FHIR IG analytics| Package | stjohn.ambulance-care-summary |
| Resource Type | Composition |
| Id | Composition-acs-cda-composition.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
| Document identifier | 1453821363387010 |
|---|---|
| Status | Final |
| Type | Ambulance Care Summary (LOINC 74207-2) |
| Document date | 2019-09-10 11:12 +12:00 |
| Patient | Mr Bob Bobby Bobson; NHI ABC1235 |
| Date of birth | 1984-06-02 |
| Gender / sex at birth | Male / Male |
| Patient contact details | (03) 444 7890 home; (03) 444 7654 work; (027) 7878 7878 mobile; bob@bobson.org.nz |
| Patient address | Bobs Big Building, 17 Bobson Boulevard, Baldrick, Boganville 6789, New Zealand |
| Encounter | 0450-1-2016/06/14, 2016-06-14 11:13 to 12:42 +12:00 |
| Author | Josephine Manu-Bloggs, Order of St John |
| Attending officers | Josephine Manu-Bloggs (100901); Bob (600821) |
| Custodian | Order of St John, HPI Organization G02780-A |
| Legal authenticator | Dr Rex Anthony Smith, HPI CPN 17AHVX, signed 2019-09-10 12:13 +12:00 |
| Destination | Sunshine Hospital Emergency Department |
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "acs-cda-composition",
"meta": {
"profile": [
"https://fhir-ig.digital.health.nz/ambulance-care-summary/StructureDefinition/ambulance-care-summary-composition"
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"system": "https://standards.digital.health.nz/ns/ambulance-care-summary-id",
"value": "1453821363387010"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "74207-2",
"display": "Ambulance Care Summary"
}
]
},
"subject": {
"reference": "Patient/acs-cda-patient-bob"
},
"encounter": {
"reference": "Encounter/acs-cda-encounter"
},
"date": "2019-09-10T11:12:00+12:00",
"author": [
{
"reference": "PractitionerRole/acs-cda-providerrole-josephine"
}
],
"title": "Ambulance Care Summary",
"attester": [
{
"mode": "legal",
"time": "2019-09-10T12:13:00+12:00",
"party": {
"reference": "PractitionerRole/acs-cda-providerrole-rex"
}
}
],
"custodian": {
"reference": "Organization/acs-cda-org-stjohn"
},
"section": [
{
"title": "Incident / Encounter",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "46240-8",
"display": "History of encounters"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Incident / Encounter</h3><table><tbody><tr><th>Master Incident Number</th><td>0450-1-2016/06/14</td></tr><tr><th>Encounter status</th><td>Finished</td></tr><tr><th>Encounter class</th><td>Emergency</td></tr><tr><th>Encounter type</th><td>Land ambulance</td></tr><tr><th>Encounter period</th><td>2016-06-14 11:13 to 12:42 +12:00</td></tr><tr><th>Incident location</th><td>MATAI RD/CAMPBELL RD 10 Miro Rd</td></tr><tr><th>Location type</th><td>Workplace</td></tr><tr><th>Unit call sign</th><td>MTWELL1</td></tr><tr><th>Time call received</th><td>2016-06-14 11:13 +12:00</td></tr><tr><th>Time unit dispatched</th><td>2016-06-14 11:14 +12:00</td></tr><tr><th>Time unit responded</th><td>2016-06-14 11:14 +12:00</td></tr><tr><th>Time unit arrived at scene</th><td>2016-06-14 11:28 +12:00</td></tr><tr><th>Time patient located</th><td>2016-06-14 11:30 +12:00</td></tr><tr><th>Patient status at scene</th><td>Immediate threat to life</td></tr><tr><th>Time unit departed with patient</th><td>2016-06-14 11:55 +12:00</td></tr><tr><th>Time unit arrived at destination</th><td>2016-06-14 12:07 +12:00</td></tr><tr><th>Final patient status</th><td>No threat to life</td></tr><tr><th>Disposition</th><td>Transport / treat and transport</td></tr><tr><th>Receiving facility</th><td>Sunshine Hospital Emergency Department</td></tr><tr><th>Referral pathway</th><td>GP Surgery Appointment</td></tr><tr><th>Disposition notes</th><td>Recommend GP appt to get more meds</td></tr><tr><th>Existing ACC claim number</th><td>XA12345</td></tr><tr><th>Time incident closed</th><td>2016-06-14 12:42 +12:00</td></tr><tr><th>Service provider</th><td>Order of St John</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Encounter/acs-cda-encounter"
},
{
"reference": "https://example.org/fhir/Location/acs-cda-incident-location"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-call-received"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-unit-dispatched"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-unit-responded"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-arrived-scene"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-patient-located"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-departed-scene"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-arrived-destination"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-event-closed"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-patient-status-scene"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-patient-status-final"
}
]
},
{
"title": "Patient Contacts",
"code": {
"coding": [
{
"system": "https://fhir-ig.digital.health.nz/ambulance-care-summary/CodeSystem/acs-metadata",
"code": "section-patient-contacts",
