Document is valid ✅ ✅ ✅

Header

Composition/ee05e1da-df1b-7f7e-166c-e182e1d39f86

{
  "date" : "2023-02-02",
  "encounter" : {
    "reference" : "urn:uuid:7cea44f9-8268-f31c-3fd1-b4b0748d867c"
  },
  "section" : [ {
    "title" : "Hospital Course",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nMs. Alice Newman is a 45 year old female with a history of Hypertension, Hypothyroidism, Iron\ndeficiency and is a recipient of Renal Allograft visits Neighborhood Physicians Practice on 6/22/2015 at\n10am EST. The patient disclosed history of nausea, loose stools and weakness. After initial examination\nthe patient was found to have fever, she was administered necessary medications and after examining\nthe history of the patient and the lab results, the doctor suspected anemia. So the patient was referred\nto Community Health Hospitals an Inpatient facility to get appropriate treatment and was asked to\nwatch for appropriate changes in body temperature, blood pressure and take nebulizer treatment as\nneeded. \n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Hospital course Narrative",
      "coding" : [ {
        "code" : "8648-8",
        "display" : "Hospital course Narrative",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Consultation Notes",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Consultation Notes\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Consultation note",
      "coding" : [ {
        "code" : "11488-4",
        "display" : "Consultation note",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Discharge Instructions",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Discharge Instructions\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Discharge instructions",
      "coding" : [ {
        "code" : "8653-8",
        "display" : "Discharge instructions",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Problems",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nActive Problems\nProblem\nNoted Date\nDiagnosed Date\nEssential hypertension\n~\n~\nSevere hypothyroidism\n~\n~\nChronic rejection of renal transplant\n~\n~\nFever (finding)\n~\n~\n</table>\n<table width='100%' border='1'>\nResolved Problems\nProblem\nNoted Date\nDiagnosed Date\nResolved Date\nOverweight (finding)\n12/31/2006 12:00AM UTC\n~\n~\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "entry" : [ {
      "reference" : "urn:uuid:aabdb608-8104-8548-b6db-29c1309da38b"
    }, {
      "reference" : "urn:uuid:dcf226d4-a514-0a62-84ab-85519dc4ad8b"
    }, {
      "reference" : "urn:uuid:0d0d5e1b-4c7c-0ba3-0262-fca578dc30b5"
    }, {
      "reference" : "urn:uuid:1757143d-7bd9-d8bf-3cc6-86313392ce83"
    }, {
      "reference" : "urn:uuid:12f77259-adfc-2136-060a-2587518b28d7"
    } ],
    "code" : {
      "text" : "Problems",
      "coding" : [ {
        "code" : "11450-4",
        "display" : "Problems",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Medications",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nMedications List\nMedication\nTiming\nRoute\nFreq\nDose\nCeftriaxone 100 MG/ML\n~\nInjection\nInjectable, two times daily, 1 unit\n1 \nTylenol 500mg\n~\nOral\nPRN\n1 \nAranesp 0.5 MG/ML\n~\nInjection\nInjectable, once a week, 1 unit\n1 \n</table>\n<table width='100%' border='1'>\nAdministered Medications\nMedication\nDate\nRoute\nDose\nNo records\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "entry" : [ {
      "reference" : "urn:uuid:8b699fa1-3d49-b751-263d-f4ebba1b2453"
    }, {
      "reference" : "urn:uuid:8eb46178-438e-f43a-4947-2061e16d42a4"
    }, {
      "reference" : "urn:uuid:5504594f-861a-9ef9-29a2-67ed970fbbca"
    } ],
    "code" : {
      "text" : "History of Medication use",
      "coding" : [ {
        "code" : "10160-0",
        "display" : "History of Medication use",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Social History",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nElement\nDate\nValue\nTobacco smoking status NHIS\n06/22/2015 12:00AM UTC\nCurrent every day smoker\nSex Assigned At Birth\n~\nFemale\n</table>\n</div>\n",
      "status" : "generated"
    },
    "entry" : [ {
      "reference" : "urn:uuid:3f35fa99-ece7-53aa-de2f-6b8dc59987a1"
    }, {
      "reference" : "urn:uuid:51f6aecc-48a5-9a00-5946-37a24c82a187"
    } ],
    "code" : {
      "text" : "Social History",
      "coding" : [ {
        "code" : "29762-2",
        "display" : "Social History",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Mental Status",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Mental Status\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Mental Status Narrative",
      "coding" : [ {
        "code" : "10190-7",
        "display" : "Mental Status Narrative",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Laboratory Notes",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nAlbert Davis - 06/22/2015 12:00AM UTC\nMs Alice Newman was tested for the Urinanalysis macro panel and the results have been found to be\nnormal.\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Laboratory Report",
      "coding" : [ {
        "code" : "11502-2",
        "display" : "Laboratory Report",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Plan of treatment",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\ni. Get an EKG done on 6/23/2015. \n\n    ii. Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract\n    Structure. \n\n    iii. Take Clindamycin 300mg three times a day as needed if pain does not subside \n\n    iv. Schedule follow on visit with Neighborhood Physicians Practice on  7/1/2015\n\n    v. Urinanalysis macro (dipstick) panel (24356-8) on 6/29/2015\n</div>\n",
      "status" : "generated"
    },
    "entry" : [ {
      "reference" : "urn:uuid:149f084e-0632-8de9-3ffa-40b19c82c8b3"
    } ],
    "code" : {
      "text" : "Plan of treatment",
      "coding" : [ {
        "code" : "18776-5",
        "display" : "Plan of treatment",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Progress Notes",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nAlbert Davis - 06/22/2015 12:00AM UTC\nMs Alice Newman seems to be developing high fever and hence we recommend her to get admitted to a\nnearby hospital using the provided referral.\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Progress Note",
      "coding" : [ {
        "code" : "11506-3",
        "display" : "Progress Note",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Functional Status",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Functional Status\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Functional Status",
      "coding" : [ {
        "code" : "47420-5",
        "display" : "Functional Status",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Vital Signs",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nVital sign\nDate\nValue and units\nBlood Pressure Systolic\n06/22/2015 3:08PM UTC\n145 mm[Hg]\nBlood Pressure Diastolic\n06/22/2015 3:08PM UTC\n88 mm[Hg]\nHeart Rate\n06/22/2015 3:10PM UTC\n80 /min\nBody Temperature\n06/22/2015 3:15PM UTC\n38 Cel\nRespiratory Rate\n06/22/2015 3:15PM UTC\n18 /min\nO2 % BldC Oximetry\n06/22/2015 3:12PM UTC\n95 %\nInhaled Oxygen Concentration\n06/22/2015 3:12PM UTC\n36 %\nWeight\n06/22/2015 3:05PM UTC\n88 kg\nHeight\n06/22/2015 3:05PM UTC\n177 cm\nBMI\n~\n~\nHead Occipital Circumference\n~\n~\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "entry" : [ {
      "reference" : "urn:uuid:d6816f09-b2b6-635d-cf7d-d2a7bea85ebf"
    }, {
      "reference" : "urn:uuid:ee5bd849-e16f-8794-61d9-c2f17c16bba5"
    }, {
      "reference" : "urn:uuid:76cb314b-643c-b670-90fe-d956bcaaa22c"
    }, {
      "reference" : "urn:uuid:fe8f9772-838d-0f88-5637-85882b416929"
    }, {
      "reference" : "urn:uuid:d09b31e9-6fc6-9df1-1ea2-783f4589c710"
    }, {
      "reference" : "urn:uuid:ca1aec55-d8dd-a9e0-546c-47d029cda2d3"
    }, {
      "reference" : "urn:uuid:5aa04ab6-1907-c68f-e9f1-4dd888d72cee"
    }, {
      "reference" : "urn:uuid:e1859cd1-905c-fce6-5bf9-ce63162dd866"
