FHIR IG analytics| Package | hl7.fhir.us.ccda |
| Resource Type | Composition |
| Id | Composition-Discharge-Summary-Example.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
| Document Id | 12345 |
| Document Created: | June 15, 2016, 16:14, PST |
| Discharge Summary | Discharge Summary 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 |
| Encounter Type | Discharge |
| Event Date | From June 15, 2016, 16:20 to June 15, 2016, 18:20 |
| Encounter Location | Inpatient Unit at Community Health and Hospitals |
| Responsible party | Ronald Boone, MD |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
| Assigned entity | Community Health and Hospitals
|
| 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 | Community Health and Hospitals |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "Discharge-Summary-Example",
"meta": {
"versionId": "4",
"lastUpdated": "2020-08-12T21:30:18.557+00:00",
"source": "#csn482LCsnDWyxbW",
"profile": [
"http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary"
]
},
"language": "en-US",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:3a94d1bd-c399-40d2-8574-8212e1491e9c"
},
"status": "preliminary",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "18842-5",
"display": "Discharge Summary"
}
]
},
"subject": {
"reference": "Patient/example",
"display": "Amy V. Shaw"
},
"date": "2016-02-28T09:10:14Z",
"author": [
{
"reference": "PractitionerRole/ccda-practitionerrole-example",
"display": "Ronald Bone, MD"
}
],
"title": "Discharge Summary",
"custodian": {
"reference": "Organization/organization-1",
"display": "Community Health and Hospitals"
},
"section": [
{
"title": "Allergies and Intolerances Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48765-2",
"display": "Allergies and adverse reactions Document"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Substance</b>\n </td>\n <td>\n <b>Overall Severity</b>\n </td>\n <td>\n <b>Reaction</b>\n </td>\n <td>\n <b>Reaction Severity</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Cashew Nut</td>\n <td>Severe</td>\n <td>Anaphylactic reaction</td>\n <td>Mild</td>\n <td>Active</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "AllergyIntolerance/allergy-intolerance"
}
]
},
{
"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": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Cramping, bloating, and constipation.</p>\n </div>"
}
},
{
"title": "Chief Complaint Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10154-3",
"display": "Chief complaint Narrative - Reported"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Dark Stools</p>\n </div>"
}
},
{
"title": "Reason for Visit Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29299-5",
"display": "Reason for visit"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Tenderness of lower abdomen</p>\n </div>"
}
},
{
"title": "Admission Diagnosis Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "46241-6",
"display": "Hospital admission diagnosis Narrative - Reported"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis</p>\n </div>"
}
},
{
"title": "Admission Medications Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "42346-7",
"display": "Medications on admission (narrative)"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Pepcid Complete (MAGNESIUM HYDROXIDE0</td>\n <td>Chew one tablet completely and swallow as needed </td>\n <td>20160615</td>\n <td>Active</td>\n <td>Bloating</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Past Medical History Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11348-0",
"display": "History of Past illness Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Problem Name</b>\n </td>\n <td>\n <b>Type</b>\n </td>\n <td>\n <b>Onset Date</b>\n </td>\n <td>\n <b>Abatement Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fever</td>\n <td>Condition</td>\n <td>2016-06-15</td>\n <td>2016-06-15</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Condition/condition-problem"
}
]
},
{
"title": "History of Present Illness Section",
"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\">\n <p>This patient was only recently discharged for a recurrent GI bleed as\n described below. </p>\n <p>He presented to the ER today c/o a dark stool yesterday but a normal\n brown stool today. On exam he was hypotensive in the 80?s resolved\n after .... .... .... </p>\n <p>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes\n normal. H. pylori antibody pending. Admission hematocrit 16%,\n discharge hematocrit 29%. WBC 7300, platelet count 256,000.\n Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. </p>\n <p>He was transfused with 6 units of packed red blood cells with ....\n .... .... </p>\n <p>GI evaluation 12 September: Colonoscopy showed single red clot in\n .... ........ </p>\n </div>"
}
},
{
"title": "Review of Systems Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10187-3",
"display": "Review of systems"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient denies recent history of fever or malaise. Positive for\n weakness and shortness of breath. One episode of melena. No recent\n headaches. Positive for osteoarthritis in hips, knees and hands.\n\t\t\t\t\t\t\t</p>\n </div>"
}
},
{
"title": "Family History Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10157-6",
"display": "History of family member diseases Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Relationship</b>\n </td>\n <td>\n <b>Diagnosis</b>\n </td>\n <td>\n <b>Age at Onset</b>\n </td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Myocardial Infarction(cause of Death)</td>\n <td>57</td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Diabetes</td>\n <td>40</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Social History Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29762-2",
"display": "Social history Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Social History Element</b>\n </td>\n <td>\n <b>Description</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n </tr>\n <tr>\n <td>Smoking</td>\n <td>1 pack tobacco per day</td>\n <td>2005/05/01 - 2010/02/28</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Observation/observation-smoker"
}
]
},
{
"title": "Functional Status Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "47420-5",
"display": "Functional status assessment note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Functional or Cognitive Finding</b>\n </td>\n <td>\n <b>Observation</b>\n </td>\n <td>\n <b>Observation Date</b>\n </td>\n <td>\n <b>Condition Status</b>\n </td>\n </tr>\n <tr>\n <td>Ambulation (Dependent to Independent</td>\n <td>Independently able</td>\n <td>2010/03/11</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Finding of Functional Performance and Activity</td>\n <td>Dyspnea</td>\n <td>2008/02/16</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Cognitive Function Finding</td>\n <td>Memory Impairment</td>\n <td>2014/04/29</td>\n <td>Active</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Hospital Course Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8648-8",