"display": "Patient contacts"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Patient Contacts</h3><table><tbody><tr><th>Relationship</th><td>Next of kin</td></tr><tr><th>Name / description</th><td>Patient's mother</td></tr><tr><th>Phone</th><td>0211211212</td></tr><tr><th>Contact instruction</th><td>Please contact mother on 0211211212</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/RelatedPerson/acs-cda-contact-mother"
}
]
},
{
"title": "Patient Additional Demographics",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "45970-1",
"display": "Patient Demographics"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Patient Additional Demographics</h3><table><tbody><tr><th>Patient age</th><td>30 years</td></tr><tr><th>Patient age is estimated</th><td>No</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-patient-age"
}
]
},
{
"title": "Smoking and Vaping",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29762-2",
"display": "Social history"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Smoking and Vaping</h3><table><tbody><tr><th>Smoking status</th><td>Ex-smoker, recorded 2016-06-14 11:30 +12:00</td></tr><tr><th>Vaping status</th><td>Not recorded in the CDA example</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-smoking"
}
]
},
{
"title": "Problems",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10154-3",
"display": "Chief complaint"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Problems</h3><h4>Complaint History</h4><table><tbody><tr><th>Presenting complaint</th><td>Shortness of breath</td></tr><tr><th>Date and time of onset</th><td>2016-06-14 02:00 +12:00</td></tr><tr><th>History of incident</th><td>History line 1<br/>History line 2<br/>History line 3</td></tr></tbody></table><h4>Accident Details</h4><table><tbody><tr><th>Mechanism of injury</th><td>Chemical poisoning</td></tr><tr><th>Sports injury</th><td>Rugby Union</td></tr><tr><th>Vehicle diagram</th><td>vehicle.jpg</td></tr><tr><th>Vehicle type</th><td>Car</td></tr><tr><th>Patient characteristic</th><td>Driver</td></tr><tr><th>Estimated impact speed</th><td>150 km/h</td></tr><tr><th>Passenger compartment intrusion</th><td>Yes</td></tr><tr><th>Patient ejected</th><td>Yes</td></tr><tr><th>Rollover</th><td>Yes</td></tr><tr><th>End over end</th><td>Yes</td></tr><tr><th>Air bag deployed</th><td>Yes</td></tr><tr><th>Seatbelt or child restraint used</th><td>Yes</td></tr><tr><th>Helmet worn</th><td>Yes</td></tr><tr><th>Self-extricated</th><td>Yes</td></tr><tr><th>Patient trapped</th><td>Yes</td></tr></tbody></table><h4>Clinical Impression</h4><table><tbody><tr><th>Body diagrams</th><td>body-front.jpg; body-back.jpg</td></tr><tr><th>Primary clinical impression</th><td>Asthma</td></tr><tr><th>Secondary clinical impression</th><td>Generally unwell</td></tr><tr><th>Clinical impression notes</th><td>Clinical impression notes line 1<br/>Clinical impression notes line 2</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-presenting-complaint"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-history-of-incident"
},
{
"reference": "https://example.org/fhir/Condition/acs-cda-diagnosis-asthma"
},
{
"reference": "https://example.org/fhir/Condition/acs-cda-diagnosis-generally-unwell"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-mechanism"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-sport"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-vehicle-type"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-patient-characteristic"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-impact-speed"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-passenger-intrusion"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-patient-ejected"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-rollover"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-end-over-end"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-airbag"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-seatbelt"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-helmet"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-self-extricated"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-accident-patient-trapped"
}
]
},
{
"title": "Primary Survey",
"code": {
"coding": [
{
"system": "https://fhir-ig.digital.health.nz/ambulance-care-summary/CodeSystem/acs-metadata",
"code": "section-primary-survey",
"display": "Primary survey"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Primary Survey</h3><table><tbody><tr><th>Patient status at scene</th><td>Immediate threat to life</td></tr><tr><th>Responsiveness</th><td>Alert</td></tr><tr><th>Airway</th><td>Patent (clear)</td></tr><tr><th>Breathing</th><td>Ineffective</td></tr><tr><th>Circulation</th><td>Compromised</td></tr><tr><th>Blood loss</th><td>Nil</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-primary-survey"
}
]
},
{
"title": "Stroke Assessments",
"code": {
"coding": [
{
"system": "https://fhir-ig.digital.health.nz/ambulance-care-summary/CodeSystem/acs-metadata",
"code": "section-stroke-assessments",
