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Narrative

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Source1

{
  "resourceType": "Composition",
  "id": "TransfusionExample",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-composition"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "extension": [
        {
          "url": "availableFlag",
          "valueBoolean": false
        }
      ],
      "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-additionaldocumentinformation"
    },
    {
      "extension": [
        {
          "url": "localCriteriaFlag",
          "valueBoolean": false
        },
        {
          "url": "localCriteriaReportType",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "urn:oid:2.16.840.1.113883.3.989.2.1.1.1003",
                "code": "2",
                "display": "Non-Expedited AE"
              }
            ]
          }
        }
      ],
      "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-expeditedreport"
    },
    {
      "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-firstsendertype",
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "urn:oid:2.16.840.1.113883.3.989.2.1.1.3",
            "code": "2",
            "display": "Other"
          }
        ]
      }
    },
    {
      "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-combinationproductreport",
      "valueBoolean": false
    },
    {
      "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-firstreceivedate",
      "valueDateTime": "2021-01-05"
    },
    {
      "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-mostrecentdate",
      "valueDateTime": "2021-01-05"
    },
    {
      "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-caseidentifier",
      "valueIdentifier": {
        "system": "urn:oid:2.16.840.1.113883.3.989.2.1.3.2",
        "value": "BEST_beafb541-3eab-eb9e-1bf1-5fa477d56e77"
      }
    }
  ],
  "identifier": {
    "system": "urn:oid:2.16.840.1.113883.3.989.2.1.3.1",
    "value": "BEST_beafb541-3eab-eb9e-1bf1-5fa477d56e77"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "85893-6",
        "display": "Adverse event note"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "urn:oid:2.16.840.1.113883.3.989.2.1.1.2",
          "code": "1",
          "display": "Spontaneous report"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/BESTPatient"
  },
  "date": "2021-01-05",
  "author": [
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/icsr-ae-reporting/StructureDefinition/icsr-ext-authorprimarysource",
          "valueBoolean": true
        }
      ],
      "reference": "PractitionerRole/BESTAuthorRole"
    }
  ],
  "title": "ICSR Submission",
  "section": [
    {
      "title": "Reaction/Event",
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/icsr-ae-reporting/CodeSystem/ICSRSectionCodeCS",
            "code": "ReactionEvent"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Allergic transfusion reaction</div>"
      },
      "entry": [
        {
          "reference": "AdverseEvent/TransfusionExampleEvent"
        }
      ]
    },
    {
      "title": "Drug Information",
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/icsr-ae-reporting/CodeSystem/ICSRSectionCodeCS",
            "code": "DrugInformation"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Description code for blood products: E7003, Blood group and type: N/A Blood processing type: Apheresis PLATELETS|ACD-A&gt;PAS-C/XX/20-24C|ResLeu:&amp;lt;5E6|2nd container</div>"
      },
      "entry": [
        {
          "reference": "Procedure/TransfusionExampleTransfusion"
        },
        {
          "reference": "MedicationAdministration/TransfusionEpinephrine"
        },
        {
          "reference": "MedicationAdministration/TransfusionDiphenhydramine"
        }
      ]
    },
    {
      "title": "Case Summary Narrative",
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/icsr-ae-reporting/CodeSystem/ICSRSectionCodeCS",
            "code": "CaseSummaryNarrative"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Header: FDA CBER BEST Automated AE Reporting Prototype Case BEST Detection Phenotype Algorithm: Phenotype link: rules-cd BEST Certainty: Definite BEST Severity: Non-Severe BEST Imputability: Probable Form Type: 3500 Contact Method: Email Adverse Event: 1 Center to which the case is being routed to: CBER Whether the case is being sent to DQRS: false Whether the report is related to drugs or food/cosmetics: 1 Whether the blood report is of type Transfusion or Collection: 2 Patient Race Code: 2f, Blood group of patient: N/A, Onset location for reaction: MedStar Location Description code for blood products: N/A, Blood group and type: N/A Blood processing type: N/A Product available for evaluation: 2 Volume of transfusion: NI NHSN Workup: NI Preliminary investigation results: Developed rash &amp;#38; stridor following transfusion prbc for anemia. Tx with benadryl &amp;#38; epinephrine &amp;#38; sx improved., Adverse Event Type Imputability: Blood Transfusion - Certainty: Definite; Notes: 1. notes, Eval+Plan Note, For admission to Hosp with Dx Anemia. Transfuse PRBC now., Date 20020109; 2. notes, Eval+Plan Note, Patient has developed a new maculopapular rash following transfusion. Will give Benadryl 25 mg., Date 20020109; 3. notes, Eval+Plan Note, New onset Stridor following transfusion. Will give Epinephrine .5mg, and do transfusion Rxn workup, Date 20020109; 4. notes, Eval+Plan Note, RN note - Administered Benadryl 25mg IV for skin sx. After 30 min pt. reports some improvement in skin symptoms, Date 20020109 Labs, Vitals, and Tests: 1. labs, Diastolic Blood Pressure, 75.918 mm[Hg], Date 20020109; 2. labs, Systolic Blood Pressure, 123.08 mm[Hg], Date 20020109; 3. labs, Physical findings of Skin, generalized rash, Date 20020109; 4. labs, Respiratory status finding, Stridor, Date 20020109; Illness at Time of Vaccination: 1. illness, Problem, Anemia, Date 20020109;</div>"
      }
    },
    {
      "title": "Patient Information",
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/icsr-ae-reporting/CodeSystem/ICSRSectionCodeCS",
            "code": "PatientInformation"
          }
        ]
      },
      "entry": [
        {
          "reference": "Observation/BESTPatientAgeGroup"
        }
      ]
    },
    {
      "title": "Relevant Medical History",
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/icsr-ae-reporting/CodeSystem/ICSRSectionCodeCS",
            "code": "RelevantMedicalHistory"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">NI</div>"
      }
    }
  ]
}