Generated Narrative with Details

id: IPS-examples-Composition-01

meta:

text:

identifier: 10501

status: FINAL

type: Patient Summary (Details : {LOINC code '60591-5' = 'Patient summary Document', given as 'Patient Summary'})

date: 26/01/2018 14:30:00 PM

author: Generated Summary: id: IPS-examples-Device-01; Sistema HCE del Hospital Municipal Dr Angel Pintos

title: Patient Summary as of January 26, 2018 14:30

confidentiality: N

attester

mode: LEGAL

time: 26/01/2018 2:30:00 PM

party: Generated Summary: id: IPS-examples-Organization-01; 14999912399913; active; Hospital Municipal Hospital Doctor Ángel Pintos

custodian: Generated Summary: id: IPS-examples-Organization-01; http://hospitalPintos.org.ar; active; name: Hospital Municipal Hospital Doctor Ángel Pintos / Dominio; ph: +54 02281 43-5200(WORK)

 <confidentiality value="N" /> <attester> <mode value="legal" /> <time value="2018-01-26T14:30:00-03:00" /> <party> <reference value="http://hapi.fhir.org/baseR4/Organization/IPS-examples-Organization-01" /> </party> </attester> <custodian> <reference value="http://hapi.fhir.org/baseR4/Organization/IPS-examples-Organization-01" /> </custodian> <section> <title value="Problemas" /> <code> <coding> <system value="http://loinc.org" /> <code value="11450-4" /> <display value="Problem list" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml">asma (trastorno)</div> </text> <entry> <reference value="http://hapi.fhir.org/baseR4/Condition/IPS-examples-Condition-01" /> </entry> </section> <section> <title value="Medicamentos" /> <code> <coding> <system value="http://loinc.org" /> <code value="10160-0" /> <display value="Medication use" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <thead> <tr> <th>Medicamento</th> <th>Strength</th> <th>Forma</th> <th>Dosis</th> <th>Comentario</th> </tr> </thead> <tbody> <tr> <td>salbutamol (sustancia)</td> <td>200 mcg</td> <td>disparo</td> <td>uno por día</td> <td>tratamiento de asma</td> </tr> </tbody> </table> </div> </text> <entry> <reference value="http://hapi.fhir.org/baseR4/MedicationStatement/IPS-examples-MedicationStatement-01" /> </entry> </section> <section> <title value="Alergias" /> <code> <coding> <system value="http://loinc.org" /> <code value="48765-2" /> <display value="Allergies and/or adverse reactions" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml">Alergia a penicilina (trastorno), criticidad alta, activo</div> </text> <entry> <reference value="http://hapi.fhir.org/baseR4/AllergyIntolerance/IPS-examples-AllergyIntolerance-01" /> </entry> </section> <section> <title value="Vacunas" /> <code> <coding> <system value="http://loinc.org" /> <code value="60484-3" /> <display value="Immunization record" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml">producto que contiene solamente antígeno de virus de la influenza (producto medicinal)</div> </text> <entry> <reference value="http://hapi.fhir.org/baseR4/Immunization/IPS-examples-Immunization-01" /> </entry> </section> </Composition> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" /> <resource> <Patient> <id value="IPS-examples-Patient-01" /> <identifier> <system value="http://hospitalPintos.org.ar/Patient" /> <value value="9000022" /> </identifier> <identifier> <system value="http://www.renaper.gob.ar/dni" /> <value value="99999999" /> </identifier> <active value="true" /> <name> <text value="Villareal Maria Victoria" /> <family value="Villareal"> <extension url="https://federador.msal.gob.ar/primer_apellido"> <valueString value="Villareal" /> </extension> </family> <given value="Maria" /> <given value="Victoria" /> </name> <telecom> <system value="phone" /> <value value="44318113" /> </telecom> <gender value="female" /> <birthDate value="1969-11-01" /> </Patient> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/Device/IPS-examples-Device-01" /> <resource> <Device> <id