Composition/ee05e1da-df1b-7f7e-166c-e182e1d39f86
{
"date" : "2023-02-02",
"encounter" : {
"reference" : "urn:uuid:d6c3788c-ed93-1199-a863-346caccfa5e4"
},
"section" : [ {
"title" : "Procedures Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nHenry Seven - 06/22/2015 12:00AM UTC\nDr Seven examined Ms Rebecca Larson 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" : "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" : "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\n05/10/1980 12:00AM UTC\n05/10/1980 12:00AM UTC - Hives - moderate\nactive\nN/A\nPenicillin G\n05/10/1980 12:00AM UTC\n05/10/1980 12:00AM UTC - Hives - moderate\nactive\n</table>\n</div>\n",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
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"entry" : [ {
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}, {
"reference" : "urn:uuid:ba493a82-b6cf-aada-dd3e-64f71508b850"
} ],
"code" : {
"text" : "Allergies",
"coding" : [ {
"code" : "48765-2",
"display" : "Allergies",
"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\nImmunization was not given - Patient rejected immunization\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" : [ {
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"url" : "entries-required"
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"entry" : [ {
"reference" : "urn:uuid:4563330c-19a4-70d6-edd2-3f9ba865de7f"
}, {
"reference" : "urn:uuid:32cbec8b-79d2-ad29-5d9d-2cede9065931"
} ],
"code" : {
"text" : "History of Immunization Narrative",
"coding" : [ {
"code" : "11369-6",
"display" : "History of Immunization Narrative",
"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" : "Goals",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\na. Need to gain more energy to do regular activities.\nb. Negotiated Goal to keep Body Temperature at 98-99 degrees Fahrenheit with regular\nmonitoring\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Goals",
"coding" : [ {
"code" : "61146-7",
"display" : "Goals",
"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" : "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" : "Medications",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nMedications List\nMedication\nTiming\nRoute\nFreq\nDose\nTylenol 500mg\n~\nOral\nOral, as needed, 1 unit\n1 \nAranesp 0.5 MG/ML\n~\nInjection\nInjectable, once a week, 1 unit\n1 \nClindamycin 300mg\n06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC\nOral\nOral, three times daily, 1 unit\n1 \nTorsemide 20mg\n06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC\nOral\nOral, daily, 1 unit\n1 \nFenoFibric Acid 35 mg\n06/24/2015 12:00AM UTC - 07/04/2015 12:00AM UTC\nOral\nAt the hour of sleep\n1 \nMycophenolic Acid 360mg\n06/24/2015 12:00AM UTC - 06/27/2015 12:00AM UTC\nOral\nOral, two times daily, 1 unit\n1 \nEverolimus 0.5mg\n06/24/2015 12:00AM UTC - 07/20/2015 12:00AM UTC\nOral\nOral, two times daily, 1 unit\n1 \nCiprofloxacin 250mg\n06/24/2015 12:00AM UTC - 07/24/2015 12:00AM UTC\nOral\nOral, three times daily, 1 unit\n1 \nCeftriaxone 100 MG/ML\n~\nInjection\n~\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" : [ {
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"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:95b04445-57b9-52a6-962d-6df7ac9c264d"
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"reference" : "urn:uuid:6d3690b1-4caa-8965-4735-f5e9b85aa6c9"
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"reference" : "urn:uuid:d923c2a9-bb00-b10f-7ba2-349131c60a83"
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"reference" : "urn:uuid:bcc83fba-658e-b750-85e7-6868405d1e80"
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"reference" : "urn:uuid:5fab3741-b848-64a8-009d-e306fcf718c8"
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"reference" : "urn:uuid:360d08e2-02f2-ca73-e7ed-272803740e41"
}, {
"reference" : "urn:uuid:2f377179-7333-f5f4-eb89-ef7fb9992084"
} ],
"code" : {
"text" : "History of Medication use",
"coding" : [ {
"code" : "10160-0",
"display" : "History of Medication use",
"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>\nCBC, No performer ID, No Lab, No Lab Address\n<table width='100%' border='1'>\nCode\nValue\nDate\nHGB\n10.2 g/dL\n06/22/2015 12:00AM UTC\nWBC\n12.3 10*3/uL\n06/22/2015 12:00AM UTC\nPLT\n123 10*3/ul\n06/22/2015 12:00AM UTC\nEverolimus Blood\n10 ng/mL\n06/22/2015 12:00AM UTC\n</table>\n</div>\n",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:32c36070-73e0-f945-9887-f285af21855d"
