FHIR IG analytics| Package | hl7.fhir.us.ccda |
| Resource Type | Composition |
| Id | Composition-History-and-Physical-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 |
| Care Provision | History and Physical Note 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 | History and Physical |
| Event Date | From June 15, 2016, 16:20 to June 15, 2016, 18:20 |
| Encounter Location | Ambulatory Care 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": "History-and-Physical-Example",
"meta": {
"versionId": "4",
"lastUpdated": "2020-08-12T21:30:12.759+00:00",
"source": "#csn482LCsnDWyxbW",
"profile": [
"http://hl7.org/fhir/us/ccda/StructureDefinition/History-and-Physical"
]
},
"language": "en-US",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:c2a73e86-2e57-4384-83ff-3bc2536107aa"
},
"status": "preliminary",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "34117-2",
"display": "History and Physical Note"
}
]
},
"subject": {
"reference": "Patient/example",
"display": "Amy V. Shaw"
},
"date": "2016-06-15T09:10:14Z",
"author": [
{
"reference": "PractitionerRole/ccda-practitionerrole-example",
"display": "Ronald Bone, MD"
}
],
"title": "History and Physical Note",
"attester": [
{
"mode": "legal",
"time": "2012-01-04T09:10:14Z",
"party": {
"reference": "PractitionerRole/ccda-practitionerrole-example",
"display": "Ronald Boone, MD"
}
}
],
"custodian": {
"reference": "Organization/organization-1",
"display": "Community Health and Hospitals"
},
"event": [
{
"code": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActClass",
"code": "PCPR",
"display": "Care Provision"
}
]
}
],
"period": {
"start": "2016-06-15",
"end": "2016-06-15"
}
}
],
"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": "Assessment Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "51848-0",
"display": "Evaluation note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Obesity.</p>\n <p>Uncontrolled brittle Type II diabetic.</p>\n <p>Shortness of breath, mild wheezing.</p>\n <p>Pressure ulder on left knee.</p>\n </div>"
}
},
{
"title": "Assessment and Plan Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "51847-2",
"display": "Evaluation + Plan note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Recurrent GI bleed of unknown etiology; hypotension perhaps secondary\n to this but as likely secondary to polypharmacy</p>\n <p>Acute on chronic anemia secondary to #1.</p>\n <p>Azotemia, acute renal failure with volume loss secondary tom#1.</p>\n <p>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</p>\n <p>Other chronic diagnoses as noted above, currently stable.</p>\n </div>"
}
},
{
"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": "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": "General Status Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10210-3",
"display": "Physical findings of General status Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Alert and in good spirits, no acute distress.</p>\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>2016-04-01</td>\n <td>2016-04-14</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>"
}
},
{
"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": "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": "Instructions Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "69730-0",
"display": "Instructions"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient may have low grade fever, mild joint pain and injection area\n tenderness.</p>\n </div>"
}
},
{
"title": "Medication Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10160-0",
"display": "History of Medication use 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>Amoxicillin</td>\n <td>Amoxicillin Powder, for Suspension 250mg/5ml</td>\n <td>20160401</td>\n <td>Active</td>\n <td>Pneumonia</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "MedicationStatement/medication-statement"
}
]
},
{
"title": "Physical Exam Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29545-1",
"display": "Physical findings Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>HEENT: All normal to examination.</p>\n <p>>HEART: RRR, no murmur.</p>\n <p>THORAX & LUNGS: Clear without rhonchi or wheeze.</p>\n <p>ABDOMEN: Marked distension and tenderness, slightly obese, pos\n bowelsounds.</p>\n <p>BACK: Normal to inspection and palpation, without tenderness; no\n presacral edema.</p>\n <p>EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no\n asymmetrical swelling.</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>2010/08/16 - 2010/08/16</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2015/10/29</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": "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": "Results Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Result Type</b>\n </td>\n <td>\n <b>Quantity Value</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>Glucose [Moles/volume] in Blood</td>\n <td>6.3 mmol/l</td>\n <td>2016/04/01</td>\n <td>Final</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Observation/observation-lab-urine"
}
]
},
{
"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. Several episodes of abdominal\n tenderness. No recent headaches. Positive for osteoarthritis in\n hips, knees and hands. </p>\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": "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"
}
]
}
]
}