"display": "Stroke assessments"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Stroke Assessments</h3><h4>ABCD2 Stroke Risk Assessment - not possible</h4><table><tbody><tr><th>Assessment date and time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>ABCD2 not possible</th><td>Patient refused</td></tr></tbody></table><h4>ABCD2 Stroke Risk Assessment - completed</h4><table><tbody><tr><th>Assessment date and time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>Age 60 or older</th><td>No</td></tr><tr><th>Hypertensive</th><td>Yes</td></tr><tr><th>Clinical features</th><td>Speech disturbance without weakness</td></tr><tr><th>Duration of symptoms</th><td>>= 60 min</td></tr><tr><th>Diabetes</th><td>No</td></tr><tr><th>ABCD2 score</th><td>3</td></tr></tbody></table><h4>FAST Stroke Test - not possible</h4><table><tbody><tr><th>Assessment date and time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>FAST not possible</th><td>Patient refused</td></tr></tbody></table><h4>FAST Stroke Test - completed</h4><table><tbody><tr><th>Assessment date and time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>Face</th><td>Right side droop</td></tr><tr><th>Face laterality</th><td>Right</td></tr><tr><th>Arms</th><td>Right side drift</td></tr><tr><th>Arms laterality</th><td>Right</td></tr><tr><th>Speech</th><td>Slurred</td></tr><tr><th>Date and time of onset</th><td>2016-06-14 09:35 +12:00</td></tr><tr><th>When last seen well</th><td>2016-06-13 17:30 +12:00</td></tr><tr><th>Patient found in this condition</th><td>Yes</td></tr><tr><th>Receiving hospital notified</th><td>Yes</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-abcd2-refused"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-abcd2-completed"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-fast-refused"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-fast-completed"
}
]
},
{
"title": "Falls Risk Assessment",
"code": {
"coding": [
{
"system": "https://fhir-ig.digital.health.nz/ambulance-care-summary/CodeSystem/acs-metadata",
"code": "section-falls-risk",
"display": "Falls risk assessment"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Falls Risk Assessment</h3><h4>Falls Risk Assessment - not possible</h4><table><tbody><tr><th>Assessment date and time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>Falls risk assessment not possible</th><td>Patient refused</td></tr></tbody></table><h4>Falls Risk Assessment - completed</h4><table><tbody><tr><th>Assessment date and time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>Fall frequency</th><td>Weekly</td></tr><tr><th>Avoids activities</th><td>Yes</td></tr><tr><th>Feet problem</th><td>Yes</td></tr><tr><th>Gait strength balance problem</th><td>Yes</td></tr><tr><th>Uses an aid</th><td>No</td></tr><tr><th>Dizziness</th><td>No</td></tr><tr><th>Cognitive impairment</th><td>No</td></tr><tr><th>Trip hazards</th><td>Yes</td></tr><tr><th>Home modifications required</th><td>Yes</td></tr><tr><th>Home modifications notes</th><td>Shower rail, handrail on front steps</td></tr><tr><th>Lives alone</th><td>Yes</td></tr><tr><th>Falls assessment notes</th><td>The house needs a tidy up there is stuff all over the floor</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-falls-refused"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-falls-completed"
}
]
},
{
"title": "Patient History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11348-0",
"display": "History of past illness"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Patient History</h3><table><tbody><tr><th>Medical history notes</th><td>Medical history notes line 1<br/>Medical history notes line 2<br/>Medical history notes line 3</td></tr><tr><th>Last oral intake time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>Last oral intake detail</th><td>Steak and cheese pie</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Condition/acs-cda-medical-history"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-last-oral-intake"
}
]
},
{
"title": "Allergies and Intolerances",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48765-2",
"display": "Allergies and adverse reactions"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Allergies and Intolerances</h3><table><tbody><tr><th>Allergies</th><td>NKA</td></tr><tr><th>Structured code</th><td>No known allergy</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/AllergyIntolerance/acs-cda-allergy-nka"
}
]
},
{
"title": "Current Medications",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10160-0",
"display": "History of medication use"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Current Medications</h3><table><tbody><tr><th>Medication notes</th><td>Ventolin, ipratropium</td></tr><tr><th>Information source</th><td>Patient self-report</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/MedicationStatement/acs-cda-current-medications"
}
]
},
{
