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Narrative

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

Source1

{
  "resourceType": "Composition",
  "id": "clinical-document-composition-revision",
  "meta": {
    "lastUpdated": "2024-05-07T13:28:17.000+00:00",
    "profile": [
      "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/clinical-document-composition"
    ]
  },
  "text": {
    "status": "additional",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version",
      "valueString": "1715171314"
    },
    {
      "extension": [
        {
          "url": "type",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                "code": "PRCP",
                "display": "primary information recipient"
              }
            ]
          }
        },
        {
          "url": "party",
          "valueReference": {
            "reference": "Practitioner/Doctor2"
          }
        }
      ],
      "url": "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/event-basedOn",
      "valueReference": {
        "reference": "ServiceRequest/revised-service1"
      }
    },
    {
      "url": "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension",
      "valueReference": {
        "reference": "Consent/revised-consent1"
      }
    },
    {
      "extension": [
        {
          "url": "change",
          "valueAnnotation": {
            "authorReference": {
              "reference": "Practitioner/Doctor1",
              "display": "Doctor Dave"
            },
            "time": "2024-05-07T13:28:17.000+00:00",
            "text": "Subject's name was corrected becuase of a misspelling."
          }
        },
        {
          "url": "version-changed",
          "valueReference": {
            "identifier": {
              "system": "https://example.com/bundleId",
              "value": "26d52355-b71b-4992-a34b-a2476983c166"
            }
          }
        }
      ],
      "url": "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade"
    }
  ],
  "identifier": {
    "system": "https://example.com/compId",
    "value": "1d6d6eb8-7d08-4ce1-94d4-19cdaa76ad6f"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "28655-9"
      }
    ],
    "text": "Attending Discharge summary"
  },
  "category": [
    {
      "text": "Temp Code: Clinical Note. Requested from LOINC"
    }
  ],
  "subject": {
    "reference": "Patient/revised-Patient",
    "display": "Eve Everywoman"
  },
  "encounter": {
    "reference": "Encounter/revised-encounter-example"
  },
  "date": "2024-05-08T11:28:17.000+00:00",
  "author": [
    {
      "reference": "Practitioner/Doctor1",
      "display": "Doctor Dave"
    }
  ],
  "title": "Discharge Summary Revision",
  "confidentiality": "N",
  "attester": [
    {
      "mode": "legal",
      "time": "2024-05-07",
      "party": {
        "reference": "Practitioner/Doctor1",
        "display": "Doctor Dave"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/revised-custodianOrganization",
    "display": "Good Health Clinic"
  },
  "relatesTo": [
    {
      "code": "replaces",
      "targetIdentifier": {
        "system": "https://example.com/bundleId",
        "value": "26d52355-b71b-4992-a34b-a2476983c166"
      }
    }
  ],
  "section": [
    {
      "title": "Reason for admission",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "29299-5",
            "display": "Reason for visit Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><thead><tr><td>Details</td><td/></tr></thead><tbody><tr><td>Acute Asthmatic attack. Was wheezing for days prior to admission.</td><td/></tr></tbody></table></div>"
      },
      "entry": [
        {
          "reference": "Observation/revised-Observation-541a72a8-df75-4484-ac89-ac4923f03b81"
        }
      ]
    },
    {
      "title": "Medications on Discharge",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "10183-2",
            "display": "Hospital discharge medications Narrative"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><thead><tr><td>Medication</td><td>Last Change</td><td>Last ChangeReason</td></tr></thead><tbody><tr><td>Theophylline 200mg BD after meals</td><td>continued</td></tr><tr><td>Ventolin Inhaler</td><td>stopped</td><td>Getting side effect of tremor</td></tr></tbody></table></div>"
      },
      "entry": [
        {
          "reference": "MedicationRequest/revised-MedRequest-124a6916-5d84-4b8c-b250-10cefb8e6e86"
        },
        {
          "reference": "MedicationStatement/revised-MedStatement-673f8db5-0ffd-4395-9657-6da00420bbc1"
        }
      ]
    },
    {
      "title": "Known allergies",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "48765-2",
            "display": "Allergies and adverse reactions Document"
          }
        ]
      },
      "text": {
        "status": "additional",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><thead><tr><td>Allergen</td><td>Reaction</td></tr></thead><tbody><tr><td>Doxycycline</td><td>Hives</td></tr></tbody></table></div>"
      },
      "entry": [
        {
          "reference": "AllergyIntolerance/revised-AllergyIntolerance-47600e0f-b6b5-4308-84b5-5dec157f7637"
        }
      ]
    }
  ]
}