FHIR IG analytics| Package | stjohn.ambulance-care-summary |
| Resource Type | Composition |
| Id | Composition-acs-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) |
| Patient | Bob Bobson |
| Encounter | 0450-1-2016/06/14 |
| Date | 2016-06-14 12:42 +12:00 |
| Author | Josephine Manu-Bloggs at Order of St John |
| Custodian | Order of St John |
The document includes incident details, smoking status, presenting problems, vital signs, medication administered, procedures, and follow-up care plan.
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "acs-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-patient-bob"
},
"encounter": {
"reference": "Encounter/acs-encounter"
},
"date": "2016-06-14T12:42:00+12:00",
"author": [
{
"reference": "PractitionerRole/acs-providerrole-josephine"
}
],
"title": "Ambulance Care Summary",
"custodian": {
"reference": "Organization/acs-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>Incident</th><td>0450-1-2016/06/14</td></tr><tr><th>Type</th><td>Land ambulance emergency encounter</td></tr><tr><th>Period</th><td>2016-06-14 11:13 to 12:42 +12:00</td></tr><tr><th>Patient status</th><td>Immediate threat to life at 11:30 +12:00</td></tr><tr><th>Disposition</th><td>Treat and transport to Sunshine Hospital Emergency Department</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Encounter/acs-encounter"
},
{
"reference": "https://example.org/fhir/Observation/acs-patient-status"
}
]
},
{
"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 at 2016-06-14 11:30 +12:00</td></tr><tr><th>Vaping status</th><td>No vaping status example recorded</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-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><table><tbody><tr><th>Presenting complaint</th><td>Severe respiratory distress (MPDS 6D1)</td></tr><tr><th>Encounter diagnosis</th><td>Asthma (SNOMED CT 195967001), active</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-presenting-complaint"
},
{
"reference": "https://example.org/fhir/Condition/acs-diagnosis-asthma"
}
]
},
{
"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><tbody><tr><th>Recorded time</th><td>2016-06-14 11:35 +12:00</td></tr><tr><th>Heart rate</th><td>136 /min</td></tr><tr><th>Respiratory rate</th><td>48 /min</td></tr><tr><th>Blood pressure</th><td>132/90 mm[Hg]</td></tr><tr><th>SpO2</th><td>95 %</td></tr><tr><th>Body temperature</th><td>38.6 Cel</td></tr><tr><th>Blood glucose</th><td>4.0 mmol/L</td></tr><tr><th>Glasgow coma score</th><td>15 {score}</td></tr><tr><th>Pain score</th><td>5 {score}</td></tr><tr><th>ECG interpretation</th><td>Atrial flutter</td></tr><tr><th>Skin condition</th><td>Diaphoretic (sweaty)</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Observation/acs-hr"
},
{
"reference": "https://example.org/fhir/Observation/acs-rr"
},
{
"reference": "https://example.org/fhir/Observation/acs-bp"
},
{
"reference": "https://example.org/fhir/Observation/acs-spo2"
},
{
"reference": "https://example.org/fhir/Observation/acs-temp"
},
{
"reference": "https://example.org/fhir/Observation/acs-bgl"
},
{
"reference": "https://example.org/fhir/Observation/acs-gcs"
},
{
"reference": "https://example.org/fhir/Observation/acs-pain"
},
{
"reference": "https://example.org/fhir/Observation/acs-ecg"
},
{
"reference": "https://example.org/fhir/Observation/acs-skin"
}
]
},
{
"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><tbody><tr><th>Medication</th><td>Adenosine</td></tr><tr><th>Time</th><td>2016-06-14 11:36 +12:00</td></tr><tr><th>Dose and route</th><td>6 mg by intravenous route</td></tr><tr><th>Performer</th><td>Josephine Manu-Bloggs, paramedic</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/MedicationAdministration/acs-medadmin-adenosine"
}
]
},
{
"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><tbody><tr><th>12:00 +12:00</th><td>Manual clearance of airway by Josephine Manu-Bloggs</td></tr><tr><th>12:06 +12:00</th><td>Cardiac defibrillation by Josephine Manu-Bloggs; outcome successful</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/Procedure/acs-proc-airway"
},
{
"reference": "https://example.org/fhir/Procedure/acs-proc-defib"
}
]
},
{
"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>Status</th><td>Active</td></tr><tr><th>Intent</th><td>Plan</td></tr><tr><th>Advice</th><td>Recommend GP appointment to review medication.</td></tr><tr><th>Note</th><td>Recommend GP appt to get more meds</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "https://example.org/fhir/CarePlan/acs-careplan"
}
]
}
]
}