Release 4 5 Draft Ballot
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Documentreference-example

Structured Documents Orders and Observations Work Group Maturity Level : N/A Standards Status : Informative Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

This is the narrative for the resource. See also the XML , JSON or Turtle format. This example conforms to the profile DocumentReference .


Generated Narrative with Details

id : example contained : masterIdentifier : urn:oid:1.3.6.1.4.1.21367.2005.3.7 identifier : id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234

status : current

docStatus : preliminary

type : Outpatient Note (Details : {LOINC code '34108-1' = 'Outpatient Note', given as 'Outpatient Note'})

category : History and Physical (Details : {http://ihe.net/xds/connectathon/classCodes code 'History and Physical' = 'History and Physical', given as 'History and Physical'})

subject : Patient/xcda Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24

encounter : Generated Summary: id: 1234213.52345873 (OFFICIAL); status: completed; ambulatory

event : Arm

facilityType : Outpatient

practiceSetting : General Medicine

period : Dec 22, 2004 9:00:00 PM --> Dec 22, 2004 9:01:00 PM

date : 24/12/2005 9:43:41 AM Dec 23, 2005 10:43:41 PM

author :

custodian name : Organization/f001 Gerald Smitty

RelatesTos Attesters

- Code Mode Target Party
* appends official DocumentReference/example Generated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); University Medical Hospital ; name: Burgers University Medical Center; Phone: 022-655 2300

description : Physical securityLabel custodian : very restricted (Details : {http://terminology.hl7.org/CodeSystem/v3-Confidentiality code 'V' = 'very restricted', given as 'very restricted'}) Generated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); University Medical Hospital ; name: Burgers University Medical Center; Phone: 022-655 2300

Contents RelatesTos

- Attachment Code Format Target
* appends Generated Summary: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234; status: current; docStatus: preliminary; Outpatient Note ; History and Physical Specification (Details: urn:oid:1.3.6.1.4.1.19376.1.2.3 code urn:ihe:pcc:handp:2008 = 'urn:ihe:pcc:handp:2008', stated as 'History and Physical Specification') Contexts ; Arm ; Outpatient ; General Medicine ; period: Dec 22, 2004 9:00:00 PM --> Dec 22, 2004 9:01:00 PM; date: Dec 23, 2005 10:43:41 PM; description: Physical; very restricted
-

Encounter description : Physical

Event securityLabel : very restricted Period

FacilityType content PracticeSetting

Attachments

SourcePatientInfo
Related -
*
Encounter/xcda

Arm (Details : {http://ihe.net/xds/connectathon/eventCodes code 'T-D8200' = 'T-D8200', given as 'Arm'}) format : History and Physical Specification 23/12/2004 8:00:00 AM --> 23/12/2004 8:01:00 AM Outpatient (Details : {http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes code 'Outpatient' = 'Outpatient', given as 'Outpatient'})

General Medicine (Details : {http://www.ihe.net/xds/connectathon/practiceSettingCodes code 'General Medicine' = 'General Medicine', given as 'General Medicine'}) identifier : id: urn:oid:1.3.6.1.4.1.21367.2005.3.7

sourcePatientInfo : Patient/xcda Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24

related : Patient/xcda Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24


 

Other examples that reference this example:

  • DocumentManifest/FM-Example
  • DocumentManifest/XDS-Example
  • DocumentReference/Generic exampl example
  • MedicinalProduct/General MedicinalProductDefinition/General Example
  • Provenance/General
  • Provenance/Signature
  •  

    Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.