}, {
"reference" : "urn:uuid:43744ab9-dc52-e669-7cb7-9213c7b53b5a"
} ],
"code" : {
"text" : "Results",
"coding" : [ {
"code" : "30954-2",
"display" : "Results",
"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:bff8d2d0-493b-357f-bf50-68bc353f15da"
}, {
"reference" : "urn:uuid:391d399b-f9c4-36eb-2943-ce5e0a189e32"
} ],
"code" : {
"text" : "Social History",
"coding" : [ {
"code" : "29762-2",
"display" : "Social History",
"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" : "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:3d6268e8-ea91-1319-a885-b208f36fbbe6"
} ],
"code" : {
"text" : "History of Medical Device Use",
"coding" : [ {
"code" : "46264-8",
"display" : "History of Medical Device Use",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Assesments",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nThe patient was found to have Anemia and Dr Seven and his staff diagnosed\nthe condition and treated Ms Rebecca for Anemia during the 2 day stay at\nCommunity Health Hospitals. Ms Rebecca recovered from Anemia during\nthe stay and is being discharged in a stable condition. If there is fever\ngreater than 101.5 F or onset of chest pain/breathlessness the patient is\nadvised to contact emergency\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\niv. Documented Anemia problem\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Health Concerns",
"coding" : [ {
"code" : "75310-3",
"display" : "Health Concerns",
"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:624617e3-6aea-40ac-2c87-a07f622fbddd"
}, {
"reference" : "urn:uuid:5ed1a8d2-846b-9311-afd5-c7984e374032"
}, {
"reference" : "urn:uuid:db6b8a63-4e38-7c3d-f699-2b651584492d"
}, {
"reference" : "urn:uuid:a878f9ed-1fed-0bb8-60b7-dd74ee8ae53e"
}, {
"reference" : "urn:uuid:098cac4e-e065-6d2f-1f0e-98eae8dc6e61"
}, {
"reference" : "urn:uuid:526262b1-d7b3-7768-c054-30075e52ef66"
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}, {
"reference" : "urn:uuid:60fd3d3c-8a3b-5cdf-d02d-e9a1705030d8"
}, {
"reference" : "urn:uuid:e4b7937b-4e50-aa99-cffd-b3812c0b1268"
} ],
"code" : {
"text" : "Vitals",
"coding" : [ {
"code" : "8716-3",
"display" : "Vitals",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Progress Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nHenry Seven - 06/22/2015 12:00AM UTC\nMs Rebecca Larson got admitted due to developing high fever and since has shown considerable\nimprovement and can be discharged shortly.\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Progress Note",
"coding" : [ {
"code" : "11506-3",
"display" : "Progress Note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Hospital Course",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nMs. Rebecca Larson is a 45 year old female with a history of Hypertension, Hypothyroidism, Iron\ndeficiency and is a recipient of Renal Allograft is admitted on 6/22/2015 at 10 am EST to Community\nHealth and Hospitals with history of intermittent fever for 2 days. The patient disclosed history of\nnausea, loose stools and weakness. She was found to have Anemia secondary to iron deficiency and\nCKD. After conducting multiple tests and administering necessary medications, the patient was\ndischarged to Ambulatory facility to follow up with immunosuppression as an out-patient. The\ncondition of the patient at discharge was stable, with controlled blood sugar levels and a pain score\nbelow 3. Additional follow up instructions have been provided to the patient. \n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Hospital course Narrative",
"coding" : [ {
"code" : "8648-8",
"display" : "Hospital course Narrative",
"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" : "Laboratory Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nHenry Seven - 06/22/2015 12:00AM UTC\nMs Rebecca Larson was tested for the Urinanalysis macro panel and CBC and the results have been\nfound to be normal.\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Laboratory Report",
"coding" : [ {
"code" : "11502-2",
