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+ Generated Narrative with Details
id: 30551ce1-5a28-4356-b684-1e639094ad4d
meta:
identifier: 3f69e0a5-2177-4540-baab-7a5d0877428f
status: final
type: Patient summary Document (Details : {LOINC code '60591-5' = 'Patient summary Document', given as 'Patient summary Document'})
date: Jul 20, 2017, 1:30:00 PM
author: Practitioner/1c616b24-3895-48c4-9a02-9a64110351ef
title: Patient Summary as of July 20, 2017 14:30
confidentiality: N
attester
mode: legal
time: Jul 20, 2017, 1:30:00 PM
attester
mode: legal
time: Jul 20, 2017, 1:30:00 PM
custodian: Organization/890751f4-2924-4636-bab7-efffc7f3cf15
- | Code | Target[x] |
* | appends | c2277753-9f90-4a95-8ddb-a0b3f6e7d292 |
- | Code | Period |
* | care provision (Details : {http://terminology.hl7.org/CodeSystem/v3-ActClass code 'PCPR' = 'care provision) | ?? --> Jul 20, 2017, 1:30:00 PM |
+
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+ Medication | +Strength | +Form | +Dosage | +Comment | +
---|---|---|---|---|
Anastrozole | +1 mg | +tablet | +once daily | +treatment for breast cancer | +
Black Cohosh Extract | ++ | pil | ++ | herbal supplement | +
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+ Blood typing | +||
---|---|---|
Blood group | +A+ | ++ |
C Ab [Presence] in Serum or Plasma | +Positive | ++ |
E Ab [Presence] in Serum or Plasma | +Positive | ++ |
Little c Ab [Presence] in Serum or Plasma | +Negative | ++ |
Hemoglobin A1c monitoring | +||
---|---|---|
Hemoglobin A1c/Hemoglobin.total in Blood by HPLC | +7.5 % | ++ |
Bacteriology | +||
---|---|---|
Methicillin resistant Staphylococcus aureus | +||
Healthy carrier of MRSA | +
Generated Narrative with Details
id: 2b90dd2b-2dab-4c75-9bb9-a355e07401e8
meta:
identifier: 574687583
active: true
name: Martha DeLarosa
telecom: ph: +31788700800(HOME)
gender: female
birthDate: May 1, 1972
address: Laan Van Europa 1600 Dordrecht 3317 DB Netherlands
- | Relationship | Name | Telecom | Address |
* | mother (Details : {http://terminology.hl7.org/CodeSystem/v3-RoleCode code 'MTH' = 'mother) | Martha Mum | ph: +33-555-20036(HOME) | Promenade des Anglais 111 Lyon 69001 France |
+ Generated Narrative with Details
id: 1c616b24-3895-48c4-9a02-9a64110351ef
identifier: 129854633
active: true
name: Beetje van Hulp
- | Code |
* | Doctor of Medicine (Details : {http://terminology.hl7.org/CodeSystem/v2-0360|2.7 code 'MD' = 'Doctor of Medicine', given as 'Doctor of Medicine'}) |
+
+
+
+
+
+
+ Generated Narrative with Details
id: 890751f4-2924-4636-bab7-efffc7f3cf15
identifier: 564738757
active: true
name: Anorg Aniza Tion BV / The best custodian ever
telecom: ph: +31-51-34343400(WORK)
address: Houttuinen 27 Dordrecht 3311 CE Netherlands (WORK)
Generated Narrative with Details
id: c64139e7-f02d-409c-bf34-75e8bf23bc80
meta:
identifier: c87bf51c-e53c-4bfe-b8b7-aa62bdd93002
clinicalStatus: Active (Details : {http://terminology.hl7.org/CodeSystem/condition-clinical code 'active' = 'Active)
verificationStatus: Confirmed (Details : {http://terminology.hl7.org/CodeSystem/condition-ver-status code 'confirmed' = 'Confirmed)
category: Problem (Details : {LOINC code '75326-9' = 'Problem', given as 'Problem'})
severity: Moderate (Details : {LOINC code 'LA6751-7' = 'Moderate', given as 'Moderate'})
code: Menopausal flushing (finding) (Details : {SNOMED CT code '198436008' = 'Hot flush', given as 'Menopausal flushing (finding)'}; {http://hl7.org/fhir/sid/icd-10 code 'N95.1' = 'Menopausal and female climacteric states', given as 'Menopausal and female climacteric states'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
onset: Jan 1, 2015, 12:00:00 AM
recordedDate: Oct 1, 2016, 12:00:00 AM
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+ Generated Narrative with Details
id: c220e36c-eb67-4fc4-9ba1-2fabc52acec6
meta:
identifier: b75f92cb-61d4-469a-9387-df5ef70d25f0
status: active
medication: Medication/976d0804-cae0-45ae-afe3-a19f3ceba6bc
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Mar 1, 2015, 12:00:00 AM --> (ongoing)
dosage:
+
+
+ Generated Narrative with Details
id: 47524493-846a-4a26-bae2-4ab03e60f02e
