Dental Data Exchange
1.0.0 - STU 1

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## : Dental Consultation Note example - JSON Representation

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    {
      "resourceType" : "Composition",
      "id" : "Dental-2-Med-Consult",
      "meta" : {
        "versionId" : "24",
        "lastUpdated" : "2021-08-24T23:27:45.426+00:00",
        "source" : "#sBPqj3BhYLw4XXH8",
        "profile" : [
          "http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult-note"
        ]
      },
      "language" : "en-US",
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative</b></p><p><b>Order Extension</b>: <a href=\"ServiceRequest-example-dental-referral-1.html\">Generated Summary: id: urn:uid:0c2aacfc-ce7d-4652-b9ea-7280ea21dec4; status: active; intent: plan; <span title=\"Codes: {http://snomed.info/sct 14736009}\">Evaluation and management of patient (procedure)</span>; priority: asap; <span title=\"Codes: {http://snomed.info/sct 103697008}\">Patient referral for dental care (procedure)</span></a></p><p><b>identifier</b>: id: urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b</p><p><b>status</b>: final</p><p><b>type</b>: <span title=\"Codes: {http://loinc.org 34756-7}\">Dentistry Consult note</span></p><p><b>encounter</b>: <a href=\"Encounter-Dental-encounter.html\">Dental Referral with patient A. Generated Summary: status: finished; <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode AMB}\">ambulatory</span>; <span title=\"Codes: {http://snomed.info/sct 185347001}\">Encounter for problem (procedure)</span>; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ActPriority R}\">routine</span>; period: Feb 16, 2020 8:00:14 PM --&gt; Feb 16, 2020 8:30:14 PM</a></p><p><b>date</b>: Feb 16, 2020 9:10:14 AM</p><p><b>author</b>: <a href=\"Practitioner-practitioner-D.html\">Dentist D, DMD. Generated Summary: id: 1234560000; John D ; Phone: 720-555-6443; gender: male; birthDate: 1990-06-09</a></p><p><b>title</b>: Consultation 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 28, 2020 9:10:14 AM</td><td><a href=\"Practitioner-practitioner-D.html\">Dentist Dentist D, DMD. Generated Summary: id: 1234560000; John D ; Phone: 720-555-6443; gender: male; birthDate: 1990-06-09</a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-GOHC-organization.html\">Good Oral Health Clinic. Generated Summary: id: 2316452725; active: true; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span>; name: Good Oral Health Clinic; Phone: (+1) 720-677-7777, customer2-service@GHclinic.org</a></p><h3>Events</h3><table class=\"grid\"><tr><td>-</td><td><b>Code</b></td><td><b>Period</b></td></tr><tr><td>*</td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ActClass PCPR}\">Care Provision</span></td><td>2020-02-16 --&gt; 2020-02-16</td></tr></table></div>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension",
          "valueReference" : {
            "reference" : "ServiceRequest/example-dental-referral-1"
          }
        }
      ],
      "identifier" : {
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b"
      },
      "status" : "final",
      "type" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "34756-7",
            "display" : "Dentistry Consult note"
          }
        ]
      },
      "subject" : {
        "reference" : "Patient/example-dental",
        "display" : "Patient A"
      },
      "encounter" : {
        "reference" : "Encounter/Dental-encounter",
        "display" : "Dental Referral with patient A"
      },
      "date" : "2020-02-16T09:10:14Z",
      "author" : [
        {
          "reference" : "Practitioner/practitioner-D",
          "display" : "Dentist D, DMD"
        }
      ],
      "title" : "Consultation Note",
      "attester" : [
        {
          "mode" : "legal",
          "time" : "2020-03-28T09:10:14Z",
          "party" : {
            "reference" : "Practitioner/practitioner-D",
            "display" : "Dentist Dentist D, DMD"
          }
        }
      ],
      "custodian" : {
        "reference" : "Organization/GOHC-organization",
        "display" : "Good Oral Health Clinic"
      },
      "event" : [
        {
          "code" : [
            {
              "coding" : [
                {
                  "system" : "http://terminology.hl7.org/CodeSystem/v3-ActClass",
                  "code" : "PCPR",
                  "display" : "Care Provision"
                }
              ]
            }
          ],
          "period" : {
            "start" : "2020-02-16",
            "end" : "2020-02-16"
          }
        }
      ],
      "section" : [
        {
          "title" : "Allergies and Intolerances Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "48765-2",
                "display" : "Allergies and adverse reactions Document"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table>\n                    <tr>\n                        <td>\n                            <b>Substance</b>\n                        </td>\n                        <td>\n                            <b>Overall Severity</b>\n                        </td>\n                        <td>\n                            <b>Reaction</b>\n                        </td>\n                        <td>\n                            <b>Reaction Severity</b>\n                        </td>\n                        <td>\n                            <b>Status</b>\n                        </td>\n                    </tr>\n                    <tr>\n                        <td>Penicillin G (Ingredient)</td>\n                        <td>Mild</td>\n                        <td>Skin rash</td>\n                        <td>Mild</td>\n                        <td>Active</td>\n                    </tr>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "AllergyIntolerance/Allergy-example-dental"
