Composition/ee05e1da-df1b-7f7e-166c-e182e1d39f86
{
"date" : "2023-02-02",
"encounter" : {
"reference" : "urn:uuid:d6c3788c-ed93-1199-a863-346caccfa5e4"
},
"section" : [ {
"title" : "Medications",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <caption>Medications List</caption>\n <thead>\n <tr>\n <th>Medication</th>\n <th>Timing</th>\n <th>Route</th>\n <th>Freq</th>\n <th>Dose</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Tylenol 500mg</td>\n <td>~</td>\n <td>Oral</td>\n <td>Oral, as needed, 1 unit</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>Aranesp 0.5 MG/ML</td>\n <td>~</td>\n <td>Injection</td>\n <td>Injectable, once a week, 1 unit</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>Clindamycin 300mg</td>\n <td>06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC</td>\n <td>Oral</td>\n <td>Oral, three times daily, 1 unit</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>Torsemide 20mg</td>\n <td>06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC</td>\n <td>Oral</td>\n <td>Oral, daily, 1 unit</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>FenoFibric Acid 35 mg</td>\n <td>06/24/2015 12:00AM UTC - 07/04/2015 12:00AM UTC</td>\n <td>Oral</td>\n <td>At the hour of sleep</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>Mycophenolic Acid 360mg</td>\n <td>06/24/2015 12:00AM UTC - 06/27/2015 12:00AM UTC</td>\n <td>Oral</td>\n <td>Oral, two times daily, 1 unit</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>Everolimus 0.5mg</td>\n <td>06/24/2015 12:00AM UTC - 07/20/2015 12:00AM UTC</td>\n <td>Oral</td>\n <td>Oral, two times daily, 1 unit</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>Ciprofloxacin 250mg</td>\n <td>06/24/2015 12:00AM UTC - 07/24/2015 12:00AM UTC</td>\n <td>Oral</td>\n <td>Oral, three times daily, 1 unit</td>\n <td>1 </td>\n </tr>\n <tr>\n <td>Ceftriaxone 100 MG/ML</td>\n <td>~</td>\n <td>Injection</td>\n <td>~</td>\n <td>1 </td>\n </tr>\n </tbody>\n </table>\n <table border=\"1\" width=\"100%\">\n <caption>Administered Medications</caption>\n <thead>\n <tr>\n <th>Medication</th>\n <th>Date</th>\n <th>Route</th>\n <th>Dose</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td colspan=\"4\">No records</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:bcc83fba-658e-b750-85e7-6868405d1e80"
}, {
"reference" : "urn:uuid:2f377179-7333-f5f4-eb89-ef7fb9992084"
}, {
"reference" : "urn:uuid:9ce42680-367b-ce84-194a-bad0580ffd16"
}, {
"reference" : "urn:uuid:95b04445-57b9-52a6-962d-6df7ac9c264d"
}, {
"reference" : "urn:uuid:d923c2a9-bb00-b10f-7ba2-349131c60a83"
}, {
"reference" : "urn:uuid:6722b204-9ef7-5b60-15bb-61d05f732552"
}, {
"reference" : "urn:uuid:360d08e2-02f2-ca73-e7ed-272803740e41"
}, {
"reference" : "urn:uuid:6d3690b1-4caa-8965-4735-f5e9b85aa6c9"
}, {
"reference" : "urn:uuid:5fab3741-b848-64a8-009d-e306fcf718c8"
} ],
"code" : {
"text" : "History of Medication use",
"coding" : [ {
"code" : "10160-0",
"display" : "History of Medication use",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Problems",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <caption>Active Problems</caption>\n <thead>\n <tr>\n <th>Problem</th>\n <th>Noted Date</th>\n <th>Diagnosed Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Severe hypothyroidism</td>\n <td>12/31/2006 12:00AM UTC</td>\n <td>~</td>\n </tr>\n <tr>\n <td>Chronic rejection of renal transplant</td>\n <td>12/31/2011 12:00AM UTC</td>\n <td>~</td>\n </tr>\n <tr>\n <td>Iron deficiency anemia</td>\n <td>06/22/2015 12:00AM UTC</td>\n <td>~</td>\n </tr>\n <tr>\n <td>Interstitial pneumonia</td>\n <td>06/22/2015 12:00AM UTC</td>\n <td>~</td>\n </tr>\n <tr>\n <td>Essential hypertension</td>\n <td>05/10/2015 12:00AM UTC</td>\n <td>~</td>\n </tr>\n </tbody>\n </table>\n <table border=\"1\" width=\"100%\">\n <caption>Resolved Problems</caption>\n <thead>\n <tr>\n <th>Problem</th>\n <th>Noted Date</th>\n <th>Diagnosed Date</th>\n <th>Resolved Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Overweight</td>\n <td>12/31/2006 12:00AM UTC</td>\n <td>~</td>\n <td>06/01/2007 12:00AM UTC</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:cea7cc62-e039-327a-167f-eff8ccdd2117"