    }, {
      "reference" : "urn:uuid:e4e8698e-1ef5-7a8c-481d-b634dd02eb54"
    } ],
    "code" : {
      "text" : "Vitals",
      "coding" : [ {
        "code" : "8716-3",
        "display" : "Vitals",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Discharge Summary",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Discharge Summary\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Discharge Summary",
      "coding" : [ {
        "code" : "18842-5",
        "display" : "Discharge Summary",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Immunizations",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nVaccine\nDate\nStatus\nLot\nNotes\nTetanus and diphtheria toxoids\n01/04/2012 12:00AM UTC\ncompleted\nN/A\nN/A\nInfluenza, intradermal, quadrivalent, preservative-free\n06/22/2015 12:00AM UTC\nnot-done\nNo Lot number provided\nImmunization was not given - Patient rejected immunization\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "entry" : [ {
      "reference" : "urn:uuid:d3a539da-5627-e308-2a0d-0165ba89457b"
    }, {
      "reference" : "urn:uuid:835f1fa3-ae6a-ab1c-08e9-868f68fbeb83"
    } ],
    "code" : {
      "text" : "History of Immunization Narrative",
      "coding" : [ {
        "code" : "11369-6",
        "display" : "History of Immunization Narrative",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Procedures",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nProcedures\nDate\nStatus\nNebulizer Therapy\n06/22/2015 12:00AM UTC\ncompleted\nIntroduction of cardiac pacemaker system via vein\n10/05/2011 12:00AM UTC\ncompleted\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "entry" : [ {
      "reference" : "urn:uuid:546d0928-424b-05e8-ee6e-2a70331b09aa"
    }, {
      "reference" : "urn:uuid:043a0ac8-d6fa-3e7b-e256-3b5f47e58cce"
    } ],
    "code" : {
      "text" : "History of Procedures Document",
      "coding" : [ {
        "code" : "47519-4",
        "display" : "History of Procedures Document",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "History And Physical Notes",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section History And Physical Notes\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "History And Physical Note",
      "coding" : [ {
        "code" : "34117-2",
        "display" : "History And Physical Note",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Results",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nUrinanalysis macro (dipstick) panel, No performer ID, No Lab, No Lab Address\n<table width='100%' border='1'>\nCode\nValue\nDate\nColor of urine\nYELLOW\n06/22/2015 12:00AM UTC\nAppearance of urine\nCLEAR\n06/22/2015 12:00AM UTC\nSpecific gravity of urine by test strip\n1.015 1\n06/22/2015 12:00AM UTC\npH of urine by test strip\n5.0 [pH]\n06/22/2015 12:00AM UTC\nGlucose [Mass/volume] in urine by test strip\n50 mg/dL\n06/22/2015 12:00AM UTC\nKetones [Mass/Volume] in urine by test strip\nNegative\n06/22/2015 12:00AM UTC\nProtein [Mass/Volume] in urine by test strip\n100 mg/dL\n06/22/2015 12:00AM UTC\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "entry" : [ {
      "reference" : "urn:uuid:48b5bc1e-8438-2247-d477-c0772aa5b993"
    } ],
    "code" : {
      "text" : "Results",
      "coding" : [ {
        "code" : "30954-2",
        "display" : "Results",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Encounters",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nDate\nType\nDepartment\nCareTeam\nDescription\nNo records\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "code" : {
      "text" : "Encounters",
      "coding" : [ {
        "code" : "46240-8",
        "display" : "Encounters",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Procedures Notes",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nAlbert Davis - 06/22/2015 12:00AM UTC\nDr Albert Davis examined Ms Alice Newman and found that the pacemaker is operating properly and the\nbreathlessness is due to high fever and anxiety.\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Procedures Note",
      "coding" : [ {
        "code" : "28570-0",
        "display" : "Procedures Note",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Assesments",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nThe patient was found to have fever and Dr Davis is suspecting Anemia\nbased on the patient history. So Dr Davis asked the patient to closely\nmonitor the temperature and blood pressure and get admitted to\nCommunity Health Hospitals if the fever does not subside within a day.\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Assessments",
      "coding" : [ {
        "code" : "51848-0",
        "display" : "Assessments",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Health Concerns",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\na. Chronic Sickness exhibited by patient\nb. HealthCare Concerns refer to underlying clinical facts\ni. Documented HyperTension problem\nii. Documented HypoThyroidism problem\niii. Watch Weight of patient\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Health Concerns",
      "coding" : [ {
        "code" : "75310-3",
        "display" : "Health Concerns",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Medical Equipment",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nID\nAssigning Auth\nCode\nDate\n(01)00643169007222(17)160128(21)BLC200461H\nFDA\nCardiac resynchronization therapy implantable pacemaker\n10/05/2011 12:00AM UTC\n</table>\n</div>\n",
      "status" : "generated"
    },
    "entry" : [ {
      "reference" : "urn:uuid:546d0928-424b-05e8-ee6e-2a70331b09aa"
    } ],
    "code" : {
      "text" : "History of Medical Device Use",
      "coding" : [ {
        "code" : "46264-8",
        "display" : "History of Medical Device Use",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Payers",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Payers\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Payment Sources Narrative",
      "coding" : [ {
        "code" : "48768-6",
        "display" : "Payment Sources Narrative",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Goals",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\na. Get rid of intermittent fever that is occurring every few weeks. \n\n    b. Need to gain more energy to do regular activities\n</div>\n",
      "status" : "generated"
    },
    "code" : {
      "text" : "Goals",
      "coding" : [ {
        "code" : "61146-7",
        "display" : "Goals",
        "system" : "http://loinc.org"
      } ]
    }
  }, {
    "title" : "Allergies and Intolerances",
    "text" : {
      "div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nType\nSubstance\nOnset\nReactions\nStatus\nallergy\nAmpicillin\n10/05/1980 12:00AM UTC\n10/05/1980 12:00AM UTC - Hives - moderate\nactive\nN/A\nPenicillin G\n10/05/1980 12:00AM UTC\n10/05/1980 12:00AM UTC - Hives - moderate\nactive\n</table>\n</div>\n",
      "status" : "generated"
    },
    "extension" : [ {
      "valueBoolean" : true,
      "url" : "entries-required"
    } ],
    "entry" : [ {
      "reference" : "urn:uuid:b2867e9f-330b-52be-3e42-f80e9c9a281b"
    }, {
      "reference" : "urn:uuid:49d280d2-2cf8-0eb4-5aa3-876f1de53c1b"
    } ],
    "code" : {
      "text" : "Allergies",
      "coding" : [ {
        "code" : "48765-2",
        "display" : "Allergies",
        "system" : "http://loinc.org"
      } ]
    }
  } ],
  "type" : {
    "text" : "Summarization of Episode Note",
    "coding" : [ {
      "code" : "34133-9",
      "display" : "Summarization of Episode Note",
      "system" : "http://loinc.org"
    } ]
  },
  "resourceType" : "Composition",
  "title" : "Summarization of Episode Note",
  "author" : [ {
    "reference" : "urn:uuid:eadba377-78d1-3140-a4bc-9b0f87867ef6"
  } ],
  "custodian" : {
    "reference" : "urn:uuid:abe6dad0-cfe3-2865-3d04-d97a7fa4e18d"
  },
  "status" : "final",
  "id" : "ee05e1da-df1b-7f7e-166c-e182e1d39f86",
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Patient/patient

