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Packagehl7.fhir.us.ccda
Resource TypeComposition
IdComposition-Diagnostic-Imaging-Report-Example.json
FHIR VersionR4

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Narrative

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

Document Id 12345
Document Created: June 15, 2016, 16:14, PST
Evaluation Diagnostic Imaging Study for Amy Shaw
Performer Ronald Boone, MD
Author Ronald Boone, MD
Contact info 1003 Healthcare Drive
Amherst MA 01002, US
Tel: +1(555)555-1003
Encounter Id 9937012 2.16.840.1.113883.19
Event Type Diagnotic Imaging Study
Event Date  From June 15, 2016, 16:20 to June 15, 2016, 18:20
Encounter Location Diagnostic Imaging Department at Acme Laboratories
Responsible party Ronald Boone, MD
Contact info 1003 Healthcare Drive
Amherst MA 01002, US
Tel: +1(555)555-1003
Assigned entity Diagnostic Imaging Department at Acme Laboratories
Emergency contact Michael Shaw

Contact info 49 Meadow St
Amherst MA 01003, US
Tel: (555)555-1212
Care giver Mrs. Lillian White
Contact info 49 Meadow St
Amherst MA 01003, US
Tel: (555)555-1215
Entered by Sally Jones
Contact info 1003 Healthcare Drive
Amherst MA 01002, US
Tel: +1(555)555-1003
Signed Ronald Boone at June 15, 2016
Contact info 1003 Healthcare Drive
Amherst MA 01002, US
Tel: +1(555)555-1003
Informant Henry Vincent, CPh
Contact info 1007 Pharmacy Drive
Portland, OR 99123, US
Tel: +1(555)555-1215
Information recipient: Primary Physician, MD
Contact info 1005 St. Clair Avenue
Amherst MA 01002, US
Tel: +1(555)555-1666
Legal authenticator Ronald Boone, MD signed at June 15, 2016
Contact info 1003 Healthcare Drive
Amherst MA 01002, US
Tel: +1(555)555-1003
Document maintained by Acme Laboratories
Contact info 1003 Healthcare Drive
Amherst MA 01002, US
Tel: +1(555)555-1003

Source1

{
  "resourceType": "Composition",
  "id": "Diagnostic-Imaging-Report-Example",
  "meta": {
    "versionId": "4",
    "lastUpdated": "2020-08-12T21:30:12.638+00:00",
    "source": "#csn482LCsnDWyxbW",
    "profile": [
      "http://hl7.org/fhir/us/ccda/StructureDefinition/Diagnostic-Imaging-Report"
    ]
  },
  "language": "en-US",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": {
    "system": "urn:ietf:rfc:3986",
    "value": "urn:uuid:895f6f22-f7d6-4feb-90d4-dbfd49b5471e"
  },
  "status": "preliminary",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "18748-4",
        "display": "Diagnostic imaging study"
      }
    ]
  },
  "subject": {
    "reference": "Patient/example",
    "display": "Amy V. Shaw"
  },
  "date": "2016-05-16T09:10:14Z",
  "author": [
    {
      "reference": "PractitionerRole/ccda-practitionerrole-example",
      "display": "Ronald Bone, MD"
    }
  ],
  "title": "Diagnostic Imaging Report",
  "attester": [
    {
      "mode": "legal",
      "time": "2016-06-15T09:10:14Z",
      "party": {
        "reference": "PractitionerRole/ccda-practitionerrole-example",
        "display": "Ronald Boone, MD"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/acme-lab",
    "display": "Acme Labs"
  },
  "event": [
    {
      "code": [
        {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "399208008",
              "display": "Plain X-ray of chest"
            }
          ]
        }
      ],
      "period": {
        "start": "2016-06-15",
        "end": "2016-06-15"
      }
    }
  ],
  "section": [
    {
      "title": "Findings Section",
      "code": {
        "coding": [
          {
            "system": "http://dicom.nema.org/resources/ontology/DCM",
            "code": "121070",
            "display": "Findings"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>The cardiomediastinum is within normal limits. The trachea is\n                                midline. The previously described opacity at the medial right lung\n                                base has cleared. There are no new infiltrates. There is a new round\n                                density at the left hilus, superiorly (diameter about 45mm). A CT\n                                scan is recommended for further evaluation. The pleural spaces are\n                                clear. The visualized musculoskeletal structures and the upper\n                                abdomen are stable and unremarkable.</p>\n            </div>"
      }
    },
    {
      "title": "DICOM Object Catalog Section",
      "code": {
        "coding": [
          {
            "system": "http://dicom.nema.org/resources/ontology/DCM",
            "code": "121181",
            "display": "DICOM Object Catalog"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>Computed Radiography Image Storage</p>\n            </div>"
      }
    }
  ]
}