}, {
"reference" : "urn:uuid:04c11196-6579-419a-cbb6-9126a300279e"
}, {
"reference" : "urn:uuid:1ace5845-3798-7823-7607-f24bb8e6fb91"
}, {
"reference" : "urn:uuid:748d5b03-c898-78b4-4ae6-3b368b02c0b2"
}, {
"reference" : "urn:uuid:63112894-558f-f990-d788-29a8ef3d9fe6"
}, {
"reference" : "urn:uuid:4f9752c7-2c2a-089c-a343-62b13917ba78"
} ],
"code" : {
"text" : "Problems",
"coding" : [ {
"code" : "11450-4",
"display" : "Problems",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Goals",
"text" : {
"div" : "a. Need to gain more energy to do regular activities.\nb. Negotiated Goal to keep Body Temperature at 98-99 degrees Fahrenheit with regular\nmonitoring",
"status" : "generated"
},
"code" : {
"text" : "Goals",
"coding" : [ {
"code" : "61146-7",
"display" : "Goals",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Results",
"text" : {
"div" : "\n <list>\n <item>\n <caption>Urinanalysis macro (dipstick) panel, No performer ID, No Lab, No Lab Address</caption>\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Code</th>\n <th>Value</th>\n <th>Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Color of urine</td>\n <td>YELLOW</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>Appearance of urine</td>\n <td>CLEAR</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>Specific gravity of urine by test strip</td>\n <td>1.015 1</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>pH of Urine by Test strip</td>\n <td>5.0 [pH]</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>Glucose [Mass/volume] in urine by test strip</td>\n <td>50 mg/dL</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>Ketones [Mass/Volume] in urine by test strip</td>\n <td>Negative</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>Protein [Mass/Volume] in urine by test strip</td>\n <td>100 mg/dL</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n </tbody>\n </table>\n </item>\n <item>\n <caption>CBC, No performer ID, No Lab, No Lab Address</caption>\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Code</th>\n <th>Value</th>\n <th>Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>HGB</td>\n <td>10.2 g/dL</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>WBC</td>\n <td>12.3 10*3/uL</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>PLT</td>\n <td>123 10*3/ul</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n <tr>\n <td>Everolimus Blood</td>\n <td>10 ng/mL</td>\n <td>06/22/2015 12:00AM UTC</td>\n </tr>\n </tbody>\n </table>\n </item>\n </list>\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" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Element</th>\n <th>Date</th>\n <th>Value</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Tobacco smoking status NHIS</td>\n <td>06/22/2015 12:00AM UTC</td>\n <td>Current every day smoker</td>\n </tr>\n <tr>\n <td>Sex Assigned At Birth</td>\n <td>~</td>\n <td>Female</td>\n </tr>\n </tbody>\n </table>\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" : "Vital Signs",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Vital sign</th>\n <th>Date</th>\n <th>Value and units</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Blood Pressure Systolic</td>\n <td>06/22/2015 3:08PM UTC</td>\n <td>145 mm[Hg]</td>\n </tr>\n <tr>\n <td>Blood Pressure Diastolic</td>\n <td>06/22/2015 3:08PM UTC</td>\n <td>88 mm[Hg]</td>\n </tr>\n <tr>\n <td>Heart Rate</td>\n <td>06/22/2015 3:10PM UTC</td>\n <td>80 /min</td>\n </tr>\n <tr>\n <td>Body Temperature</td>\n <td>06/22/2015 3:15PM UTC</td>\n <td>38 Cel</td>\n </tr>\n <tr>\n <td>Respiratory Rate</td>\n <td>06/22/2015 3:15PM UTC</td>\n <td>18 /min</td>\n </tr>\n <tr>\n <td>O2 % BldC Oximetry</td>\n <td>06/22/2015 3:12PM UTC</td>\n <td>95 %</td>\n </tr>\n <tr>\n <td>Inhaled Oxygen Concentration</td>\n <td>06/22/2015 3:12PM UTC</td>\n <td>36 %</td>\n </tr>\n <tr>\n <td>Weight</td>\n <td>06/22/2015 3:05PM UTC</td>\n <td>88 kg</td>\n </tr>\n <tr>\n <td>Height</td>\n <td>06/22/2015 3:05PM UTC</td>\n <td>177 cm</td>\n </tr>\n <tr>\n <td>BMI</td>\n <td>~</td>\n <td>~</td>\n </tr>\n <tr>\n <td>Head Occipital Circumference</td>\n <td>~</td>\n <td>~</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:e4b7937b-4e50-aa99-cffd-b3812c0b1268"
}, {
"reference" : "urn:uuid:624617e3-6aea-40ac-2c87-a07f622fbddd"
}, {
"reference" : "urn:uuid:098cac4e-e065-6d2f-1f0e-98eae8dc6e61"
}, {
"reference" : "urn:uuid:526262b1-d7b3-7768-c054-30075e52ef66"
}, {
"reference" : "urn:uuid:a878f9ed-1fed-0bb8-60b7-dd74ee8ae53e"
}, {
"reference" : "urn:uuid:b1ae2d24-60ff-6fce-3ced-4bdceeeaf2e6"
}, {
"reference" : "urn:uuid:60fd3d3c-8a3b-5cdf-d02d-e9a1705030d8"
}, {
"reference" : "urn:uuid:5ed1a8d2-846b-9311-afd5-c7984e374032"
}, {
"reference" : "urn:uuid:db6b8a63-4e38-7c3d-f699-2b651584492d"
} ],
"code" : {
"text" : "Vitals",
"coding" : [ {
"code" : "8716-3",
"display" : "Vitals",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Allergies and Intolerances",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Type</th>\n <th>Substance</th>\n <th>Onset</th>\n <th>Reactions</th>\n <th>Status</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>allergy</td>\n <td>Ampicillin</td>\n <td>05/10/1980 12:00AM UTC</td>\n <td>\n <paragraph>05/10/1980 12:00AM UTC - Hives - moderate</paragraph>\n </td>\n <td>active</td>\n </tr>\n <tr>\n <td>N/A</td>\n <td>Penicillin G</td>\n <td>05/10/1980 12:00AM UTC</td>\n <td>\n <paragraph>05/10/1980 12:00AM UTC - Hives - moderate</paragraph>\n </td>\n <td>active</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:8bf761e1-efc7-5e99-ce6c-f25592c4b92b"
}, {
"reference" : "urn:uuid:ba493a82-b6cf-aada-dd3e-64f71508b850"
} ],
"code" : {
"text" : "Allergies",
"coding" : [ {
"code" : "48765-2",
"display" : "Allergies",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Encounters",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Date</th>\n <th>Type</th>\n <th>Department</th>\n <th>CareTeam</th>\n <th>Description</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td colspan=\"5\">No records</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"code" : {
"text" : "Encounters",
"coding" : [ {
"code" : "46240-8",
"display" : "Encounters",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Functional Status",
"text" : {
"div" : "No data for section Functional Status",
"status" : "generated"
},
"code" : {
"text" : "Functional Status",
"coding" : [ {
"code" : "47420-5",
"display" : "Functional Status",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Immunizations",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Vaccine</th>\n <th>Date</th>\n <th>Status</th>\n <th>Lot</th>\n <th>Notes</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Tetanus and diphtheria toxoids</td>\n <td>01/04/2012 12:00AM UTC</td>\n <td>completed</td>\n <td>N/A</td>\n <td>Immunization was not given - Patient rejected immunization</td>\n </tr>\n <tr>\n <td>Influenza, intradermal, quadrivalent, preservative-free</td>\n <td>06/22/2015 12:00AM UTC</td>\n <td>not-done</td>\n <td>No Lot number provided</td>\n <td>Immunization was not given - Patient rejected immunization</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:32cbec8b-79d2-ad29-5d9d-2cede9065931"