"title": "Measurements and Vital Signs",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital signs"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Measurements and Vital Signs</h3><table><thead><tr><th>Date</th><th>Time</th><th>GCS</th><th>Heart rate</th><th>Resp rate</th><th>BP</th><th>SpO2</th><th>ECG</th><th>BGL</th><th>Cap refill</th><th>Temp</th><th>Pain</th><th>Pupils</th><th>ETCO2</th><th>Skin</th><th>PEFR</th></tr></thead><tbody><tr><td>2016-06-14</td><td>11:35</td><td>15</td><td>136 /min</td><td>48 /min</td><td>132/90 mmHg</td><td>95%</td><td>Atrial Flutter</td><td>4.0 mmol/L</td><td>P=2 sec; C=3 sec</td><td>38.6 degC</td><td>5</td><td>Left 5 mm reactive; Right 5 mm reactive</td><td>70 mmHg</td><td>Diaphoretic (sweaty)</td><td>92 L/min</td></tr><tr><td colspan=\"16\">A note about the observations. CDA structured ECG coded Atrial Fibrillation while the CDA narrative table displayed Atrial Flutter. CDA structured ETCO2 unit was %, while the clinical summary heading labelled ETCO2 as mmHg.</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-gcs"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-hr"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-rr"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-bp"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-spo2"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-ecg"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-bgl"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-caprefill-peripheral"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-caprefill-central"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-temp"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-pain"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-pupil-reaction-left"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-pupil-size-left"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-pupil-reaction-right"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-pupil-size-right"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-etco2"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-skin"
},
{
"reference": "https://example.org/fhir/Observation/acs-cda-pefr"
}
]
},
{
"title": "Medications Administered or Supplied",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29549-3",
"display": "Medication administered"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Medications Administered or Supplied</h3><table><thead><tr><th>Date</th><th>Time</th><th>Medication</th><th>Dose</th><th>Route</th><th>PRN</th><th>Notes</th></tr></thead><tbody><tr><td>2016-06-14</td><td>11:01</td><td>Adenosine</td><td>6 mg</td><td>Intravenous</td><td>No</td><td>A note about Adenosine</td></tr><tr><td>2016-06-14</td><td>11:02</td><td>Adrenaline (bolus)</td><td>0.1 mg</td><td>Intravenous</td><td>No</td><td>A note about Adrenaline (bolus)</td></tr><tr><td>2016-06-14</td><td>11:03</td><td>Adrenaline (infusion)</td><td>0.1 mg</td><td>Intravenous</td><td>No</td><td>A note about Adrenaline (infusion)</td></tr><tr><td>2016-06-14</td><td>11:04</td><td>Adrenaline (NEB)</td><td>5 mg</td><td>Nebuliser mask</td><td>No</td><td>A note about Adrenaline (NEB)</td></tr><tr><td>2016-06-14</td><td>11:05</td><td>Adrenaline (IM, IN)</td><td>0.3 mg</td><td>Intramuscular</td><td>No</td><td>A note about Adrenaline (IM, IN)</td></tr><tr><td>2016-06-14</td><td>11:06</td><td>Adrenaline (IV for arrest)</td><td>1 mg</td><td>Intravenous</td><td>No</td><td>A note about Adrenaline (IV for arrest)</td></tr><tr><td>2016-06-14</td><td>11:07</td><td>Amiodarone (IV for arrest)</td><td>300 mg</td><td>Intravenous</td><td>No</td><td>A note about Amiodarone (IV for arrest)</td></tr><tr><td>2016-06-14</td><td>11:08</td><td>Amiodarone (bolus)</td><td>300 mg</td><td>Intravenous</td><td>No</td><td>A note about Amiodarone (bolus)</td></tr><tr><td>2016-06-14</td><td>11:09</td><td>Amiodarone (infusion)</td><td>300 mg</td><td>Intravenous</td><td>No</td><td>A note about Amiodarone (infusion)</td></tr><tr><td>2016-06-14</td><td>11:10</td><td>Aspirin</td><td>300 mg</td><td>Per oral</td><td>No</td><td>A note about Aspirin</td></tr><tr><td>2016-06-14</td><td>11:11</td><td>Atropine</td><td>0.6 mg</td><td>Intravenous</td><td>No</td><td>A note about Atropine</td></tr><tr><td>2016-06-14</td><td>11:12</td><td>Calcium chloride</td><td>1 g</td><td>Intravenous</td><td>No</td><td>A note about Calcium chloride</td></tr><tr><td>2016-06-14</td><td>11:13</td><td>Ceftriaxone</td><td>2 g</td><td>Intravenous</td><td>No</td><td>A note about Ceftriaxone</td></tr><tr><td>2016-06-14</td><td>11:14</td><td>Clopidogrel</td><td>600 mg</td><td>Per oral</td><td>No</td><td>A note about Clopidogrel</td></tr><tr><td>2016-06-14</td><td>11:15</td><td>Entonox</td><td>Dose not recorded</td><td>Inhalation</td><td>Yes</td><td>A note about Entonox</td></tr><tr><td>2016-06-14</td><td>11:16</td><td>Fentanyl</td><td>10 mcg</td><td>Subcutaneous</td><td>No</td><td>A note about Fentanyl</td></tr><tr><td>2016-06-14</td><td>11:17</td><td>Glucagon</td><td>1 mg</td><td>Intramuscular</td><td>No</td><td>A note about Glucagon</td></tr><tr><td>2016-06-14</td><td>11:18</td><td>Oral Glucose (sachet)</td><td>10 g</td><td>Per oral</td><td>No</td><td>A note about Oral Glucose (sachet)</td></tr><tr><td>2016-06-14</td><td>11:19</td><td>10% Glucose</td><td>100 