Dental Data Exchange
1.0.0 - STU 1

Publication Build: This will be filled in by the publication tooling

## : Dental Referral Note example - XML Representation

Raw xml | Download

    <Composition xmlns="http://hl7.org/fhir">
      <id value="Med-2-Dental-Referral"/>
      <meta>
        <versionId value="25"/>
        <lastUpdated value="2021-08-26T17:48:27.238+00:00"/>
        <source value="#D3muhSqHq8nuVF61"/>
        <profile
                 value="http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referral-note"/>
      </meta>
      <language value="en-US"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: http://any.org/1</p><p><b>status</b>: final</p><p><b>type</b>: <span title="Codes: {http://loinc.org 57134-9}">Dentistry Referral note</span></p><p><b>encounter</b>: <a href="Encounter-Med-visit-1.html">PCP visit. Generated Summary: status: finished; <span title="{http://terminology.hl7.org/CodeSystem/v3-ActCode AMB}">ambulatory</span>; <span title="Codes: {http://www.ama-assn.org/go/cpt 99201}">Office Visit</span>; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ActPriority R}">routine</span>; period: Feb 14, 2020 8:00:14 PM --&gt; Feb 14, 2020 8:30:14 PM</a></p><p><b>date</b>: Jan 14, 2020 3:10:14 AM</p><p><b>author</b>: <a href="Practitioner-practitioner-M.html">Dr. John M, MD. Generated Summary: id: 1234569999; John M ; Phone: 303-303-6443; gender: male; birthDate: 1975-06-09</a></p><p><b>title</b>: Referral Note</p><h3>Attesters</h3><table class="grid"><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>legal</td><td>Mar 14, 2020 9:10:14 AM</td><td><a href="PractitionerRole-PractitionerRole-M.html">Dr. John M, MD. Generated Summary: <span title="Codes: {http://snomed.info/sct 394814009}">General practice (specialty)</span>; Phone: 5555557777</a></td></tr></table><p><b>custodian</b>: <a href="Organization-GHC-organization.html">Good Health Clinic. Generated Summary: id: 1316452725; active: true; <span title="Codes: {http://terminology.hl7.org/CodeSystem/organization-type prov}">Healthcare Provider</span>; name: Good Health Clinic; Phone: (+1) 555-677-7777, customer-service@GHclinic.org</a></p></div>
      </text>
      <identifier>
        <system value="urn:ietf:rfc:3986"/>
        <value value="http://any.org/1"/>
      </identifier>
      <status value="final"/>
      <type>
        <coding>
          <system value="http://loinc.org"/>
          <code value="57134-9"/>
          <display value="Dentistry Referral note"/>
        </coding>
      </type>
      <subject>
        <reference value="Patient/example-dental"/>
        <display value="Patient A"/>
      </subject>
      <encounter>
        <reference value="Encounter/Med-visit-1"/>
        <display value="PCP visit"/>
      </encounter>
      <date value="2020-01-14T03:10:14Z"/>
      <author>
        <reference value="Practitioner/practitioner-M"/>
        <display value="Dr. John M, MD"/>
      </author>
      <title value="Referral Note"/>
      <attester>
        <mode value="legal"/>
        <time value="2020-03-14T09:10:14Z"/>
        <party>
          <reference value="PractitionerRole/PractitionerRole-M"/>
          <display value="Dr. John M, MD"/>
        </party>
      </attester>
      <custodian>
        <reference value="Organization/GHC-organization"/>
        <display value="Good Health Clinic"/>
      </custodian>
      <section>
        <title value="Allergies and Intolerances Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="48765-2"/>
            <display value="Allergies and adverse reactions Document"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <table>
                        <tr>
                            <td>
                                <b>Allergen</b>
                            </td>
                            <td>
                                <b>Code</b>
                            </td>
                            <td>
                                <b>Manifestation</b>
                            </td>
                            <td>
                                <b>Severity</b>
                            </td>
                        </tr>
                        <tr>
                            <td>Penicillin G</td>
                            <td>7908</td>
                            <td>Skin rash</td>
                            <td>mild</td>
                        </tr>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="AllergyIntolerance/Allergy-example-dental"/>
        </entry>
      </section>
      <section>
        <title value="Medication Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="10160-0"/>
            <display value="History of Medication use Narrative"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <table>
                        <tr>
                            <td>
                                <b>Medication</b>
                            </td>
                            <td>
                                <b>Directions</b>
                            </td>
                            <td>
                                <b>Start Date</b>
                            </td>
                            <td>
                                <b>Status</b>
                            </td>
                            <td>
                                <b>Indications</b>
                            </td>
                            <td>
