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Packagetelus.dw.emr.extract-1-1-21
Resource TypeDocumentReference
IdDocumentReference-ma-ma-schema-1-DocumentReference-12001.json
FHIR VersionR4

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Narrative

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

Generated Narrative: DocumentReference ma-ma-schema-1-DocumentReference-12001

Last updated: 2023-12-18 23:07:47+0000;

Information Source: urn:telus:emr:ma:ma-schema-1

Security Label: normal (Details: Confidentiality code N = 'normal')

identifier: urn:telus:emr:ma:ma-schema-1:DocumentReference/12001 (use: official, )

status: Current

docStatus: Final

type: Clinical Summary Document

category: Clinical Note

subject: John Michael Smith

date: 2023-12-18 10:45:00+0000

author: Dr. Sarah Johnson

authenticator: Dr. Sarah Johnson

custodian: Main Street Family Practice

description: Comprehensive clinical summary from annual physical examination visit. Includes vital signs, laboratory results, current medications, and care plan.

securityLabel: normal

content

Attachments

-ContentTypeLanguageSizeHashTitleCreation
*application/pdfEnglish2457602jmj7l5rSw0yVb/vlWAYkK/YBwk=Annual Physical Examination Summary - December 18, 20232023-12-18 10:45:00+0000

format: IHE.FormatCode.codesystem: urn:ihe:iti:xds:2017:mimeTypeSufficient (mimeType Sufficient)

Contexts

-EncounterEventPeriodFacilityTypePracticeSettingRelated
*Encounter: identifier = urn:telus:emr:ma:ma-schema-1:Encounter#2001 (use: official, ); status = finished; class = ambulatory (ActCode#AMB); type = ; period = 2023-12-18 10:00:00+0000 --> 2023-12-18 10:45:00+0000; reasonCode = Care Provision2023-12-18 10:00:00+0000 --> 2023-12-18 10:45:00+0000Ambulatory care siteFamily practiceDiagnostic Report for 'Glucose [Mass/volume] in Serum or Plasma' for '->John Michael Smith'

Source1

{
  "resourceType": "DocumentReference",
  "id": "ma-ma-schema-1-DocumentReference-12001",
  "meta": {
    "lastUpdated": "2023-12-18T23:07:47Z",
    "source": "urn:telus:emr:ma:ma-schema-1",
    "security": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
        "code": "N",
        "display": "normal"
      }
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": [
    {
      "use": "official",
      "system": "urn:telus:emr:ma:ma-schema-1:DocumentReference",
      "value": "12001"
    }
  ],
  "status": "current",
  "docStatus": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "11503-0",
        "display": "Medical records"
      }
    ],
    "text": "Clinical Summary Document"
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code": "clinical-note",
          "display": "Clinical Note"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/ma-ma-schema-1-Patient-12345",
    "type": "Patient",
    "display": "John Michael Smith"
  },
  "date": "2023-12-18T10:45:00Z",
  "author": [
    {
      "reference": "Practitioner/ma-ma-schema-1-Practitioner-789",
      "type": "Practitioner",
      "display": "Dr. Sarah Johnson"
    }
  ],
  "authenticator": {
    "reference": "Practitioner/ma-ma-schema-1-Practitioner-789",
    "type": "Practitioner",
    "display": "Dr. Sarah Johnson"
  },
  "custodian": {
    "reference": "Organization/ma-ma-schema-1-Organization-0",
    "type": "Organization",
    "display": "Main Street Family Practice"
  },
  "description": "Comprehensive clinical summary from annual physical examination visit. Includes vital signs, laboratory results, current medications, and care plan.",
  "securityLabel": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
          "code": "N",
          "display": "normal"
        }
      ]
    }
  ],
  "content": [
    {
      "attachment": {
        "contentType": "application/pdf",
        "language": "en",
        "size": 245760,
        "hash": "2jmj7l5rSw0yVb/vlWAYkK/YBwk=",
        "title": "Annual Physical Examination Summary - December 18, 2023",
        "creation": "2023-12-18T10:45:00Z"
      },
      "format": {
        "system": "http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem",
        "code": "urn:ihe:iti:xds:2017:mimeTypeSufficient",
        "display": "mimeType Sufficient"
      }
    }
  ],
  "context": {
    "encounter": [
      {
        "reference": "Encounter/ma-ma-schema-1-Encounter-2001",
        "type": "Encounter"
      }
    ],
    "event": [
      {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code": "PCPR",
            "display": "Care Provision"
          }
        ]
      }
    ],
    "period": {
      "start": "2023-12-18T10:00:00Z",
      "end": "2023-12-18T10:45:00Z"
    },
    "facilityType": {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "35971002",
          "display": "Ambulatory care site"
        }
      ]
    },
    "practiceSetting": {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "419772000",
          "display": "Family practice"
        }
      ]
    },
    "related": [
      {
        "reference": "DiagnosticReport/ma-ma-schema-1-DiagnosticReport-9002",
        "type": "DiagnosticReport"
      }
    ]
  }
}