}, {
"reference" : "urn:uuid:4563330c-19a4-70d6-edd2-3f9ba865de7f"
} ],
"code" : {
"text" : "History of Immunization Narrative",
"coding" : [ {
"code" : "11369-6",
"display" : "History of Immunization Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Medical Equipment",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>ID</th>\n <th>Assigning Auth</th>\n <th>Code</th>\n <th>Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>(01)00643169007222(17)160128(21)BLC200461H</td>\n <td>FDA</td>\n <td>Cardiac resynchronization therapy implantable pacemaker</td>\n <td>10/05/2011 12:00AM UTC</td>\n </tr>\n </tbody>\n </table>\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" : "Mental Status",
"text" : {
"div" : "No data for section Mental Status",
"status" : "generated"
},
"code" : {
"text" : "Mental Status Narrative",
"coding" : [ {
"code" : "10190-7",
"display" : "Mental Status Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Payers",
"text" : {
"div" : "No data for section Payers",
"status" : "generated"
},
"code" : {
"text" : "Payment Sources Narrative",
"coding" : [ {
"code" : "48768-6",
"display" : "Payment Sources Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Procedures",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Procedures</th>\n <th>Date</th>\n <th>Status</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Bronchoscopy</td>\n <td>06/22/2015 12:00AM UTC</td>\n <td>completed</td>\n </tr>\n <tr>\n <td>Chest X-Ray, PA and Lateral Views</td>\n <td>06/22/2015 12:00AM UTC</td>\n <td>completed</td>\n </tr>\n <tr>\n <td>Introduction of cardiac pacemaker system via vein</td>\n <td>10/05/2011 12:00AM UTC</td>\n <td>completed</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:e6f51902-ed1d-4c9c-1ea0-7700f99456e5"
}, {
"reference" : "urn:uuid:62584a0a-793c-4846-e92d-7f2a7a2bce7f"
}, {
"reference" : "urn:uuid:3d6268e8-ea91-1319-a885-b208f36fbbe6"
} ],
"code" : {
"text" : "History of Procedures Document",
"coding" : [ {
"code" : "47519-4",
"display" : "History of Procedures Document",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Hospital Course",
"text" : {
"div" : "Ms. 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. ",
"status" : "generated"
},
"code" : {
"text" : "Hospital course Narrative",
"coding" : [ {
"code" : "8648-8",
"display" : "Hospital course Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Assesments",
"text" : {
"div" : "The 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",
"status" : "generated"
},
"code" : {
"text" : "Assessments",
"coding" : [ {
"code" : "51848-0",
"display" : "Assessments",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Procedures Notes",
"text" : {
"div" : "\n <paragraph>\n <caption>Henry Seven - 06/22/2015 12:00AM UTC</caption>Dr Seven examined Ms Rebecca Larson and found that the pacemaker is operating properly and the\nbreathlessness is due to high fever and anxiety.</paragraph>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:21a0e458-6891-f769-1633-a3c149edb9db"
} ],
"code" : {
"text" : "Procedures Note",
"coding" : [ {
"code" : "28570-0",
"display" : "Procedures Note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "History And Physical Notes",
"text" : {
"div" : "No data for section History And Physical Notes",
"status" : "generated"
},
"code" : {
"text" : "History And Physical Note",
"coding" : [ {
"code" : "34117-2",
"display" : "History And Physical Note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Consultation Notes",
"text" : {
"div" : "No data for section Consultation Notes",
"status" : "generated"
},
"code" : {
"text" : "Consultation note",
"coding" : [ {
"code" : "11488-4",
"display" : "Consultation note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Progress Notes",