{
  "address" : [ {
    "line" : [ "1357 Amber Dr" ],
    "use" : "home",
    "city" : "Beaverton",
    "state" : "OR",
    "postalCode" : "97006",
    "country" : "USA"
  } ],
  "name" : [ {
    "given" : [ "Alice", "Jones" ],
    "family" : "Newman",
    "use" : "official"
  }, {
    "given" : [ "Alicia" ],
    "family" : "Newman",
    "use" : "old"
  } ],
  "birthDate" : "1970-05-01",
  "resourceType" : "Patient",
  "extension" : [ {
    "extension" : [ {
      "valueCoding" : {
        "code" : "2106-3",
        "display" : "White",
        "system" : "urn:oid:2.16.840.1.113883.6.238"
      },
      "url" : "ombCategory"
    }, {
      "valueCoding" : {
        "code" : "2108-9",
        "display" : "White European",
        "system" : "urn:oid:2.16.840.1.113883.6.238"
      },
      "url" : "detailed"
    } ],
    "url" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-race"
  } ],
  "communication" : [ {
    "language" : {
      "coding" : [ {
        "code" : "en",
        "display" : "en",
        "system" : "urn:oid:"
      } ]
    },
    "preferred" : true
  } ],
  "id" : "patient",
  "telecom" : [ {
    "system" : "phone",
    "value" : "+1-(555)723-1544",
    "use" : "home"
  }, {
    "system" : "phone",
    "value" : "+1-(555)777-1234",
    "use" : "mobile"
  } ],
  "gender" : "female",
  "maritalStatus" : {
    "coding" : [ {
      "code" : "UNK",
      "display" : "Unknown",
      "system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"
    } ]
  }
}