mL</td><td>Intravenous</td><td>No</td><td>A note about 10% Glucose</td></tr><tr><td>2016-06-14</td><td>11:20</td><td>GTN</td><td>0.4 mg</td><td>Sublingual</td><td>No</td><td>A note about GTN</td></tr><tr><td>2016-06-14</td><td>11:21</td><td>Ibuprofen</td><td>400 mg</td><td>Per oral</td><td>No</td><td>A note about Ibuprofen</td></tr><tr><td>2016-06-14</td><td>11:22</td><td>Ipratropium</td><td>500 mcg</td><td>Nebuliser mask</td><td>No</td><td>A note about Ipratropium</td></tr><tr><td>2016-06-14</td><td>11:23</td><td>Ipratropium (MDI)</td><td>1 puff</td><td>Inhalation</td><td>No</td><td>A note about Ipratropium (MDI)</td></tr><tr><td>2016-06-14</td><td>11:24</td><td>Ketamine</td><td>10 mg</td><td>Intravenous</td><td>No</td><td>A note about Ketamine</td></tr><tr><td>2016-06-14</td><td>11:25</td><td>Lignocaine</td><td>1 mL</td><td>Subcutaneous</td><td>No</td><td>A note about Lignocaine</td></tr><tr><td>2016-06-14</td><td>11:26</td><td>Lignocaine (SC for ring block)</td><td>1 mL</td><td>Subcutaneous</td><td>No</td><td>A note about Lignocaine (SC for ring block)</td></tr><tr><td>2016-06-14</td><td>11:27</td><td>Lignocaine (SC for cannulation)</td><td>0.1 mL</td><td>Subcutaneous</td><td>No</td><td>A note about Lignocaine (SC for cannulation)</td></tr><tr><td>2016-06-14</td><td>11:28</td><td>Loratadine</td><td>10 mg</td><td>Per oral</td><td>No</td><td>A note about Loratadine</td></tr><tr><td>2016-06-14</td><td>11:29</td><td>Methoxyflurane</td><td>3 mL</td><td>Inhalation</td><td>No</td><td>A note about Methoxyflurane</td></tr><tr><td>2016-06-14</td><td>11:30</td><td>Midazolam (IM)</td><td>5 mg</td><td>Intramuscular</td><td>No</td><td>A note about Midazolam (IM)</td></tr><tr><td>2016-06-14</td><td>11:31</td><td>Midazolam</td><td>0.5 mg</td><td>Intravenous</td><td>No</td><td>A note about Midazolam</td></tr><tr><td>2016-06-14</td><td>11:32</td><td>Morphine</td><td>1 mg</td><td>Intravenous</td><td>No</td><td>A note about Morphine</td></tr><tr><td>2016-06-14</td><td>11:33</td><td>Naloxone</td><td>0.1 mg</td><td>Intravenous</td><td>No</td><td>A note about Naloxone</td></tr><tr><td>2016-06-14</td><td>11:34</td><td>Ondansetron (injection)</td><td>4 mg</td><td>Intravenous</td><td>No</td><td>A note about Ondansetron (injection)</td></tr><tr><td>2016-06-14</td><td>11:35</td><td>Ondansetron (wafer)</td><td>4 mg</td><td>Per oral</td><td>No</td><td>A note about Ondansetron (wafer)</td></tr><tr><td>2016-06-14</td><td>11:36</td><td>Other (specify in Notes)</td><td>12.5 mg</td><td>Per oral</td><td>No</td><td>Patients own Quinapril</td></tr><tr><td>2016-06-14</td><td>11:37</td><td>Oxygen</td><td>1 L/min</td><td>Inhalation</td><td>No</td><td>A note about Oxygen</td></tr><tr><td>2016-06-14</td><td>11:38</td><td>Oxytocin</td><td>5 units</td><td>Intramuscular</td><td>No</td><td>A note about Oxytocin</td></tr><tr><td>2016-06-14</td><td>11:39</td><td>Paracetamol (tablet)</td><td>1000 mg</td><td>Per oral</td><td>No</td><td>A note about Paracetamol (tablet)</td></tr><tr><td>2016-06-14</td><td>11:40</td><td>Paracetamol (syrup)</td><td>1000 mg</td><td>Per oral</td><td>No</td><td>A note about Paracetamol (syrup)</td></tr><tr><td>2016-06-14</td><td>11:41</td><td>Prednisone</td><td>40 mg</td><td>Per oral</td><td>No</td><td>A note about Prednisone</td></tr><tr><td>2016-06-14</td><td>11:42</td><td>Rocuronium</td><td>50 mg</td><td>Intravenous</td><td>No</td><td>A note about Rocuronium</td></tr><tr><td>2016-06-14</td><td>11:43</td><td>Salbutamol</td><td>5 mg</td><td>Nebuliser mask</td><td>No</td><td>A note about Salbutamol</td></tr><tr><td>2016-06-14</td><td>11:44</td><td>Salbutamol (MDI)</td><td>1 puff</td><td>Inhalation</td><td>No</td><td>A note about Salbutamol (MDI)</td></tr><tr><td>2016-06-14</td><td>11:45</td><td>Salbutamol + Ipratropium MDI</td><td>1 puff</td><td>Inhalation</td><td>No</td><td>A note about Salbutamol + Ipratropium MDI</td></tr><tr><td>2016-06-14</td><td>11:46</td><td>Sodium bicarbonate</td><td>100 mL</td><td>Intravenous</td><td>No</td><td>A note about Sodium bicarbonate</td></tr><tr><td>2016-06-14</td><td>11:47</td><td>0.9% Sodium chloride</td><td>50 mL</td><td>Intravenous</td><td>No</td><td>A note about 0.9% Sodium chloride</td></tr><tr><td>2016-06-14</td><td>11:48</td><td>Suxamethonium</td><td>100 mg</td><td>Intravenous</td><td>No</td><td>A note about Suxamethonium</td></tr><tr><td>2016-06-14</td><td>11:49</td><td>Tramadol</td><td>50 mg</td><td>Per oral</td><td>No</td><td>A note about