                                <b>Fill Instructions</b>
                            </td>
                        </tr>
                        <tr>
                            <td>Lisinopril 10 mg tab</td>
                            <td>1 tab once/day</td>
                            <td/>
                            <td>Active</td>
                            <td/>
                            <td>Generic substitution allowed</td>
                        </tr>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="MedicationRequest/Lisinopril-medreq"/>
        </entry>
      </section>
      <section>
        <title value="Problem Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="11450-4"/>
            <display value="Problem list - Reported"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>Mild, Hypertension</p>
                    <p>Type 1 diabetes</p>
                    <p>Teeth covered in plague</p>
                    <p>Toothache</p>
                    <p>Swollen Gums</p>
                    <p>Bleeding Gums</p>
                    <p>At high risk for dental carries</p>
                </div>
        </text>
        <entry>
          <reference value="Condition/HTN-example"/>
        </entry>
        <entry>
          <reference value="Condition/DM1-example"/>
        </entry>
        <entry>
          <reference value="Condition/Dental-plaque-example"/>
        </entry>
        <entry>
          <reference value="Condition/toothache-example"/>
        </entry>
        <entry>
          <reference value="Condition/Swollen-gums-example"/>
        </entry>
        <entry>
          <reference value="Condition/Bleeding-gums-example"/>
        </entry>
        <entry>
          <reference value="Condition/Caries-risk"/>
        </entry>
      </section>
      <section>
        <title value="Reason for Referral Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="42349-1"/>
            <display value="Reason for referral (narrative)"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>Toothache</p>
                    <p>Left lower quadrant pain</p>
                    <p>Bleeding gums</p>
                </div>
        </text>
        <entry>
          <reference value="ServiceRequest/example-dental-referral-1"/>
        </entry>
      </section>
      <section>
        <title value="Plan of Treatment Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="18776-5"/>
            <display value="Plan of care note"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>D0150 - Comprehensive Oral Evaluation</p>
                </div>
        </text>
        <entry>
          <reference value="Encounter/Comp-oral-eval"/>
        </entry>
      </section>
      <section>
        <title value="Assessment Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="51848-0"/>
            <display value="Evaluation note"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>Patient has pain in his lower left jaw and occassional bleeding from his gums - referring for dental evaluation.</p>
                </div>
        </text>
      </section>
      <section>
        <title value="History of Present Illness Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="10164-2"/>
            <display value="History of Present illness Narrative"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>The patient has not visited a dentist or received flouride treatments in the past 4 years while away at college</p>
                </div>
        </text>
      </section>
      <section>
        <title value="Immunizations Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="11369-6"/>
            <display value="History of Immunization Narrative"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <table border="1" width="100%">
                        <thead>
                            <tr>
                                <th>Vaccine</th>
                                <th>Date</th>
                                <th>Status</th>
                            </tr>
                        </thead>
                        <tbody>
                            <tr>
                                <td>
                    Hepatitis B vaccine
                  </td>
                                <td>January 4, 2020</td>
                                <td>Completed</td>
                            </tr>
                        </tbody>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="Immunization/imm-1"/>
        </entry>
      </section>
      <section>
        <title value="Medical Equipment Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="46264-8"/>
            <display value="History of medical device use"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <table border="1" width="100%">
                        <thead>
                            <tr>
                                <th>Device Type</th>
                                <th>Procedure</th>
                                <th>Implant Date</th>
                            </tr>
                        </thead>
                        <tbody>
                            <tr>
                                <td>Insulin Pump</td>
                                <td>Insertion of insulin pump (procedure)</td>
                                <td>November 3, 2013</td>
                            </tr>
                        </tbody>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="Procedure/Insulin-pump-insertion"/>