PractitionerRole/6fb4eef9-561e-4fbd-ea5e-1e8817ce5de4

{
  "practitioner" : {
    "reference" : "urn:uuid:c9fd6361-151b-4bbf-ae45-802643f47070"
  },
  "id" : "6fb4eef9-561e-4fbd-ea5e-1e8817ce5de4",
  "organization" : {
    "reference" : "urn:uuid:abe6dad0-cfe3-2865-3d04-d97a7fa4e18d"
  },
  "resourceType" : "PractitionerRole",
  "period" : {
    "start" : "2015-06-22"
  }
}

Encounter/9fdca075-5b4a-c896-8856-8d87beebffeb

{
  "period" : {
    "start" : "2015-06-20",
    "end" : "2015-06-25"
  },
  "resourceType" : "Encounter",
  "status" : "finished",
  "class" : {
    "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
    "code" : "AMB",
    "display" : "AMB"
  },
  "id" : "9fdca075-5b4a-c896-8856-8d87beebffeb",
  "participant" : [ {
    "individual" : {
      "reference" : "urn:uuid:999fec79-8fbc-f8c7-a9d0-f3da469b7778"
    }
  }, {
    "individual" : {
      "reference" : "urn:uuid:eadba377-78d1-3140-a4bc-9b0f87867ef6"
    }
  } ]
}

Hospital Course (0 entries)

Ms. Alice Newman is a 45 year old female with a history of Hypertension, Hypothyroidism, Iron deficiency and is a recipient of Renal Allograft visits Neighborhood Physicians Practice on 6/22/2015 at 10am EST. The patient disclosed history of nausea, loose stools and weakness. After initial examination the patient was found to have fever, she was administered necessary medications and after examining the history of the patient and the lab results, the doctor suspected anemia. So the patient was referred to Community Health Hospitals an Inpatient facility to get appropriate treatment and was asked to watch for appropriate changes in body temperature, blood pressure and take nebulizer treatment as needed.

Consultation Notes (0 entries)

No data for section Consultation Notes

Discharge Instructions (0 entries)

No data for section Discharge Instructions

Problems (5 entries)

Active Problems Problem Noted Date Diagnosed Date Essential hypertension ~ ~ Severe hypothyroidism ~ ~ Chronic rejection of renal transplant ~ ~ Fever (finding) ~ ~
Resolved Problems Problem Noted Date Diagnosed Date Resolved Date Overweight (finding) 12/31/2006 12:00AM UTC ~ ~

Condition/1c063b41-c058-b10c-746b-7d261e3d53ae

{
  "category" : [ {
    "coding" : [ {
      "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
      "code" : "problem-list-item",
      "display" : "Problem List Item"
    } ]
  } ],
  "clinicalStatus" : {
    "coding" : [ {
      "code" : "active",
      "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
    } ]
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
  },
  "resourceType" : "Condition",
  "id" : "1c063b41-c058-b10c-746b-7d261e3d53ae",
  "code" : {
    "text" : "Essential hypertension",
    "coding" : [ {
      "code" : "59621000",
      "display" : "Essential hypertension",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Condition/9cb49672-ad78-e186-9484-8c2bb407d045

{
  "category" : [ {
    "coding" : [ {
      "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
      "code" : "problem-list-item",
      "display" : "Problem List Item"
    } ]
  } ],
  "clinicalStatus" : {
    "coding" : [ {
      "code" : "active",
      "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
    } ]
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
  },
  "resourceType" : "Condition",
  "id" : "9cb49672-ad78-e186-9484-8c2bb407d045",
  "code" : {
    "text" : "Severe hypothyroidism",
    "coding" : [ {
      "code" : "83986005",
      "display" : "Severe hypothyroidism",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Condition/a0b57f97-9c33-5ce1-485e-c9cc6289d114

{
  "category" : [ {
    "coding" : [ {
      "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
      "code" : "problem-list-item",
      "display" : "Problem List Item"
    } ]
  } ],
  "clinicalStatus" : {
    "coding" : [ {
      "code" : "active",
      "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
    } ]
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
  },
  "resourceType" : "Condition",
  "id" : "a0b57f97-9c33-5ce1-485e-c9cc6289d114",
  "code" : {
    "text" : "Chronic rejection of renal transplant",
    "coding" : [ {
      "code" : "236578006",
      "display" : "Chronic rejection of renal transplant",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Condition/25be3422-8dea-a003-03a1-4c9253b084cb

{
  "category" : [ {
    "coding" : [ {
      "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
      "code" : "problem-list-item",
      "display" : "Problem List Item"
    } ]
  } ],
  "clinicalStatus" : {
    "coding" : [ {
      "code" : "active",
      "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
    } ]
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
  },
  "resourceType" : "Condition",
  "id" : "25be3422-8dea-a003-03a1-4c9253b084cb",
  "code" : {
    "text" : "Fever (finding)",
    "coding" : [ {
      "code" : "386661006",
      "display" : "Fever (finding)",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Condition/7d019ef8-b5a8-eecc-825a-af1f627de542

{
  "onsetDateTime" : "2006-12-31",
  "category" : [ {
    "coding" : [ {
      "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
      "code" : "problem-list-item",
      "display" : "Problem List Item"
    } ]
  } ],
  "clinicalStatus" : {
    "coding" : [ {
      "code" : "resolved",
      "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
    } ]
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
  },
  "resourceType" : "Condition",
  "id" : "7d019ef8-b5a8-eecc-825a-af1f627de542",
  "code" : {
    "text" : "Overweight (finding)",
    "coding" : [ {
      "code" : "238131007",
      "display" : "Overweight (finding)",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Medications (3 entries)