"text" : {
"div" : "\n <paragraph>\n <caption>Henry Seven - 06/22/2015 12:00AM UTC</caption>Ms Rebecca Larson got admitted due to developing high fever and since has shown considerable\nimprovement and can be discharged shortly.</paragraph>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:c3780ee7-514b-dc3c-91bb-2d376bd486f7"
} ],
"code" : {
"text" : "Progress Note",
"coding" : [ {
"code" : "11506-3",
"display" : "Progress Note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Plan of treatment",
"text" : {
"div" : "i. Schedule an appointment with Dr Seven after 1 week for Follow up with\nOutpatient facility for Immunosuppressive therapy.",
"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" : "Health Concerns",
"text" : {
"div" : "a. 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",
"status" : "generated"
},
"code" : {
"text" : "Health Concerns",
"coding" : [ {
"code" : "75310-3",
"display" : "Health Concerns",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Laboratory Notes",
"text" : {
"div" : "\n <paragraph>\n <caption>Henry Seven - 06/22/2015 12:00AM UTC</caption>Ms Rebecca Larson was tested for the Urinanalysis macro panel and CBC and the results have been\nfound to be normal.</paragraph>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:759dff78-ea64-297e-c79d-a5993b72ed59"
} ],
"code" : {
"text" : "Laboratory Report",
"coding" : [ {
"code" : "11502-2",
"display" : "Laboratory Report",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Discharge Instructions",
"text" : {
"div" : "a. 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.",
"status" : "generated"
},
"code" : {
"text" : "Discharge instructions",
"coding" : [ {
"code" : "8653-8",
"display" : "Discharge instructions",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Discharge Summary",
"text" : {
"div" : "No data for section Discharge Summary",
"status" : "generated"
},
"code" : {
"text" : "Discharge Summary",
"coding" : [ {
"code" : "18842-5",
"display" : "Discharge Summary",
"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" : [ "Rebecca", "Jones" ],
"family" : "Larson",
"use" : "official"
}, {
"given" : [ "Robin", "Jones" ],
"family" : "Larson",
"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"
}, {
"valueCoding" : {
"code" : "2186-5",
"display" : "Not Hispanic or Latino",
"system" : "urn:oid:2.16.840.1.113883.6.238"
},
"url" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity"
} ],
"communication" : [ {
"language" : {
"coding" : [ {
"code" : "en",
"display" : "en",
"system" : "urn:oid:"
} ]
},
"preferred" : true
} ],
"id" : "patient",
"telecom" : [ {
"system" : "phone",
"value" : "+1-555-777-1234",
"use" : "mobile"
}, {
"system" : "phone",
"value" : "+1-555-723-1544",
"use" : "home"
} ],
"gender" : "female",
"maritalStatus" : {
"coding" : [ {
"code" : "UNK",
"display" : "Unknown",
"system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"
} ]
}
}
PractitionerRole/1d4a6865-54a5-63fb-0b62-203037254391
{
"practitioner" : {
"reference" : "urn:uuid:48a2209a-478c-fa48-2e15-51e323854be3"
},
"id" : "1d4a6865-54a5-63fb-0b62-203037254391",
"organization" : {
"reference" : "urn:uuid:63f4567c-487e-bf07-1867-f4b907251f43"
},
"resourceType" : "PractitionerRole",
"period" : {
"start" : "2015-06-22"
}
}
Encounter/07edd8a4-d933-6a04-c81b-3f9bd5a8ed81
{
"period" : {
"start" : "2015-06-22",
"end" : "2015-06-24"
},
"resourceType" : "Encounter",
"status" : "finished",
"class" : {
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "AMB",
"display" : "AMB"
},
"id" : "07edd8a4-d933-6a04-c81b-3f9bd5a8ed81",
"participant" : [ {
"individual" : {
"reference" : "urn:uuid:ada42cdd-ed1d-da17-4de7-267d7a3ffef6"
}
}, {
"individual" : {
"reference" : "urn:uuid:cf44ec5a-c00d-e99d-1645-d044281d1151"
}
} ]
}