Tramadol</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-adenosine"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-adrenaline-bolus"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-adrenaline-infusion"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-adrenaline-neb"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-adrenaline-im-in"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-adrenaline-arrest"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-amiodarone-arrest"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-amiodarone-bolus"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-amiodarone-infusion"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-aspirin"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-atropine"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-calcium-chloride"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-ceftriaxone"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-clopidogrel"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-entonox"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-fentanyl"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-glucagon"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-oral-glucose"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-glucose-10-percent"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-gtn"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-ibuprofen"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-ipratropium-neb"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-ipratropium-mdi"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-ketamine"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-lignocaine"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-lignocaine-ring-block"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-lignocaine-cannulation"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-loratadine"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-methoxyflurane"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-midazolam-im"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-midazolam-iv"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-morphine"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-naloxone"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-ondansetron-injection"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-ondansetron-wafer"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-other-quinapril"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-oxygen"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-oxytocin"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-paracetamol-tablet"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-paracetamol-syrup"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-prednisone"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-rocuronium"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-salbutamol-neb"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-salbutamol-mdi"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-salbutamol-ipratropium-mdi"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-sodium-bicarbonate"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-sodium-chloride"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-suxamethonium"
},
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-cda-med-tramadol"
}
]
},
{
"title": "Procedures",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "47519-4",
"display": "History of procedures"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Procedures</h3><table><thead><tr><th>Date</th><th>Time</th><th>Procedure</th><th>Detail / body site</th><th>Outcome</th><th>Notes</th></tr></thead><tbody><tr><td>2016-06-14</td><td>11:52</td><td>Airway Management Manual Clear</td><td>Airway</td><td>Not recorded</td><td>A note about Manual Clear</td></tr><tr><td>2016-06-14</td><td>11:53</td><td>Airway Management Suction</td><td>Airway</td><td>Not recorded</td><td>A note about Suction</td></tr><tr><td>2016-06-14</td><td>11:54</td><td>Airway Management OPA</td><td>Airway</td><td>Unsuccessful</td><td>A note about OPA</td></tr><tr><td>2016-06-14</td><td>11:55</td><td>Airway Management NPA</td><td>Airway</td><td>Unsuccessful</td><td>A note about NPA</td></tr><tr><td>2016-06-14</td><td>11:56</td><td>Airway Management LMA</td><td>Airway</td><td>Unsuccessful</td><td>A note about LMA</td></tr><tr><td>2016-06-14</td><td>11:57</td><td>Airway Management Intubation</td><td>Airway</td><td>Unsuccessful</td><td>A note about Intubation</td></tr><tr><td>2016-06-14</td><td>11:58</td><td>Airway Management Cricothyroidotomy</td><td>Airway</td><td>Unsuccessful</td><td>A note about Cricothyroidotomy</td></tr><tr><td>2016-06-14</td><td>11:59</td><td>Airway Management Laryngoscopy</td><td>Airway</td><td>Unsuccessful</td><td>A note about Laryngoscopy</td></tr><tr><td>2016-06-14</td><td>12:00</td><td>Airway Management Other Device</td><td>Airway</td><td>Not recorded</td><td>A note about Other Device</td></tr><tr><td>2016-06-14</td><td>12:01</td><td>Ventilation (Manual)</td><td>Manual ventilation</td><td>Not recorded</td><td>A note about Ventilation</td></tr><tr><td>2016-06-14</td><td>12:01</td><td>Cardioversion</td><td>Energy 360 J</td><td>Not recorded</td><td>A note about Cardioversion; CDA summary table also displays Cardioversion 25J at 12:07</td></tr><tr><td>2016-06-14</td><td>12:02</td><td>Catheter troubleshooting</td><td>Catheter</td><td>Unsuccessful</td><td>A note about Catheter troubleshooting</td></tr><tr><td>2016-06-14</td><td>12:03</td><td>Chest decompression</td><td>Right