"display": "Hospital course"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Following a colonoscopy, the patient was admitted and started on\n Lovenox and nitroglycerin paste. The patient had serial cardiac\n enzymes and was ruled out for myocardial infarction. The patient\n underwent a dual isotope stress test. There was no evidence of\n reversible ischemia on the Cardiolite scan. The patient has been\n ambulated. The patient had a Holter monitor placed but the report is\n not available at this time. The patient has remained hemodynamically\n stable. Will discharge.</p>\n </div>"
}
},
{
"title": "Hospital Consultations Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18841-7",
"display": "Hospital consultations Document"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>listType="ordered"</p>\n <p>Gastroenterology</p>\n <p>Cardiology</p>\n <p>Dietitian</p>\n </div>"
}
},
{
"title": "Plan of Treatment Section",
"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\">\n <table>\n <tr>\n <td>\n <b>Planned Activity</b>\n </td>\n <td>\n <b>Period</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Colonoscopy</td>\n <td>2016/08/16 - 2016/08/16</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2016/06/29</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Problem Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11450-4",
"display": "Problem list - Reported"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Problem Name</b>\n </td>\n <td>\n <b>Type</b>\n </td>\n <td>\n <b>Onset Date</b>\n </td>\n <td>\n <b>Abatement Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fever</td>\n <td>Condition</td>\n <td>2016-04-01</td>\n <td>2016-04-14</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Condition/condition-problem"
}
]
},
{
"title": "Procedures Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "47519-4",
"display": "History of Procedures Document"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Procedure Name</b>\n </td>\n <td>\n <b>Body Site</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Date Performed</b>\n </td>\n <td>\n <b>Reason</b>\n </td>\n </tr>\n <tr>\n <td>Appendectomy (Procedure)</td>\n <td>Abdomen</td>\n <td>Dr. Adam Everyman</td>\n <td>20160405</td>\n <td>Generalized abdominal pain 24 hours. Localized in RIF with\n rebound and guarding</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Procedure/procedure-rehab"
}
]
},
{
"title": "Discharge Diagnosis Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11535-2",
"display": "Hospital discharge Dx Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Diverticula of intestine</p>\n </div>"
}
},
{
"title": "Discharge Medications Section (entries required)",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10183-2",
"display": "Hospital discharge medications"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Acetaminophen Tab 325 mg</td>\n <td>Take 2 tablet(s) every four hours if needed</td>\n <td>20160618</td>\n <td>Active</td>\n <td>Pain management</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Hospital Discharge Instructions Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8653-8",
"display": "Hospital discharge instructions"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Take all of your prescription medication as directed. </p>\n <p>Make an appointment with your doctor to be seen two weeks from the\n date of your procedure. </p>\n <p>You may feel slightly bloated after the procedure because of air that\n was introduced during the examination. </p>\n <p> Call your physician if you notice: \n <br/> Bleeding or black stools.\n\t\t\t\t\t\t\t\t\n <br/> Abdominal pain. \n <br/> Fever or chills. \n <br/> Nausea or\n vomiting. \n <br/> Any unusual pain or problem. \n <br/> Pain or redness\n at the site where the intravenous needle was placed. \n <br/>\n </p>\n <p>Do not drink alcohol for 24 hours. Alcohol amplifies the effect of\n the sedatives given. </p>\n <p>Do not drive or operate machinery for 24 hours.</p>\n </div>"
}
},
{
"title": "Hospital Discharge Physical Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10184-0",
"display": "Hospital discharge physical findings Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>GENERAL: Well-developed, slightly obese man. </p>\n <p>NECK: Supple, with no jugular venous distension.</p>\n <p>HEART: Intermittent tachycardia without murmurs or gallops. </p>\n <p>PULMONARY: Decreased breath sounds, but no clear-cut rales or\n wheezes.</p>\n <p>EXTREMITIES: Free of edema.</p>\n </div>"
}
},
{
"title": "Hospital Discharge Studies Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11493-4",
"display": "Hospital discharge studies summary"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Laboratory Information</th>\n <th>Chemistries and drug levels</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Potasium</td>\n <td>4.0</td>\n </tr>\n <tr>\n <td>NA (135-145meq/l)</td>\n <td>140</td>\n </tr>\n </tbody>\n </table>\n <br/>\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Other Tests</th>\n <th>Results</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>EKG</td>\n <td>Sinus rhythm without acute changes.</td>\n </tr>\n </tbody>\n </table>\n </div>"
}
},
{
"title": "Immunizations Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11369-6",
"display": "History of Immunization Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vaccine</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fluvax (Influenza)</td>\n <td>2016-04-05</td>\n <td>Completed</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Immunization/immunization"
}
]
},
{
"title": "Nutrition Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61144-2",
"display": "Diet and nutrition Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Nutritional Status</b>\n </td>\n <td>\n <b>Diet</b>\n </td>\n </tr>\n <tr>\n <td>2016/06/15</td>\n <td>Well nourished</td>\n <td>Low sodium diet, excessive carbohydrate</td>\n </tr>\n <tr>\n <td>2016/06/15</td>\n <td>Slight dehydration</td>\n <td>High protein, low fibre</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Vital Signs Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital signs"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vital Sign</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Value</b>\n </td>\n </tr>\n <tr>\n <td>Temperature</td>\n <td>2016/06/15</td>\n <td>39 Degrees Celcius</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Observation/observation-vitals-temp"
}
]
}
]
}