FHIR IG analytics| Package | hl7.fhir.us.ccda.r4 |
| Resource Type | Composition |
| Id | Composition-Transfer-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 |
| Care Provision | Transfer 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 |
| Event Type | Transfer Summary |
| Event Date | From June 15, 2016, 16:20 to June 15, 2016, 18:20 |
| Encounter Location | Inpatient 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": "Transfer-Summary-Example",
"meta": {
"versionId": "4",
"lastUpdated": "2020-08-12T21:30:12.324+00:00",
"source": "#csn482LCsnDWyxbW",
"profile": [
"http://hl7.org/fhir/us/ccda/StructureDefinition/Transfer-Summary"
]
},
"language": "en-US",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:e4edfcc8-bc7a-4c79-a844-42c83f209ddc"
},
"status": "preliminary",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "18761-7",
"display": "Transfer summary 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": "Transfer Summary",
"custodian": {
"reference": "Organization/organization-1",
"display": "Acme Labs"
},
"event": [
{
"code": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "73761001",
"display": "Colonoscopy"
}
]
}
],
"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": "Advance Directives Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "42348-3",
"display": "Advance directives"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Name</b>\n </td>\n <td>\n <b>Applies Period</b>\n </td>\n </tr>\n <tr>\n <td>Resuscitation</td>\n <td>2015/01/01 - 2016/12/31</td>\n </tr>\n </table>\n </div>"
}
},
{
"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": "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": "Encounters Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "46240-8",
"display": "History of Hospitalizations+Outpatient visits Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Encounter</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Location</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n </tr>\n <tr>\n <td>Checkup Examination</td>\n <td>Dr. S. Steene</td>\n <td>Community Urgent Care Center</td>\n <td>2015/09/26</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>2016-04-01</td>\n <td>2016-04-14</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Condition/condition-problem"
}
]
},
{
"title": "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": "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": "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": "Mental Status Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10190-7",
"display": "Mental status"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <td>\n <b>Mental Status Findings</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n <td>\n <b>Condition Status</b>\n </td>\n </tr>\n </thead>\n <tr>\n <td>Mental Function</td>\n <td>July 31, 2013</td>\n <td>Impaired</td>\n </tr>\n <tr>\n <td>Cognitive Abilities</td>\n <td>July 31, 2013</td>\n <td>Judgement, Intact</td>\n </tr>\n <tr>\n <td>Cognitive Function</td>\n <td>July 31, 2013</td>\n <td>Aggressive Behavior</td>\n </tr>\n <tr>\n <td>Cognitive Function</td>\n <td>July 31, 2013</td>\n <td>Difficulty understanding own emotions</td>\n </tr>\n <tr>\n <td>Cognitive Function</td>\n <td>July 31, 2013</td>\n <td>Difficulty communicating Thoughts </td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Medical Equipment Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "46264-8",
"display": "History of medical device use"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Supply/Device</b>\n </td>\n <td>\n <b>Date Supplied</b>\n </td>\n </tr>\n <tr>\n <td>Automatic Implantable cardioverter/defbrillator</td>\n <td>2008/11/16</td>\n </tr>\n <tr>\n <td>Wheelchair</td>\n <td>1999/12/01</td>\n </tr>\n </table>\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": "Payers Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48768-6",
"display": "Payment sources Document"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Payer Name</b>\n </td>\n <td>\n <b>Policy ID</b>\n </td>\n <td>\n <b>Policy Holder</b>\n </td>\n </tr>\n <tr>\n <td>United Healthcare</td>\n <td>12341</td>\n <td>Self</td>\n </tr>\n <tr>\n <td>Cigna</td>\n <td>53123</td>\n <td>Spouse</td>\n </tr>\n </table>\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>2016/10/29</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": "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": "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>2005/12/29</td>\n <td>Well nourished</td>\n <td>Low sodium diet, excessive carbohydrate</td>\n </tr>\n <tr>\n <td>2010/05/26</td>\n <td>Slight dehydration</td>\n <td>High protein, low fibre</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Reason for Referral Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "42349-1",
"display": "Reason for referral (narrative)"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Colonoscopy</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>2016/06/15</td>\n <td>Final</td>\n </tr>\n </table>\n </div>"
},
"entry": [
{
"reference": "Observation/observation-lab-urine"
}
]
},
{
"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"
}
]
}
]
}