value="IPS-examples-Device-01" /> <identifier> <system value="http://hospitalPintos.org.ar/Device" /> <value value="HCE_HtalPintos_v1.0" /> </identifier> <deviceName> <name value="Sistema HCE del Hospital Municipal Dr Angel Pintos" /> <type value="manufacturer-name" /> </deviceName> <type> <coding> <system value="http://snomed.info/sct" /> <code value="462894001" /> <display value="software de aplicación de sistema de información de historias clínicas de pacientes (objeto físico)" /> </coding> </type> <owner> <reference value="http://argentina.gob.ar/salud/refes/Organization/14999912399913" /> </owner> </Device> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/Organization/IPS-examples-Organization-01" /> <resource> <Organization> <id value="IPS-examples-Organization-01" /> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <p> <b>Generated Narrative with Details</b> </p> <p> <b>id</b>: IPS-examples-Organization-01</p> <p> <b>text</b>: </p> <p> <b>identifier</b>: 14999912399913</p> <p> <b>active</b>: true</p> <p> <b>name</b>: Hospital Municipal Hospital Doctor Ángel Pintos</p> <p> <b>telecom</b>: ph: +54 02281 43-5200</p> <p> <b>address</b>: Amado Diab 270, B7300 Azul, Buenos Aires, Argentina</p> </div> </text> <identifier> <system value="http://argentina.gob.ar/salud/refes" /> <value value="14999912399913" /> </identifier> <identifier> <system value="http://argentina.gob.ar/salud/bus-interoperabilidad/dominio" /> <value value="http://hospitalPintos.org.ar" /> </identifier> <active value="true" /> <name value="Hospital Municipal Hospital Doctor Ángel Pintos" /> <telecom> <system value="phone" /> <value value="+54 02281 43-5200" /> <use value="work" /> </telecom> <address> <use value="work" /> <line value="Amado Diab 270," /> <city value="Azul" /> <postalCode value="B7300" /> <country value="Argentina" /> </address> </Organization> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/Condition/IPS-examples-Condition-01" /> <resource> <Condition> <id value="IPS-examples-Condition-01" /> <meta> <profile value="http://hl7.org/fhir/uv/ips/StructureDefinition/condition-uv-ips" /> </meta> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <p> <b>Generated Narrative with Details</b> </p> <p> <b>id</b>: IPS-examples-Condition-01</p> <p> <b>meta</b>: </p> <p> <b>text</b>: </p> <p> <b>identifier</b>: c87bf51c-e53c-4bfe-b8b7-aa62bdd93002</p> <p> <b>clinicalStatus</b>: Active <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/condition-clinical code 'active' = 'Active)</span></p> <p> <b>verificationStatus</b>: Confirmed <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/condition-ver-status code 'confirmed' = 'Confirmed)</span></p> <p> <b>category</b>: Problem <span style="background: LightGoldenRodYellow">(Details : {LOINC code '75326-9' = 'Problem', given as 'Problem'})</span></p> <p> <b>severity</b>: Moderate <span style="background: LightGoldenRodYellow">(Details : {LOINC code 'LA6751-7' = 'LA6751-7', given as 'Moderate'})</span></p> <p> <b>code</b>: Menopausal flushing (finding) <span style="background: LightGoldenRodYellow">(Details : {SNOMED CT code '198436008' = 'Hot flush', given as 'Menopausal flushing (finding)'})</span></p> <p> <b>subject</b>: <a href="#patient_IPS-examples-Patient-01">Generated Summary: id: IPS-examples-Patient-01; 574687583; active; Martha DeLarosa ; ph: +31788700800(HOME); FEMALE; birthDate: 01/05/1972</a></p> <p> <b>recordedDate</b>: 01/10/2016</p> </div> </text> <clinicalStatus> <coding> <system value="http://terminology.hl7.org/CodeSystem/condition-clinical" /> <code value="active" /> </coding> </clinicalStatus> <verificationStatus> <coding> <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" /> <code value="confirmed" /> </coding> </verificationStatus> <category> <coding> <system value="http://loinc.org" /> <code