            }
          ]
        },
        {
          "title" : "History of Present Illness Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "10164-2",
                "display" : "History of Present illness Narrative"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>The patient has not visited a dentist or received fluoride treatments in the past four years while away at college</p>\n            </div>"
          }
        },
        {
          "title" : "Problem Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "11450-4",
                "display" : "Problem list - Reported"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>Mild, Hypertension</p>\n                <p>Type 1 diabetes</p>\n                <p>Dental caries</p>\n                <p>Unable to chew</p>\n                <p>Teeth covered in plague</p>\n                <p>Toothache</p>\n                <p>Chronic periodontitis</p>\n                <p>Infection of tooth</p>\n                <p>At high risk for dental caries (finding)</p>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Condition/HTN-example"
            },
            {
              "reference" : "Condition/DM1-example"
            },
            {
              "reference" : "Condition/Dental-caries"
            },
            {
              "reference" : "Condition/no-chew"
            },
            {
              "reference" : "Condition/Dental-plaque-example"
            },
            {
              "reference" : "Condition/toothache-example"
            },
            {
              "reference" : "Condition/Chronic-periodontitis-example"
            },
            {
              "reference" : "Condition/Tooth-infection18"
            },
            {
              "reference" : "Condition/Caries-risk"
            }
          ]
        },
        {
          "title" : "Medication Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "10160-0",
                "display" : "History of Medication use Narrative"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table>\n                    <tr>\n                        <td>\n                            <b>Medication</b>\n                        </td>\n                        <td>\n                            <b>Directions</b>\n                        </td>\n                        <td>\n                            <b>Start Date</b>\n                        </td>\n                        <td>\n                            <b>Status</b>\n                        </td>\n                        <td>\n                            <b>Indications</b>\n                        </td>\n                        <td>\n                            <b>Fill Instructions</b>\n                        </td>\n                    </tr>\n                    <tr>\n                        <td>erythromycin 500 mg</td>\n                        <td>Take 1 tablet every six hours X10 days</td>\n                        <td/>\n                        <td>Active</td>\n                        <td/>\n                        <td/>\n                    </tr>\n                    <tr>\n                        <td>ibuprofen (OTC)  200 mg tab</td>\n                        <td>Take 2-3 tablets every 8 hours as needed for pain</td>\n                        <td>Take 2-3 tablets every 8 hours as needed for pain</td>\n                        <td/>\n                        <td>Active</td>\n                        <td/>\n                        <td/>\n                    </tr>\n                    <tr>\n                        <td>acetaminophen (OTC) 325 mg</td>\n                        <td>Take 2 tablets every 4-6 hours as needed for pain</td>\n                        <td/>\n                        <td>Active</td>\n                        <td/>\n                        <td/>\n                    </tr>\n                    <tr>\n                        <td>Lisinopril 10 mg tab</td>\n                        <td>1 tab once a day</td>\n                        <td/>\n                        <td>Active</td>\n                        <td/>\n                        <td/>\n                    </tr>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "MedicationRequest/erythromycin-medreq-2"
            },
            {
              "reference" : "MedicationRequest/Ibuprofen-medreq-2"
            },
            {
              "reference" : "MedicationRequest/Tylenol-med-dental"
            },
            {
              "reference" : "MedicationRequest/Lisinopril-medreq"
            }
          ]
        },
        {
          "title" : "Assessment Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "51848-0",
                "display" : "Evaluation note"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p> Patient reports inability to chew on left side due to pain and\n        sensitivity, a condition that has increased in severity in the two days\n        since his medical appointment </p>\n                <p> Significant decay on the left lower second molar (tooth #18)\n         with signs of infection  </p>\n                <p> Early signs of a caries lesion (decay) on the right upper\n        lateral incisor (tooth #7) </p>\n                <p> Recommend an extraction of the left lower second molar(tooth\n        #18) and a restoration on the right upper lateral incisor (tooth #7) due\n        to a caries lesion </p>\n            </div>"
          }
        },
        {