"display" : "Laboratory Report",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Discharge Instructions",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\na. Diet: Diabetic low salt diet\nb. Medications: Take prescribed medications as advised.\nc. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up\nwith Outpatient facility for Immunosuppression treatment.\nd. For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.\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\nSevere hypothyroidism\n12/31/2006 12:00AM UTC\n~\nChronic rejection of renal transplant\n12/31/2011 12:00AM UTC\n~\nIron deficiency anemia\n06/22/2015 12:00AM UTC\n~\nInterstitial pneumonia\n06/22/2015 12:00AM UTC\n~\nEssential hypertension\n05/10/2015 12:00AM UTC\n~\n</table>\n<table width='100%' border='1'>\nResolved Problems\nProblem\nNoted Date\nDiagnosed Date\nResolved Date\nOverweight\n12/31/2006 12:00AM UTC\n~\n06/01/2007 12:00AM UTC\n</table>\n</div>\n",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:cea7cc62-e039-327a-167f-eff8ccdd2117"
}, {
"reference" : "urn:uuid:63112894-558f-f990-d788-29a8ef3d9fe6"
}, {
"reference" : "urn:uuid:4f9752c7-2c2a-089c-a343-62b13917ba78"
}, {
"reference" : "urn:uuid:04c11196-6579-419a-cbb6-9126a300279e"
}, {
"reference" : "urn:uuid:748d5b03-c898-78b4-4ae6-3b368b02c0b2"
}, {
"reference" : "urn:uuid:1ace5845-3798-7823-7607-f24bb8e6fb91"
} ],
"code" : {
"text" : "Problems",
"coding" : [ {
"code" : "11450-4",
"display" : "Problems",
"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\nBronchoscopy\n06/22/2015 12:00AM UTC\ncompleted\nChest X-Ray, PA and Lateral Views\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:e6f51902-ed1d-4c9c-1ea0-7700f99456e5"
}, {
"reference" : "urn:uuid:3d6268e8-ea91-1319-a885-b208f36fbbe6"
}, {
"reference" : "urn:uuid:62584a0a-793c-4846-e92d-7f2a7a2bce7f"
} ],
"code" : {
"text" : "History of Procedures Document",
"coding" : [ {
"code" : "47519-4",
"display" : "History of Procedures Document",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Plan of treatment",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\ni. Schedule an appointment with Dr Seven after 1 week for Follow up with\nOutpatient facility for Immunosuppressive therapy.\n</div>\n",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:6d63ac66-6837-748d-8c31-d06338e86647"
} ],
"code" : {
"text" : "Plan of treatment",
"coding" : [ {
"code" : "18776-5",
"display" : "Plan of treatment",
"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"
} ]
}
} ],
"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:ada42cdd-ed1d-da17-4de7-267d7a3ffef6"
} ],
"custodian" : {
"reference" : "urn:uuid:63f4567c-487e-bf07-1867-f4b907251f43"
},
"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" : [ "Robin", "Jones" ],
"family" : "Larson",
"use" : "old"
}, {
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} ],
"birthDate" : "1970-05-01",
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},
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} ],
"url" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-race"
}, {
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"url" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity"
} ],
"communication" : [ {
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} ]
},
"preferred" : true
} ],
"id" : "patient",
"telecom" : [ {
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"use" : "mobile"
}, {
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"value" : "+1-555-723-1544",
"use" : "home"
} ],
"gender" : "female",
"maritalStatus" : {
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"system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"
} ]
}
}
PractitionerRole/1d4a6865-54a5-63fb-0b62-203037254391
{
"practitioner" : {
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},
"id" : "1d4a6865-54a5-63fb-0b62-203037254391",
"organization" : {
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},
"resourceType" : "PractitionerRole",
"period" : {
"start" : "2015-06-22"
}
}
Encounter/07edd8a4-d933-6a04-c81b-3f9bd5a8ed81
{
"period" : {
"start" : "2015-06-22",
"end" : "2015-06-24"
},
"resourceType" : "Encounter",
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"class" : {
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},
"id" : "07edd8a4-d933-6a04-c81b-3f9bd5a8ed81",
"participant" : [ {
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}
}, {
"individual" : {
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}
} ]
}