value="75326-9" /> <display value="Problem" /> </coding> </category> <severity> <coding> <system value="http://loinc.org" /> <code value="LA6751-7" /> <display value="Moderate" /> </coding> </severity> <code> <coding> <system value="http://snomed.info/sct" /> <code value="195967001" /> <display value="asma (trastorno)" /> </coding> </code> <subject> <reference value="http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" /> </subject> <onsetDateTime value="2016" /> <recordedDate value="2016-10" /> </Condition> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/MedicationStatement/IPS-examples-MedicationStatement-01" /> <resource> <MedicationStatement> <id value="IPS-examples-MedicationStatement-01" /> <meta> <profile value="http://hl7.org/fhir/uv/ips/StructureDefinition/medicationstatement-uv-ips" /> </meta> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <p> <b>Generated Narrative with Details</b> </p> <p> <b>id</b>: IPS-examples-MedicationStatement-01</p> <p> <b>meta</b>: </p> <p> <b>text</b>: </p> <p> <b>identifier</b>: b75f92cb-61d4-469a-9387-df5ef70d25f0</p> <p> <b>status</b>: ACTIVE</p> <p> <b>medication</b>: <a href="#medication_IPS-examples-Medication-01">Generated Summary: id: IPS-examples-Medication-01; <span title="Codes: {http://snomed.info/sct 108774000}, {urn:oid:2.16.840.1.113883.2.4.4.1 99872}, {urn:oid:2.16.840.1.113883.2.4.4.7 2076667}">Anastrozole (product)</span></a></p> <p> <b>subject</b>: <a href="#patient_IPS-examples-Patient-01">Generated Summary: id: IPS-examples-Patient-01; 574687583; active; Martha DeLarosa ; ph: +31788700800(HOME); FEMALE; birthDate: 01/05/1972</a></p> <p> <b>effective</b>: 01/03/2015 --> (ongoing)</p> <p> <b>dosage</b>: </p> </div> </text> <status value="active" /> <medicationReference> <reference value="http://hapi.fhir.org/baseR4/Medication/IPS-examples-Medication-01" /> </medicationReference> <subject> <reference value="http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" /> </subject> <effectivePeriod> <start value="2015-03" /> </effectivePeriod> <dosage> <timing> <repeat> <count value="1" /> <periodUnit value="d" /> </repeat> </timing> <route> <coding> <system value="http://snomed.info/sct" /> <code value="447694001" /> <display value="vía de administración en el tracto respiratorio (calificador)" /> </coding> </route> <doseAndRate> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/dose-rate-type" /> <code value="ordered" /> <display value="Ordered" /> </coding> </type> <doseQuantity> <value value="1" /> <unit value="disparo (unidad de presentación)" /> <system value="http://snomed.info/sct" /> <code value="732981002" /> </doseQuantity> </doseAndRate> </dosage> </MedicationStatement> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/Medication/IPS-examples-Medication-01" /> <resource> <Medication> <id value="IPS-examples-Medication-01" /> <meta> <profile value="http://hl7.org/fhir/uv/ips/StructureDefinition/medication-uv-ips" /> </meta> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <p> <b>Generated Narrative with Details</b> </p> <p> <b>id</b>: IPS-examples-Medication-01</p> <p> <b>meta</b>: </p> <p> <b>text</b>: </p> <p> <b>code</b>: producto que contiene exactamente salbutamol 200 microgramos/disparo en polvo de liberación convencional para administración por inhalación (fármaco de uso clínico) <span style="background: LightGoldenRodYellow">(Details : {SNOMED CT code '770301006' = 'producto que contiene exactamente salbutamol 200 microgramos/disparo en polvo de liberación convencional para administración por inhalación (fármaco de uso clínico)', given as 'Anastrozole (product)'};</span></p> </div> </text> <code> <coding> <system value="http://snomed.info/sct" /> <code value="770301006" /> <display value="producto que contiene exactamente salbutamol 200 microgramos/disparo en polvo