second intercostal, midclavicular</td><td>Unsuccessful</td><td>A note about Chest decompression</td></tr><tr><td>2016-06-14</td><td>12:03</td><td>CPAP</td><td>5 cmH2O</td><td>Not recorded</td><td>A note about CPAP</td></tr><tr><td>2016-06-14</td><td>12:03</td><td>CPR</td><td>Cardiac resuscitation</td><td>Not recorded</td><td>A note about CPR</td></tr><tr><td>2016-06-14</td><td>12:05</td><td>Defibrillation</td><td>Professional defibrillator monitor; 360 J</td><td>Not recorded</td><td>A note about Defibrillation</td></tr><tr><td>2016-06-14</td><td>12:06</td><td>Defibrillation AED</td><td>AED</td><td>Not recorded</td><td>A note about Defibrillation AED</td></tr><tr><td>2016-06-14</td><td>12:07</td><td>IO insertion</td><td>Left tibial</td><td>Unsuccessful</td><td>A note about IO insertion</td></tr><tr><td>2016-06-14</td><td>12:08</td><td>IV insertion</td><td>Right forearm</td><td>Unsuccessful</td><td>A note about IV insertion</td></tr><tr><td>2016-06-14</td><td>12:09</td><td>Valsalva</td><td>Valsalva manoeuvre</td><td>Not recorded</td><td>A note about Valsalva</td></tr><tr><td>2016-06-14</td><td>12:09</td><td>Limb reduction Wrist</td><td>Left wrist</td><td>Unsuccessful</td><td>A note about Limb reduction Wrist</td></tr><tr><td>2016-06-14</td><td>12:10</td><td>Limb reduction Elbow</td><td>Right elbow</td><td>Unsuccessful</td><td>A note about Limb reduction Elbow</td></tr><tr><td>2016-06-14</td><td>12:11</td><td>Limb reduction Shoulder</td><td>Left shoulder</td><td>Unsuccessful</td><td>A note about Limb reduction Shoulder</td></tr><tr><td>2016-06-14</td><td>12:12</td><td>Limb reduction Ankle</td><td>Right ankle</td><td>Unsuccessful</td><td>A note about Limb reduction Ankle</td></tr><tr><td>2016-06-14</td><td>12:13</td><td>Limb reduction Other</td><td>Other limb</td><td>Unsuccessful</td><td>A note about Limb reduction Other</td></tr><tr><td>2016-06-14</td><td>12:14</td><td>Pacing</td><td>Cardiac pacing</td><td>Unsuccessful</td><td>A note about Pacing</td></tr><tr><td>2016-06-14</td><td>12:15</td><td>PEEP</td><td>Valve size 5</td><td>Not recorded</td><td>A note about PEEP; CDA summary table displayed this at 12:02</td></tr><tr><td>2016-06-14</td><td>12:16</td><td>Positioning Recovery</td><td>Recovery position</td><td>Not recorded</td><td>A note about Positioning Recovery</td></tr><tr><td>2016-06-14</td><td>12:17</td><td>Positioning Supine</td><td>Supine position</td><td>Not recorded</td><td>A note about Positioning Supine</td></tr><tr><td>2016-06-14</td><td>12:18</td><td>Positioning Seated</td><td>Seated position</td><td>Not recorded</td><td>A note about Positioning Seated</td></tr><tr><td>2016-06-14</td><td>12:19</td><td>Positioning Lateral</td><td>Lateral position</td><td>Not recorded</td><td>A note about Positioning Lateral</td></tr><tr><td>2016-06-14</td><td>12:20</td><td>Positioning Semi-recumbent</td><td>Semi-recumbent position</td><td>Not recorded</td><td>A note about Positioning Semi-recumbent</td></tr><tr><td>2016-06-14</td><td>12:21</td><td>Positioning Prone</td><td>Prone position</td><td>Not recorded</td><td>A note about Positioning Prone</td></tr><tr><td>2016-06-14</td><td>12:22</td><td>Positioning Other</td><td>Other positioning</td><td>Not recorded</td><td>A note about Positioning Other</td></tr><tr><td>2016-06-14</td><td>12:23</td><td>RSI</td><td>Rapid sequence induction</td><td>Unsuccessful</td><td>A note about RSI; CDA summary table displayed RSI at 12:04</td></tr><tr><td>2016-06-14</td><td>12:24</td><td>Splint/dressing</td><td>Splint or dressing</td><td>Not recorded</td><td>A note about Splint/dressing</td></tr><tr><td>2016-06-14</td><td>12:25</td><td>Stomach decompression</td><td>Stomach decompression</td><td>Unsuccessful</td><td>A note about Stomach decompression</td></tr><tr><td>2016-06-14</td><td>12:26</td><td>Tourniquet</td><td>Leg</td><td>Unsuccessful</td><td>A note about Tourniquet</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-manual-clear"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-suction"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-opa"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-npa"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-lma"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-intubation"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-cricothyroidotomy"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-laryngoscopy"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-airway-other-device"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-ventilation-manual"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-cardioversion"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-catheter-troubleshooting"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-chest-decompression"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-cpap"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-cpr"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-defibrillation"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-defibrillation-aed"