6-7142-4cac-8478-042516975bf3",
"type": "Observation",
"display": "Hypertension monitoring"
},
{
"reference": "urn:uuid:388867f2-2e40-4b13-91e5-7bbf6b309a5b",
"type": "Observation",
"display": "Hypertension six month review"
},
{
"reference": "urn:uuid:b26a203d-51d9-4dfe-a6f1-143dec6a7d28",
"type": "Observation",
"display": "Medication review done"
}
]
},
{
"title": "Additional",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Additional"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Hypertension resolved</p><p>Excepted from hypertension quality indicators - patient unsuitable</p><p>British or mixed British - ethnic category 2001 census</p><p>Dietary advice</p><p>Education about alcohol consumption</p><p>ECG requested</p></div>"
},
"entry": [
{
"reference": "urn:uuid:470190a2-309a-4f28-a107-418bfc22ba77",
"type": "Observation",
"display": "Hypertension resolved"
},
{
"reference": "urn:uuid:d47702bf-a108-41a2-8f1f-0e34f718a654",
"type": "Observation",
"display": "Excepted from hypertension quality indicators - patient unsuitable"
},
{
"reference": "urn:uuid:f47bd9a2-5de0-4598-be29-d45b242c18b7",
"type": "Observation",
"display": "British or mixed British - ethnic category 2001 census"
},
{
"reference": "urn:uuid:77828dc0-c740-4d22-8543-be5e44036c79",
"type": "Observation",
"display": "Dietary advice"
},
{
"reference": "urn:uuid:5ea579ff-88c8-4265-a539-c15d0e0ba185",
"type": "Observation",
"display": "Education about alcohol consumption"
},
{
"reference": "urn:uuid:22ba9307-b02e-4424-9856-3c424b2cdfe9",
"type": "Observation",
"display": "ECG requested"
}
]
},
{
"title": "Social",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29762-2",
"display": "Social history Narrative"
}
],
"text": "Social"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Alcohol consumption, 0 U/week</p></div>"
},
"entry": [
{
"reference": "urn:uuid:01247827-f6d8-4766-bf19-97d0cb029d1a",
"type": "Observation",
"display": "Alcohol consumption, 0 U/week"
}
]
},
{
"title": "Result",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data Narrative"
}
],
"text": "Result"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Serum cholesterol level, 123 mmol/L</p><p>Serum high density lipoprotein cholesterol level, 234 mmol/L</p><p>Serum creatinine level, 123 umol/L</p></div>"
},
"entry": [
{
"reference": "urn:uuid:9955d4bb-51fb-41c3-9e24-182eb108dfe7",
"type": "Observation",
"display": "Serum cholesterol level, 123 mmol/L"
},
{
"reference": "urn:uuid:02bb3059-6ff1-48af-a4ec-27afb78ef59d",
"type": "Observation",
"display": "Serum high density lipoprotein cholesterol level, 234 mmol/L"
},
{
"reference": "urn:uuid:44fa1523-ffef-4d71-ba05-4a38f629b02e",
"type": "Observation",
"display": "Serum creatinine level, 123 umol/L"
}
]
},
{
"title": "Follow up",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Plan of care note"
}
],
"text": "Follow up"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Hypertension monitoring 08/11/2024</p></div>"
},
"entry": [
{
"reference": "urn:uuid:b8657275-8d33-4b78-9f93-8977ffb319df",
"type": "Task",
"display": "Hypertension monitoring 08/11/2024"
}
]
},
{
"title": "Additional",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61150-9",
"display": "Subjective Narrative"
}
],
"text": "Additional"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Test request : Full Blood Count</p><p>Test request : Plasma Viscosity</p><p>Test request : Antenatal</p><p>Blood Pressure 117/75 mmHg</p></div>"
},
"entry": [
{
"reference": "urn:uuid:39e7a63a-4f09-4ad9-a2a0-66ad94a77851"
},
{
"reference": "urn:uuid:2715a9e3-7c06-4925-ae4a-0b11e5b8e987"
},
{
"reference": "urn:uuid:c59dee86-4d6e-40e0-ad1e-e7959075e753"
},
{
"reference": "urn:uuid:107b410c-384c-4c0f-b5f5-def84619d40f"
}
]
}
]
}