de liberación convencional para administración por inhalación (fármaco de uso clínico)" /> </coding> </code> <form> <coding> <system value="http://snomed.info/sct" /> <code value="732981002" /> <display value="disparo (unidad de presentación)" /> </coding> </form> <ingredient> <isActive value="true" /> <strength> <numerator> <value value="200" /> <unit value="mcg" /> </numerator> <denominator> <value value="1" /> <unit value="disparo" /> </denominator> </strength> </ingredient> </Medication> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/AllergyIntolerance/IPS-examples-AllergyIntolerance-01" /> <resource> <AllergyIntolerance> <id value="IPS-examples-AllergyIntolerance-01" /> <meta> <profile value="http://hl7.org/fhir/uv/ips/StructureDefinition/allergyintolerance-uv-ips" /> </meta> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <p> <b>Generated Narrative with Details</b> </p> <p> <b>id</b>: IPS-examples-AllergyIntolerance-01</p> <p> <b>meta</b>: </p> <p> <b>text</b>: </p> <p> <b>identifier</b>: 3a462598-009c-484a-965c-d6b24a821424</p> <p> <b>type</b>: ALLERGY</p> <p> <b>category</b>: MEDICATION</p> <p> <b>criticality</b>: HIGH</p> <p> <b>code</b>: Penicillin -class of antibiotic- (substance) <span style="background: LightGoldenRodYellow">(Details : {SNOMED CT code '373270004' = 'Penicillin -class of antibiotic- (substance)', given as 'Penicillin -class of antibiotic- (substance)'})</span></p> <p> <b>patient</b>: <a href="#patient_IPS-examples-Patient-01">Generated Summary: id: IPS-examples-Patient-01; 574687583; active; Martha DeLarosa ; ph: +31788700800(HOME); FEMALE; birthDate: 01/05/1972</a></p> </div> </text> <type value="allergy" /> <category value="medication" /> <criticality value="high" /> <code> <coding> <system value="http://snomed.info/sct" /> <code value="91936005" /> <display value="alergia a la penicilina (trastorno)" /> </coding> </code> <patient> <reference value="http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" /> </patient> <onsetDateTime value="2010" /> </AllergyIntolerance> </resource> </entry> <entry> <fullUrl value="http://hapi.fhir.org/baseR4/Immunization/IPS-examples-Immunization-01" /> <resource> <Immunization> <id value="IPS-examples-Immunization-01" /> <status value="completed" /> <vaccineCode> <coding> <system value="https://snomed.info/sct/11000221109/id/228100022110" /> <code value="1181000221105" /> <display value="producto que contiene solamente antígeno de virus de la influenza (producto medicinal)" /> </coding> </vaccineCode> <patient> <reference value="http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" /> </patient> <occurrenceDateTime value="2017-05-22" /> <primarySource value="true" /> <location> <reference value="http://argentina.gob.ar/salud/refes/Location/14999912399913" /> </location> <lotNumber value="649718" /> <expirationDate value="2017-12-22" /> <reasonCode> <coding> <system value="http://snomed.info/sct" /> <code value="429060002" /> <display value="procedimiento para cumplir con el requerimiento ocupacional (procedimiento)" /> </coding> <coding> <system value="http://saluddigital.ar/valueSet/NOMIVAC-condicion-code" /> <code value="17" /> <display value="Personal de Salud" /> </coding> </reasonCode> <isSubpotent value="false" /> <protocolApplied> <extension url="http://saluddigital.ar/fhir/esquema"> <valueCoding> <system value="http://saluddigital.ar/valueSet/NOMIVAC-esquema-code" /> <code value="81" /> <display value="Antigripal Esquema Personal de Salud" /> </valueCoding> </extension> <series value="Antigripal Esquema Personal de Salud" /> <targetDisease> <coding> <system value="http://snomed.info/sct" /> <code value="6142004" /> <display value="gripe (trastorno)" /> </coding> </targetDisease> <doseNumberPositiveInt value="1" /> </protocolApplied> </Immunization> </resource> </entry> </Bundle>