Medications List Medication Timing Route Freq Dose Ceftriaxone 100 MG/ML ~ Injection Injectable, two times daily, 1 unit 1 Tylenol 500mg ~ Oral PRN 1 Aranesp 0.5 MG/ML ~ Injection Injectable, once a week, 1 unit 1
Administered Medications Medication Date Route Dose No records

MedicationStatement/f13f5e41-ec9d-5117-4e7e-1c213967311d

{
  "resourceType" : "MedicationStatement",
  "medicationCodeableConcept" : {
    "text" : "Ceftriaxone 100 MG/ML",
    "coding" : [ {
      "code" : "309090",
      "display" : "Ceftriaxone 100 MG/ML",
      "system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
    } ]
  },
  "id" : "f13f5e41-ec9d-5117-4e7e-1c213967311d",
  "status" : "active",
  "dosage" : [ {
    "route" : {
      "text" : "Injection",
      "coding" : [ {
        "code" : "C38276",
        "display" : "Injection",
        "system" : "http://ncithesaurus-stage.nci.nih.gov"
      } ]
    },
    "text" : "Injectable, two times daily, 1 unit",
    "doseAndRate" : [ {
      "doseQuantity" : {
        "value" : 1.0
      }
    } ],
    "asNeededBoolean" : true
  } ],
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

MedicationStatement/38b9bc17-bcfc-3db1-8be6-5a30c11cc4b1

{
  "resourceType" : "MedicationStatement",
  "medicationCodeableConcept" : {
    "text" : "Tylenol 500mg",
    "coding" : [ {
      "code" : "209459",
      "display" : "Tylenol 500mg",
      "system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
    } ]
  },
  "id" : "38b9bc17-bcfc-3db1-8be6-5a30c11cc4b1",
  "status" : "active",
  "dosage" : [ {
    "route" : {
      "text" : "Oral",
      "coding" : [ {
        "code" : "C38288",
        "display" : "Oral",
        "system" : "http://ncithesaurus-stage.nci.nih.gov"
      } ]
    },
    "text" : "Oral, as needed, 1 unit",
    "doseAndRate" : [ {
      "doseQuantity" : {
        "value" : 1.0
      }
    } ],
    "asNeededBoolean" : true
  } ],
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

MedicationStatement/d8aa38f1-e9e4-07b6-a264-949552d94e9e

{
  "resourceType" : "MedicationStatement",
  "medicationCodeableConcept" : {
    "text" : "Aranesp 0.5 MG/ML",
    "coding" : [ {
      "code" : "731241",
      "display" : "Aranesp 0.5 MG/ML",
      "system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
    } ]
  },
  "id" : "d8aa38f1-e9e4-07b6-a264-949552d94e9e",
  "status" : "active",
  "dosage" : [ {
    "route" : {
      "text" : "Injection",
      "coding" : [ {
        "code" : "C38276",
        "display" : "Injection",
        "system" : "http://ncithesaurus-stage.nci.nih.gov"
      } ]
    },
    "text" : "Injectable, once a week, 1 unit",
    "doseAndRate" : [ {
      "doseQuantity" : {
        "value" : 1.0
      }
    } ],
    "asNeededBoolean" : true
  } ],
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Social History (2 entries)

Element Date Value Tobacco smoking status NHIS 06/22/2015 12:00AM UTC Current every day smoker Sex Assigned At Birth ~ Female

Observation/fbaaacd0-78b5-fbc5-259c-b4caeb23f928

{
  "category" : [ {
    "coding" : [ {
      "code" : "social-history",
      "display" : "Social History",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueCodeableConcept" : {
    "text" : "Current every day smoker",
    "coding" : [ {
      "code" : "449868002",
      "display" : "Current every day smoker",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22",
  "id" : "fbaaacd0-78b5-fbc5-259c-b4caeb23f928",
  "code" : {
    "text" : "Tobacco smoking status NHIS",
    "coding" : [ {
      "code" : "72166-2",
      "display" : "Tobacco smoking status NHIS",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/9e1b5cec-aba1-4791-e4e3-3a802aa8d6c1

{
  "category" : [ {
    "coding" : [ {
      "code" : "social-history",
      "display" : "Social History",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueCodeableConcept" : {
    "text" : "Female",
    "coding" : [ {
      "code" : "F",
      "display" : "Female",
      "system" : "urn:oid:2.16.840.1.113883.5.1"
    } ]
  },
  "resourceType" : "Observation",
  "status" : "final",
  "id" : "9e1b5cec-aba1-4791-e4e3-3a802aa8d6c1",
  "code" : {
    "text" : "Sex Assigned At Birth",
    "coding" : [ {
      "code" : "76689-9",
      "display" : "Sex Assigned At Birth",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Mental Status (0 entries)

No data for section Mental Status

Laboratory Notes (0 entries)

Albert Davis - 06/22/2015 12:00AM UTC Ms Alice Newman was tested for the Urinanalysis macro panel and the results have been found to be normal.

Plan of treatment (1 entries)

i. Get an EKG done on 6/23/2015. ii. Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure. iii. Take Clindamycin 300mg three times a day as needed if pain does not subside iv. Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015 v. Urinanalysis macro (dipstick) panel (24356-8) on 6/29/2015

Observation/f3d50e78-42e2-f89b-a915-2d784c48b256

{
  "resourceType" : "Observation",
  "status" : "registered",
  "effectiveDateTime" : "2015-06-29T00:00:00Z",
  "id" : "f3d50e78-42e2-f89b-a915-2d784c48b256",
  "code" : {
    "text" : "Urinanalysis macro (dipstick) panel",
    "coding" : [ {
      "code" : "24356-8",
      "display" : "Urinanalysis macro (dipstick) panel",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Progress Notes (0 entries)

Albert Davis - 06/22/2015 12:00AM UTC Ms Alice Newman seems to be developing high fever and hence we recommend her to get admitted to a nearby hospital using the provided referral.