        </entry>
      </section>
      <section>
        <title value="Procedures Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="47519-4"/>
            <display value="History of Procedures Document"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>No Procedures performed</p>
                </div>
        </text>
      </section>
      <section>
        <title value="Social History Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="29762-2"/>
            <display value="Social history Narrative"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <table>
                        <tr>
                            <td>
                                <b>Social History Element</b>
                            </td>
                            <td>
                                <b>Description</b>
                            </td>
                            <td>
                                <b>Effective Dates</b>
                            </td>
                        </tr>
                        <tr>
                            <td>Smoking Status</td>
                            <td>NA</td>
                            <td>2005/05/01 - 2020/03/28</td>
                        </tr>
                        <tr>
                            <td>Highest Education Received</td>
                            <td>Collect Education</td>
                            <td>2010/05/01 - 2014/03/28</td>
                        </tr>
                        <tr>
                            <td>Employment</td>
                            <td>Full-time accountant</td>
                            <td>2015/05/01 - current</td>
                        </tr>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="Observation/Smoker-obs-example-dental"/>
        </entry>
        <entry>
          <reference value="Observation/Education-level-example-dental"/>
        </entry>
        <entry>
          <reference value="Observation/Present-job-example-dental"/>
        </entry>
      </section>
      <section>
        <title value="Vital Signs Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="8716-3"/>
            <display value="Vital signs"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <table>
                        <tr>
                            <td>
                                <b>Vital Sign</b>
                            </td>
                            <td>
                                <b>Date</b>
                            </td>
                            <td>
                                <b>Value</b>
                            </td>
                        </tr>
                        <tr>
                            <td>Temperature</td>
                            <td>2020/04/15</td>
                            <td>98.5</td>
                        </tr>
                        <tr>
                            <td>Heart Rate</td>
                            <td>2020/04/15</td>
                            <td>78</td>
                        </tr>
                        <tr>
                            <td>Respiration Rate</td>
                            <td>2020/04/15</td>
                            <td>20</td>
                        </tr>
                        <tr>
                            <td>Blood Pressure</td>
                            <td>2020/04/15</td>
                            <td>120/80</td>
                        </tr>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="Observation/vitals-panel"/>
        </entry>
      </section>
      <section>
        <title value="Goals Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="61146-7"/>
            <display value="Goals"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>No soda/sugary drinks/energy drinks</p>
                    <p>Use fluoride toothpaste</p>
                </div>
        </text>
      </section>
      <section>
        <title value="Health Concerns Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="75310-3"/>
            <display value="Health concerns Document"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>Neuropathy due to diabetes mellitus</p>
                </div>
        </text>
      </section>
      <section>
        <title value="Instructions Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="69730-0"/>
            <display value="Instructions"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride
              toothpaste, floss</p>
                </div>
        </text>
        <entry>
          <reference value="Communication/dental-education"/>
        </entry>
      </section>
      <section>
        <title value="Payers Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="48768-6"/>
            <display value="Payment sources Document"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>Aetna Comprehensive Medical /Dental Insurance</p>
                </div>
        </text>
        <entry>
          <reference value="Coverage/Dental-Aetna"/>
        </entry>
      </section>
      <section>
        <title value="Dental Findings Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="8704-9"/>
            <display value="Physical findings of Mouth and Throat and Teeth"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>No Information</p>
                </div>
        </text>
      </section>
    </Composition>