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-io-insertion"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-iv-insertion"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-valsalva"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-limb-reduction-wrist"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-limb-reduction-elbow"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-limb-reduction-shoulder"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-limb-reduction-ankle"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-limb-reduction-other"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-pacing"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-peep"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-position-recovery"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-position-supine"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-position-seated"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-position-lateral"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-position-semi-recumbent"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-position-prone"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-position-other"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-rsi"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-splint-dressing"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-stomach-decompression"
},
{
"reference": "https://example.org/fhir/Procedure/acs-cda-proc-tourniquet"
}
]
},
{
"title": "Transport/treatment Refusal",
"code": {
"coding": [
{
"system": "https://fhir-ig.digital.health.nz/ambulance-care-summary/CodeSystem/acs-metadata",
"code": "section-refusal",
"display": "Transport/treatment refusal"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Transport/treatment Refusal</h3><table><tbody><tr><th>Treatment required</th><td>Yes</td></tr><tr><th>Transport required</th><td>Yes</td></tr><tr><th>Consulted with</th><td>Patients mother</td></tr><tr><th>Reason for refusal</th><td>Doesnt like hospital</td></tr><tr><th>Consequences explained</th><td>Possible blindness, insanity and death</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-refusal"
}
]
},
{
"title": "Patient Competence",
"code": {
"coding": [
{
"system": "https://fhir-ig.digital.health.nz/ambulance-care-summary/CodeSystem/acs-metadata",
"code": "section-competence",
"display": "Patient competence"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Patient Competence</h3><table><tbody><tr><th>Assessment date and time</th><td>2016-06-14 11:00 +12:00</td></tr><tr><th>Patient appears able to understand information provided to them on proposed treatments</th><td>Yes</td></tr><tr><th>Patient appears able to understand the consequences of their decisions</th><td>Yes</td></tr><tr><th>Patient appears able to remember information given to them</th><td>Yes</td></tr><tr><th>Patient has attempted or expressed serious thoughts of self-harm</th><td>No</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-cda-competence"
}
]
},
{
"title": "Care Plan",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Plan of care"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Care Plan</h3><table><tbody><tr><th>Advice to Patient</th><td>Per asthma leaflet<br/>Recommend ask Housing NZ to remove privet bush</td></tr><tr><th>Advice to GP</th><td>Pt states stressors at home which seem to precipitate asthma attacks<br/>Also note flowering privet bush outside front door see photo</td></tr><tr><th>Referral pathway</th><td>GP Surgery Appointment</td></tr><tr><th>Referral reason / notes</th><td>Recommend GP appt to get more meds</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/CarePlan/acs-cda-careplan"
},
{
"reference": "https://example.org/fhir/ServiceRequest/acs-cda-referral-gp"
}
]
},
{
"title": "Clinical Images",
"code": {
"coding": [
{
"system": "https://fhir-ig.digital.health.nz/ambulance-care-summary/CodeSystem/acs-metadata",
"code": "section-clinical-images",
"display": "Clinical images"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Clinical Images</h3><table><thead><tr><th>Image</th><th>Reference</th><th>Body site / context</th><th>Note</th></tr></thead><tbody><tr><td>Vehicle diagram</td><td>vehicle.jpg</td><td>Road traffic accident details</td><td>Vehicle diagram</td></tr><tr><td>Body diagram front</td><td>body-front.jpg</td><td>Body front</td><td>Body diagram (front)</td></tr><tr><td>Body diagram back</td><td>body-back.jpg</td><td>Body back</td><td>Body diagram (back)</td></tr><tr><td>Photo 1</td><td>image-01.jpg</td><td>Clinical image</td><td>Photo 1</td></tr><tr><td>Photo 2</td><td>image-02.jpg</td><td>Clinical image</td><td>Photo 2</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Media/acs-cda-image-vehicle"
},
{
"reference": "https://example.org/fhir/Media/acs-cda-image-body-front"
},
{
"reference": "https://example.org/fhir/Media/acs-cda-image-body-back"
},
{
"reference": "https://example.org/fhir/Media/acs-cda-image-01"
},
{
"reference": "https://example.org/fhir/Media/acs-cda-image-02"
}
]
}
]
}