Functional Status (0 entries)

No data for section Functional Status

Vital Signs (9 entries)

Vital sign Date Value and units Blood Pressure Systolic 06/22/2015 3:08PM UTC 145 mm[Hg] Blood Pressure Diastolic 06/22/2015 3:08PM UTC 88 mm[Hg] Heart Rate 06/22/2015 3:10PM UTC 80 /min Body Temperature 06/22/2015 3:15PM UTC 38 Cel Respiratory Rate 06/22/2015 3:15PM UTC 18 /min O2 % BldC Oximetry 06/22/2015 3:12PM UTC 95 % Inhaled Oxygen Concentration 06/22/2015 3:12PM UTC 36 % Weight 06/22/2015 3:05PM UTC 88 kg Height 06/22/2015 3:05PM UTC 177 cm BMI ~ ~ Head Occipital Circumference ~ ~

Observation/92eff251-27f6-3afa-bc22-86bb719946a3

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 88,
    "unit" : "kg"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:05:00-05:00",
  "id" : "92eff251-27f6-3afa-bc22-86bb719946a3",
  "code" : {
    "text" : "Weight",
    "coding" : [ {
      "code" : "29463-7",
      "display" : "Weight",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/69389369-1147-9a8e-768c-a404ce4159bd

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 80,
    "unit" : "/min"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:10:00-05:00",
  "id" : "69389369-1147-9a8e-768c-a404ce4159bd",
  "code" : {
    "text" : "Heart Rate",
    "coding" : [ {
      "code" : "8867-4",
      "display" : "Heart Rate",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/5cef3588-c3a8-f272-839a-a354fe357baa

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 18,
    "unit" : "/min"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:15:00-05:00",
  "id" : "5cef3588-c3a8-f272-839a-a354fe357baa",
  "code" : {
    "text" : "Respiratory Rate",
    "coding" : [ {
      "code" : "9279-1",
      "display" : "Respiratory Rate",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/d66c3562-f007-0815-4450-eaa7d5892d4b

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 88,
    "unit" : "mm[Hg]"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:08:00-05:00",
  "id" : "d66c3562-f007-0815-4450-eaa7d5892d4b",
  "code" : {
    "text" : "Blood Pressure Diastolic",
    "coding" : [ {
      "code" : "8462-4",
      "display" : "Blood Pressure Diastolic",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/0b10f3ca-1303-381d-a682-cb755df65828

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 38,
    "unit" : "Cel"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:15:00-05:00",
  "id" : "0b10f3ca-1303-381d-a682-cb755df65828",
  "code" : {
    "text" : "Body Temperature",
    "coding" : [ {
      "code" : "8310-5",
      "display" : "Body Temperature",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/ee745893-5338-378e-6153-a3bf5fce0bb8

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 95,
    "unit" : "%"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:12:00-05:00",
  "id" : "ee745893-5338-378e-6153-a3bf5fce0bb8",
  "code" : {
    "text" : "O2 % BldC Oximetry",
    "coding" : [ {
      "code" : "59408-5",
      "display" : "O2 % BldC Oximetry",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/8fa4f85d-c889-a715-1ebc-8e6c85b0b5bf

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 177,
    "unit" : "cm"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:05:00-05:00",
  "id" : "8fa4f85d-c889-a715-1ebc-8e6c85b0b5bf",
  "code" : {
    "text" : "Height",
    "coding" : [ {
      "code" : "8302-2",
      "display" : "Height",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/63dc71be-9ec9-6d30-4336-1dc386eedfcf

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 36,
    "unit" : "%"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:12:00-05:00",
  "id" : "63dc71be-9ec9-6d30-4336-1dc386eedfcf",
  "code" : {
    "text" : "Inhaled Oxygen Concentration",
    "coding" : [ {
      "code" : "3150-0",
      "display" : "Inhaled Oxygen Concentration",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Observation/9a4c7239-6053-d67f-5f25-e850ade9c3f0

{
  "category" : [ {
    "coding" : [ {
      "code" : "vital-signs",
      "display" : "Vital Signs",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "valueQuantity" : {
    "value" : 145,
    "unit" : "mm[Hg]"
  },
  "resourceType" : "Observation",
  "status" : "final",
  "effectiveDateTime" : "2015-06-22T10:08:00-05:00",
  "id" : "9a4c7239-6053-d67f-5f25-e850ade9c3f0",
  "code" : {
    "text" : "Blood Pressure Systolic",
    "coding" : [ {
      "code" : "8480-6",
      "display" : "Blood Pressure Systolic",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Discharge Summary (0 entries)

No data for section Discharge Summary

Immunizations (2 entries)

Vaccine Date Status Lot Notes Tetanus and diphtheria toxoids 01/04/2012 12:00AM UTC completed N/A N/A Influenza, intradermal, quadrivalent, preservative-free 06/22/2015 12:00AM UTC not-done No Lot number provided Immunization was not given - Patient rejected immunization

Immunization/3eda4363-c631-9793-c446-789a1c4583ec

{
  "patient" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
  },
  "vaccineCode" : {
    "text" : "Tetanus and diphtheria toxoids",
    "coding" : [ {
      "code" : "106",
      "display" : "Tetanus and diphtheria toxoids",
      "system" : "http://hl7.org/fhir/sid/cvx"
    } ]
  },
  "resourceType" : "Immunization",
  "primarySource" : false,
  "status" : "completed",
  "id" : "3eda4363-c631-9793-c446-789a1c4583ec",
  "lotNumber" : "N/A",
  "occurrenceDateTime" : "2012-01-04"
}