          "title" : "Immunizations Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "11369-6",
                "display" : "History of Immunization Narrative"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table border=\"1\" width=\"100%\">\n                    <thead>\n                        <tr>\n                            <th>Vaccine</th>\n                            <th>Date</th>\n                            <th>Status</th>\n                        </tr>\n                    </thead>\n                    <tbody>\n                        <tr>\n                            <td>\n              Hepatitis B vaccine\n            </td>\n                            <td>January 4, 2020</td>\n                            <td>Completed</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Immunization/imm-1"
            }
          ]
        },
        {
          "title" : "Medical Equipment Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "46264-8",
                "display" : "History of medical device use"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table border=\"1\" width=\"100%\">\n                    <thead>\n                        <tr>\n                            <th>Device Type</th>\n                            <th>Procedure</th>\n                            <th>Implant Date</th>\n                        </tr>\n                    </thead>\n                    <tbody>\n                        <tr>\n                            <td>Insulin Pump</td>\n                            <td>Insertion of insulin pump (procedure)</td>\n                            <td>November 3, 2013</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Procedure/Insulin-pump-insertion"
            }
          ]
        },
        {
          "title" : "Plan of Treatment Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "18776-5",
                "display" : "Plan of care note"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table border=\"1\" width=\"100%\">\n                    <thead>\n                        <tr>\n                            <th>Date</th>\n                            <th>Code</th>\n                            <th>Description</th>\n                            <th>Mouth Location</th>\n                        </tr>\n                    </thead>\n                    <tbody>\n                        <tr>\n                            <td>Feb 23, 2020</td>\n                            <td>D7140</td>\n                            <td>Extraction, erupted tooth or exposed root (elevation and/or\n                forceps removal)</td>\n                            <td>Tooth #18</td>\n                        </tr>\n                        <tr>\n                            <td>Mar 3, 2020</td>\n                            <td>D1352</td>\n                            <td>Preventive resin restoration in a moderate to high caries\n                risk patient-permanent tooth</td>\n                            <td>Tooth #7</td>\n                        </tr>\n                        <tr>\n                            <td>Mar 10, 2020</td>\n                            <td>D0150</td>\n                            <td>comprehensive oral evaluation - new or established\n                patient</td>\n                            <td>N/A</td>\n                        </tr>\n                        <tr>\n                            <td>Mar 10, 2020</td>\n                            <td>D1110</td>\n                            <td>Prophylaxis - Adult</td>\n                            <td>N/A</td>\n                        </tr>\n                        <tr>\n                            <td>Mar 10, 2020</td>\n                            <td>D0210</td>\n                            <td>Full mouth radiographic survey</td>\n                            <td>N/A</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "ServiceRequest/Dental-extraction-example"
            },
            {
              "reference" : "ServiceRequest/Resin-restore-example"
            },
            {
              "reference" : "ServiceRequest/prophylaxis-example"
            },
            {
              "reference" : "ServiceRequest/Radiograph-survey"
            }
          ]
        },
        {
          "title" : "Procedures Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "47519-4",
                "display" : "History of Procedures Document"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table border=\"1\" width=\"100%\">\n                    <thead>\n                        <tr>\n                            <th>Date</th>\n                            <th>Code</th>\n                            <th>Description</th>\n                            <th>Mouth Location</th>\n                        </tr>\n                    </thead>\n                    <tbody>\n                        <tr>\n                            <td>Feb 16, 2020</td>\n                            <td>D1206</td>\n                            <td>topical application of fluoride varnish</td>\n                            <td>N/A</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Procedure/Dental-flouride-tx-example"
            }
          ]
        },
        {
          "title" : "Reason for Visit Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "29299-5",
                "display" : "Reason for visit"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>Patient referred for evaluation and treatment for toothache lower left</p>\n            </div>"
          }
        },
        {
          "title" : "Social History Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "29762-2",