meta:
identifier: 9e312d6b-c6b6-439a-a730-6efaa5dcf8bc
status: active
medication: Medication/8adc0999-9468-4ac9-9557-680fa133d626
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Jan 1, 2016, 12:00:00 AM --> (ongoing)
dosage:
+ Generated Narrative with Details
id: 976d0804-cae0-45ae-afe3-a19f3ceba6bc
meta:
code: Product containing anastrozole (medicinal product) (Details : {SNOMED CT code '108774000' = 'Product containing anastrozole (medicinal product)', given as 'Product containing anastrozole (medicinal product)'}; {urn:oid:2.16.840.1.113883.2.4.4.1 code '99872' = '99872', given as 'ANASTROZOL 1MG TABLET'}; {urn:oid:2.16.840.1.113883.2.4.4.7 code '2076667' = '2076667', given as 'ANASTROZOL CF TABLET FILMOMHULD 1MG'}; {http://www.whocc.no/atc code 'L02BG03' = 'anastrozole', given as 'anastrozole'})
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+
+
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+
+
+
+
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+
+
+ Generated Narrative with Details
id: 8adc0999-9468-4ac9-9557-680fa133d626
meta:
code: Black Cohosh Extract herbal supplement (Details : {SNOMED CT code '412588001' = 'Cimicifuga racemosa extract (substance)', given as 'Cimicifuga racemosa extract (substance)'}; {http://www.whocc.no/atc code 'G02CX04' = 'Cimicifugae rhizoma', given as 'Cimicifugae rhizoma'})
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+ Generated Narrative with Details
id: 72884cad-ebe6-4f43-a51a-2f978275f132
meta:
identifier: 3a462598-009c-484a-965c-d6b24a821424
clinicalStatus: Active (Details : {http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical code 'active' = 'Active)
verificationStatus: Confirmed (Details : {http://terminology.hl7.org/CodeSystem/allergyintolerance-verification code 'confirmed' = 'Confirmed)
type: allergy
category: medication
criticality: high
code: Penicillin -class of antibiotic- (substance) (Details : {SNOMED CT code '373270004' = 'Substance with penicillin structure and antibacterial mechanism of action', given as 'Penicillin -class of antibiotic- (substance)'})
patient: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
onset: Jan 1, 2010, 12:00:00 AM
+
+
+
+
+
+
+
+
+ Generated Narrative with Details
id: c4597aa2-688a-401b-a658-70acc6de28c6
meta:
identifier: 66d4a8c7-9081-43e0-a63f-489c2ae6edd6
clinicalStatus: Remission (Details : {http://terminology.hl7.org/CodeSystem/condition-clinical code 'remission' = 'Remission)
verificationStatus: Confirmed (Details : {http://terminology.hl7.org/CodeSystem/condition-ver-status code 'confirmed' = 'Confirmed)
category: Problem (Details : {LOINC code '75326-9' = 'Problem', given as 'Problem'})
severity: Severe (Details : {LOINC code 'LA6750-9' = 'Severe', given as 'Severe'})
code: Malignant tumor of breast (Details : {SNOMED CT code '254837009' = 'Malignant neoplasm of breast (disorder)', given as 'Malignant tumor of breast'}; {urn:oid:2.16.840.1.113883.6.43.1 code '8500/3' = 'Infiltrating duct carcinoma, NOS', given as 'Infiltrating duct carcinoma, NOS'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
onset: Jan 1, 2015, 12:00:00 AM
abatement: Mar 1, 2015, 12:00:00 AM
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+
+
+
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+
+
+
+
+
+
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+
+
+
+
+
+
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+ Generated Narrative with Details
id: 45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7
active: true
type: Other (Details : {http://terminology.hl7.org/CodeSystem/organization-type code 'other' = 'Other)
name: Laboratoire de charme
+ Generated Narrative with Details
id: aa11a2be-3e36-4be7-b58a-6fc3dace2741
meta:
status: final
category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'laboratory' = 'Laboratory)
code: ABO and Rh group [Type] in Blood (Details : {LOINC code '882-1' = 'ABO and Rh group [Type] in Blood', given as 'ABO and Rh group [Type] in Blood'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Oct 10, 2015, 8:15:00 AM
value: Blood group A Rh(D) positive (Details : {SNOMED CT code '278149003' = 'Blood group A Rh(D) positive', given as 'Blood group A Rh(D) positive'})