Immunization/d4935478-43cf-be05-049b-cf4705aa2dbc

{
  "patient" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
  },
  "vaccineCode" : {
    "text" : "Influenza, intradermal, quadrivalent, preservative-free",
    "coding" : [ {
      "code" : "166",
      "display" : "Influenza, intradermal, quadrivalent, preservative-free",
      "system" : "http://hl7.org/fhir/sid/cvx"
    } ]
  },
  "statusReason" : {
    "text" : "patient objection",
    "coding" : [ {
      "code" : "PATOBJ",
      "display" : "patient objection",
      "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason"
    } ]
  },
  "resourceType" : "Immunization",
  "primarySource" : false,
  "status" : "not-done",
  "id" : "d4935478-43cf-be05-049b-cf4705aa2dbc",
  "lotNumber" : "No Lot number provided",
  "occurrenceDateTime" : "2015-06-22"
}

Procedures (2 entries)

Procedures Date Status Nebulizer Therapy 06/22/2015 12:00AM UTC completed Introduction of cardiac pacemaker system via vein 10/05/2011 12:00AM UTC completed

Procedure/c44ac11b-e5d4-888c-6b0e-15ccbc0bd3f5

{
  "focalDevice" : [ {
    "manipulated" : {
      "reference" : "urn:uuid:96367297-2eac-9b27-bf43-6b5071a1b82f"
    },
    "action" : {
      "text" : "Cardiac resynchronization therapy implantable pacemaker",
      "coding" : [ {
        "code" : "704708004",
        "display" : "Cardiac resynchronization therapy implantable pacemaker",
        "system" : "http://snomed.info/sct"
      } ]
    }
  } ],
  "resourceType" : "Procedure",
  "extension" : [ {
    "valueCode" : "procedure",
    "url" : "rim-class"
  } ],
  "status" : "completed",
  "id" : "c44ac11b-e5d4-888c-6b0e-15ccbc0bd3f5",
  "performedDateTime" : "2011-10-05T00:00:00Z",
  "code" : {
    "text" : "Introduction of cardiac pacemaker system via vein",
    "coding" : [ {
      "code" : "175135009",
      "display" : "Introduction of cardiac pacemaker system via vein",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "bodySite" : [ {
    "text" : "Structure of subclavian vein",
    "coding" : [ {
      "code" : "9454009",
      "display" : "Structure of subclavian vein",
      "system" : "http://snomed.info/sct"
    } ]
  } ],
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Procedure/c5c3e76e-213c-e920-6e5e-9d0ddae53a1c

{
  "performedDateTime" : "2015-06-22T00:00:00Z",
  "resourceType" : "Procedure",
  "extension" : [ {
    "valueCode" : "act",
    "url" : "rim-class"
  } ],
  "status" : "completed",
  "id" : "c5c3e76e-213c-e920-6e5e-9d0ddae53a1c",
  "code" : {
    "text" : "Nebulizer Therapy",
    "coding" : [ {
      "code" : "56251003",
      "display" : "Nebulizer Therapy",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

History And Physical Notes (0 entries)

No data for section History And Physical Notes

Results (1 entries)

Urinanalysis macro (dipstick) panel, No performer ID, No Lab, No Lab Address Code Value Date Color of urine YELLOW 06/22/2015 12:00AM UTC Appearance of urine CLEAR 06/22/2015 12:00AM UTC Specific gravity of urine by test strip 1.015 1 06/22/2015 12:00AM UTC pH of urine by test strip 5.0 [pH] 06/22/2015 12:00AM UTC Glucose [Mass/volume] in urine by test strip 50 mg/dL 06/22/2015 12:00AM UTC Ketones [Mass/Volume] in urine by test strip Negative 06/22/2015 12:00AM UTC Protein [Mass/Volume] in urine by test strip 100 mg/dL 06/22/2015 12:00AM UTC

Observation/1cf59783-94ad-f34c-1c14-ac398cdc26c0

{
  "category" : [ {
    "coding" : [ {
      "code" : "laboratory",
      "display" : "Laboratory",
      "system" : "http://terminology.hl7.org/CodeSystem/observation-category"
    } ]
  } ],
  "hasMember" : [ {
    "reference" : "urn:uuid:3c30cf73-92ce-8755-de0e-2c110b2044f0"
  }, {
    "reference" : "urn:uuid:a334086c-eb07-e6b4-e96d-86646c9128e0"
  }, {
    "reference" : "urn:uuid:af274b05-e27a-40aa-72c9-208c9e3a71de"
  }, {
    "reference" : "urn:uuid:94f9830a-0011-141c-3333-d6a1df2fce49"
  }, {
    "reference" : "urn:uuid:a6166fa5-5458-0cac-9673-6b6ea45601ad"
  }, {
    "reference" : "urn:uuid:1486a305-ba49-6aa7-311b-8b207d6f0579"
  }, {
    "reference" : "urn:uuid:eef16f1d-d8c0-a08f-f961-67595938632d"
  } ],
  "resourceType" : "Observation",
  "status" : "final",
  "id" : "1cf59783-94ad-f34c-1c14-ac398cdc26c0",
  "code" : {
    "text" : "Urinanalysis macro (dipstick) panel",
    "coding" : [ {
      "code" : "24357-6",
      "display" : "Urinanalysis macro (dipstick) panel",
      "system" : "http://loinc.org"
    } ]
  },
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Encounters (0 entries)

Date Type Department CareTeam Description No records

Procedures Notes (0 entries)

Albert Davis - 06/22/2015 12:00AM UTC Dr Albert Davis examined Ms Alice Newman and found that the pacemaker is operating properly and the breathlessness is due to high fever and anxiety.