                "display" : "Social history Narrative"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table>\n                    <tr>\n                        <td>\n                            <b>Social History Element</b>\n                        </td>\n                        <td>\n                            <b>Description</b>\n                        </td>\n                        <td>\n                            <b>Effective Dates</b>\n                        </td>\n                    </tr>\n                    <tr>\n                        <td>Smoking Status - Meaningful Use</td>\n                        <td>Never smoked tobacco</td>\n                        <td>Feb 14, 2020</td>\n                    </tr>\n                    <tr>\n                        <td>Highest Education Level</td>\n                        <td>College Education</td>\n                        <td>2005/05/01 - 2010/02/28</td>\n                    </tr>\n                    <tr>\n                        <td>Employment</td>\n                        <td>Accountaint, Full Time</td>\n                        <td>2005/05/01 - 2010/02/28</td>\n                    </tr>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Observation/Smoker-obs-example-dental"
            },
            {
              "reference" : "Observation/Education-level-example-dental"
            },
            {
              "reference" : "Observation/Present-job-example-dental"
            }
          ]
        },
        {
          "title" : "Vital Signs Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "8716-3",
                "display" : "Vital signs"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table border=\"1\" width=\"100%\">\n                    <thead>\n                        <tr>\n                            <th>Observation Type</th>\n                            <th>Value</th>\n                            <th>Units</th>\n                        </tr>\n                    </thead>\n                    <tbody>\n                        <tr>\n                            <td>Body Temperature</td>\n                            <td>99</td>\n                            <td>[degF]</td>\n                        </tr>\n                        <tr>\n                            <td>Heart Rate</td>\n                            <td>82</td>\n                            <td>/min</td>\n                        </tr>\n                        <tr>\n                            <td>Blood Pressure - Diastolic</td>\n                            <td>80</td>\n                            <td>mmHg</td>\n                        </tr>\n                        <tr>\n                            <td>Blood Pressure - Systolic</td>\n                            <td>120</td>\n                            <td>mmHg</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Observation/body-temperature"
            },
            {
              "reference" : "Observation/heart-rate"
            },
            {
              "reference" : "Observation/blood-pressure"
            }
          ]
        },
        {
          "title" : "Instructions Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "69730-0",
                "display" : "Instructions"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>Patient educated on the benefits of using a fluoride toothpaste, daily\n          flossing, and bi-annual routine dental cleaning visits.</p>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Communication/dental-education2"
            }
          ]
        },
        {
          "title" : "Payers Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "48768-6",
                "display" : "Payment sources Document"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>Aetna Comprehensive Medical /Dental Insurance</p>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Coverage/Dental-Aetna"
            }
          ]
        },
        {
          "title" : "Dental Findings Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "8704-9",
                "display" : "Physical findings of Mouth and Throat and Teeth"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <table border=\"1\" width=\"100%\">\n                    <thead>\n                        <tr>\n                            <th>Finding Type</th>\n                            <th>Value</th>\n                            <th>Location</th>\n                        </tr>\n                    </thead>\n                    <tbody>\n                        <tr>\n                            <td>Problem</td>\n                            <td>Dental Caries</td>\n                            <td>Tooth #18</td>\n                        </tr>\n                        <tr>\n                            <td>Problem</td>\n                            <td>Infection of Tooth</td>\n                            <td>Tooth #18</td>\n                        </tr>\n                        <tr>\n                            <td>Problem</td>\n                            <td>Dental Caries</td>\n                            <td>Tooth #7</td>\n                        </tr>\n                        <tr>\n                            <td>Result</td>\n                            <td>Overjet</td>\n                            <td>3mm</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Condition/Mandibular-perm18-example"
            },
            {
              "reference" : "Condition/Tooth-infection18"
            },
            {
              "reference" : "Condition/Maxillary-perm7-example"
            },
            {
              "reference" : "Observation/Overjet"
            }
          ]
        }
      ]
    }