FHIR IG analytics| Package | ihe.pcc.maps.us |
| Resource Type | Composition |
| Id | Composition-ex-APS-Composition-AmandaAlvarez.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: Composition ex-APS-Composition-AmandaAlvarez
Profile: Antepartum Summary US Realm
Security Label: test health data (Details: ActReason code HTEST = 'test health data')
status: Final
type: Antepartum summary note
category: Pregnancy summary Document
date: 2023-01-08 14:30:00+0100
author: Practitioner Simone Heps (official)
title: Antepartum Summary
confidentiality: normal
attester
mode: Legal
time: 2023-01-08 14:30:00+0100
attester
mode: Legal
time: 2023-01-08 14:30:00+0100
party: Organization Acme Healthcare
custodian: Organization Acme Healthcare
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "ex-APS-Composition-AmandaAlvarez",
"meta": {
"profile": [
"https://profiles.ihe.net/us/PCC/mAPS/StructureDefinition/IHE.PCC.mAPS.Composition.US"
],
"security": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
"code": "HTEST"
}
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "57055-6"
}
]
},
"category": [
{
"coding": [
{
"system": "http://loinc.org",
"code": "90767-5"
}
]
}
],
"subject": {
"reference": "Patient/ex-Patient-AmandaAlvarez"
},
"date": "2023-01-08T14:30:00+01:00",
"author": [
{
"reference": "Practitioner/ex-Practitioner"
}
],
"title": "Antepartum Summary",
"confidentiality": "N",
"attester": [
{
"mode": "legal",
"time": "2023-01-08T14:30:00+01:00",
"party": {
"reference": "Practitioner/ex-Practitioner"
}
},
{
"mode": "legal",
"time": "2023-01-08T14:30:00+01:00",
"party": {
"reference": "Organization/ex-Organization-OB"
}
}
],
"custodian": {
"reference": "Organization/ex-Organization-OB"
},
"section": [
{
"title": "Medication Summary 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\">Active Medications - Amoxicillin</div>"
},
"entry": [
{
"reference": "MedicationStatement/ex-medicationStatement"
}
]
},
{
"title": "Allergies and Intolerances",
"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\">active allergies - latex and fish</div>"
},
"entry": [
{
"reference": "AllergyIntolerance/ex-Allergy-Latex"
},
{
"reference": "AllergyIntolerance/ex-Allergy-Fish"
}
]
},
{
"title": "Problems",
"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\">active problems - sepsis and gestational diabedies</div>"
},
"entry": [
{
"reference": "Condition/ex-Problem-Sepsis"
},
{
"reference": "Condition/ex-Problem-GestationalDiabetes"
}
]
},
{
"title": "Past Illness History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11348-0",
"display": "History of Past illness note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">none found</div>"
},
"emptyReason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/list-empty-reason",
"code": "unavailable"
}
]
}
},
{
"title": "Procedures History",
"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\">past procedures - Education for smoking provided and Cephallic Version</div>"
},
"entry": [
{
"reference": "Procedure/ex-Procedure-CephalicVersion"
},
{
"reference": "Procedure/ex-Procedure-EducationSmoking"
}
]
},
{
"title": "Pregnancy History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10162-6",
"display": "Pregnancies Hx"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">observations for pregnancy history</div>"
},
"entry": [
{
"reference": "Observation/ex-PregnencyStatus-pregnant"
},
{
"reference": "Observation/ex-EstimatedDeliveryDate"
},
{
"reference": "Observation/ex-GestationalAge"
},
{
"reference": "Observation/ex-DateOfLastMenstralPeriod"
},
{
"reference": "Observation/ex-DateOfFirstPrenatalVisit"
},
{
"reference": "Observation/ex-PregnancyHistory-AmandaAlvarez"
}
]
},
{
"title": "Immunizations",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11369-6",
"display": "History of Immunization note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Immunizations - Varicella</div>"
},
"entry": [
{
"reference": "Immunization/ex-Immunization-Vericella"
}
]
},
{
"title": "Chief Complaint",
"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\">Complains of fever and having lack of energy</div>"
}
},
{
"title": "Results",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">no abnormal results for labs</div>"
},
"entry": [
{
"reference": "Observation/ex-AntepartumLabs"
},
{
"reference": "Observation/ex-Antepartum-Genetic-Screening"
}
]
},
{
"title": "Vital Signs",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital signs note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">body weight - 185 lbs , prepregnancy weight - 148 lbs</div>"
},
"entry": [
{
"reference": "Observation/ex-VitalSigns-BodyWeight"
}
]
},
{
"title": "Review Of Systems",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10187-3",
"display": "Review of systems Narrative - Reported"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">last menstral period</div>"
},
"entry": [
{
"reference": "Observation/ex-MenstralStatus-Pregnancy"
}
]
},
{
"title": "Physical Exams",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29545-1",
"display": "Physical findings note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">abdominal tenderness</div>"
},
"entry": [
{
"reference": "Observation/ex-PhysicalExam-AbdominalTenderness"
}
]
},
{
"title": "History Of Infection",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "56838-6",
"display": "History of Infectious disease Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">history of clamidia infection</div>"
},
"entry": [
{
"reference": "Condition/ex-HistoryOfInfection"
}
]
},
{
"title": "Plan Of Care",
"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\">Birth Plan</div>"
},
"entry": [
{
"reference": "CarePlan/ex-CarePlan-BirthPlan"
}
]
},
{
"title": "Social History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29762-2"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">active smoker, drinks occasionally, no domestic violence risk, no homlessness, currently working</div>"
},
"entry": [
{
"reference": "Observation/ex-SocialHistory-smokingTobaccoUse"
},
{
"reference": "Observation/ex-SocialHistory-alcoholUse"
},
{
"reference": "Observation/ex-DomesticViolenceRisk"
},
{
"reference": "Observation/ex-Homelessness"
},
{
"reference": "Observation/ex-SocialHistory-EmploymentStatus"
}
]
},
{
"title": "Advance Directives",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "42348-3",
"display": "Advance healthcare directives"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">advance directve present</div>"
},
"entry": [
{
"reference": "Consent/ex-AdvanceDirectives-BloodTransfusion"
}
]
},
{
"title": "Payors",
"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\">payors for coverage</div>"
},
"entry": [
{
"reference": "Coverage/ex-Coverage"
}
]
},
{
"title": "Antepartum Education",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "34895-3",
"display": "Education Note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">education on smoking provided to patient in first and second trimesters</div>"
},
"entry": [
{
"reference": "Observation/ex-PregnancyEducationObservation"
},
{
"reference": "Observation/ex-PregnancyEducationObservation"
}
]
},
{
"title": "Antepartum Visit Summary Flowsheet",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "57059-8",
"display": "Pregnancy visit summary note Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Antepartum visit summary flowsheet documented</div>"
},
"entry": [
{
"reference": "Observation/ex-VitalSigns-BodyWeight-PrePregnancy"
},
{
"reference": "Observation/ex-AntepartumVisitSummaryFlowsheetBattery"
}
]
}
]
}