+
+
+
+
+
+
+
+
+ Generated Narrative with Details
id: 6e39ccf3-f997-4a2b-8f28-b4b71c778c70
meta:
status: final
category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'laboratory' = 'Laboratory)
code: C Ab [Presence] in Serum or Plasma (Details : {LOINC code '945-6' = 'C Ab [Presence] in Serum or Plasma', given as 'C Ab [Presence] in Serum or Plasma'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Oct 10, 2015, 8:35:00 AM
value: Positive (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})
+
+
+
+
+
+
+
+
+ Generated Narrative with Details
id: b4916505-a06b-460c-9be8-011609282457
meta:
status: final
category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'laboratory' = 'Laboratory)
code: E Ab [Presence] in Serum or Plasma (Details : {LOINC code '1018-1' = 'E Ab [Presence] in Serum or Plasma', given as 'E Ab [Presence] in Serum or Plasma'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Oct 10, 2015, 8:35:00 AM
value: Positive (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})
+
+
+
+
+
+
+
+
+ Generated Narrative with Details
id: a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4
meta:
status: final
category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'laboratory' = 'Laboratory)
code: little c Ab [Presence] in Serum or Plasma (Details : {LOINC code '1156-9' = 'little c Ab [Presence] in Serum or Plasma', given as 'little c Ab [Presence] in Serum or Plasma'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Oct 10, 2015, 8:35:00 AM
value: Negative (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})
+
+
+
+
+
+
+
+
+ Generated Narrative with Details
id: 2639657a-c19a-48e2-82cc-471e13b8ad94
meta:
status: final
category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'laboratory' = 'Laboratory)
code: Blood typing (Details )
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Oct 10, 2015, 12:00:00 AM
performer: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7
hasMember:
+
+
+
+ Generated Narrative with Details
id: cc354e00-a419-47ea-8b6c-1768b2a01646
meta:
status: final
category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'laboratory' = 'Laboratory)
code: Hemoglobin A1c/Hemoglobin.total in Blood by HPLC (Details : {LOINC code '17856-6' = 'Hemoglobin A1c/Hemoglobin.total in Blood by HPLC', given as 'Hemoglobin A1c/Hemoglobin.total in Blood by HPLC'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Nov 10, 2017, 7:20:00 AM
performer: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7
value: 7.5 % (Details: UCUM code % = '%')
note: Above stated goal of 7.0 %
+
+
+
+
+
+
+
+
+ Generated Narrative with Details
id: 26bee0a9-5997-4557-ab9d-c6adbb05b572
meta:
status: final
category: Laboratory (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'laboratory' = 'Laboratory)
code: Bacteria identified in Isolate (Details : {LOINC code '42803-7' = 'Bacteria identified in Isolate', given as 'Bacteria identified in Isolate'})
subject: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
effective: Dec 10, 2017, 7:20:00 AM
performer: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7
value: Methicillin resistant Staphylococcus aureus (Details : {SNOMED CT code '115329001' = 'MRSA', given as 'Methicillin resistant Staphylococcus aureus'})
note: Healthy carrier of MRSA
+
+
+
+
+
+
+
+
+ Generated Narrative with Details
id: c7781f44-6df8-4a8b-9e06-0b34263a47c5
meta:
identifier: 3a462598-009c-484a-965c-d6b24a821424
clinicalStatus: Active (Details : {http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical code 'active' = 'Active)
verificationStatus: Confirmed (Details : {http://terminology.hl7.org/CodeSystem/allergyintolerance-verification code 'confirmed' = 'Confirmed)
type: allergy
category: medication
criticality: high
code: No known food allergies (Details : {http://hl7.org/fhir/uv/ips/CodeSystem/absent-unknown-uv-ips code 'no-known-food-allergies' = 'No known food allergies)
patient: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8
onset: Jan 1, 2010, 12:00:00 AM
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+