Assesments (0 entries)

The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.

Health Concerns (0 entries)

a. Chronic Sickness exhibited by patient b. HealthCare Concerns refer to underlying clinical facts i. Documented HyperTension problem ii. Documented HypoThyroidism problem iii. Watch Weight of patient

Medical Equipment (1 entries)

ID Assigning Auth Code Date (01)00643169007222(17)160128(21)BLC200461H FDA Cardiac resynchronization therapy implantable pacemaker 10/05/2011 12:00AM UTC

Procedure/c44ac11b-e5d4-888c-6b0e-15ccbc0bd3f5

{
  "focalDevice" : [ {
    "manipulated" : {
      "reference" : "urn:uuid:96367297-2eac-9b27-bf43-6b5071a1b82f"
    },
    "action" : {
      "text" : "Cardiac resynchronization therapy implantable pacemaker",
      "coding" : [ {
        "code" : "704708004",
        "display" : "Cardiac resynchronization therapy implantable pacemaker",
        "system" : "http://snomed.info/sct"
      } ]
    }
  } ],
  "resourceType" : "Procedure",
  "extension" : [ {
    "valueCode" : "procedure",
    "url" : "rim-class"
  } ],
  "status" : "completed",
  "id" : "c44ac11b-e5d4-888c-6b0e-15ccbc0bd3f5",
  "performedDateTime" : "2011-10-05T00:00:00Z",
  "code" : {
    "text" : "Introduction of cardiac pacemaker system via vein",
    "coding" : [ {
      "code" : "175135009",
      "display" : "Introduction of cardiac pacemaker system via vein",
      "system" : "http://snomed.info/sct"
    } ]
  },
  "bodySite" : [ {
    "text" : "Structure of subclavian vein",
    "coding" : [ {
      "code" : "9454009",
      "display" : "Structure of subclavian vein",
      "system" : "http://snomed.info/sct"
    } ]
  } ],
  "subject" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  }
}

Payers (0 entries)

No data for section Payers

Goals (0 entries)

a. Get rid of intermittent fever that is occurring every few weeks. b. Need to gain more energy to do regular activities

Allergies and Intolerances (2 entries)

Type Substance Onset Reactions Status allergy Ampicillin 10/05/1980 12:00AM UTC 10/05/1980 12:00AM UTC - Hives - moderate active N/A Penicillin G 10/05/1980 12:00AM UTC 10/05/1980 12:00AM UTC - Hives - moderate active

AllergyIntolerance/c1c7861d-9571-1d86-d474-cddb42168d90

{
  "patient" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  },
  "criticality" : "high",
  "clinicalStatus" : {
    "coding" : [ {
      "code" : "active",
      "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"
    } ]
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance" ]
  },
  "resourceType" : "AllergyIntolerance",
  "extension" : [ {
    "valueCodeableConcept" : {
      "text" : "Allergy to substance (disorder)",
      "coding" : [ {
        "code" : "419199007",
        "display" : "Allergy to substance (disorder)",
        "system" : "http://snomed.info/sct"
      } ]
    },
    "url" : "http://onc.org/allergy-observation-value"
  }, {
    "valueCodeableConcept" : {
      "coding" : [ {
        "code" : "CONC",
        "display" : "CONC",
        "system" : "HL7ActClass"
      } ]
    },
    "url" : "http://onc.org/allergy-act-code"
  } ],
  "recordedDate" : "1980-10-05",
  "id" : "c1c7861d-9571-1d86-d474-cddb42168d90",
  "code" : {
    "text" : "Ampicillin",
    "coding" : [ {
      "code" : "733",
      "display" : "Ampicillin",
      "system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
    } ]
  },
  "onsetDateTime" : "1980-10-05",
  "reaction" : [ {
    "manifestation" : [ {
      "text" : "Hives",
      "coding" : [ {
        "code" : "247472004",
        "display" : "Hives",
        "system" : "http://snomed.info/sct"
      } ]
    } ],
    "onset" : "1980-10-05",
    "severity" : "moderate"
  } ]
}

AllergyIntolerance/e087ce6d-9008-f9e3-1ac8-28a807369554

{
  "patient" : {
    "reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
  },
  "criticality" : "unable-to-assess",
  "clinicalStatus" : {
    "coding" : [ {
      "code" : "active",
      "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"
    } ]
  },
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance" ]
  },
  "resourceType" : "AllergyIntolerance",
  "extension" : [ {
    "valueCodeableConcept" : {
      "coding" : [ {
        "code" : "CONC",
        "display" : "CONC",
        "system" : "HL7ActClass"
      } ]
    },
    "url" : "http://onc.org/allergy-act-code"
  } ],
  "recordedDate" : "1980-10-05",
  "id" : "e087ce6d-9008-f9e3-1ac8-28a807369554",
  "code" : {
    "text" : "Penicillin G",
    "coding" : [ {
      "code" : "7980",
      "display" : "Penicillin G",
      "system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
    } ]
  },
  "onsetDateTime" : "1980-10-05",
  "reaction" : [ {
    "manifestation" : [ {
      "text" : "Hives",
      "coding" : [ {
        "code" : "247472004",
        "display" : "Hives",
        "system" : "http://snomed.info/sct"
      } ]
    } ],
    "onset" : "1980-10-05",
    "severity" : "moderate"
  } ]
}