Dental Data Exchange
1.0.0 - STU 1

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## : Dental Referral Note example - JSON Representation

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    {
      "resourceType" : "Composition",
      "id" : "Med-2-Dental-Referral",
      "meta" : {
        "versionId" : "25",
        "lastUpdated" : "2021-08-26T17:48:27.238+00:00",
        "source" : "#D3muhSqHq8nuVF61",
        "profile" : [
          "http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referral-note"
        ]
      },
      "language" : "en-US",
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      },
      "identifier" : {
        "system" : "urn:ietf:rfc:3986",
        "value" : "http://any.org/1"
      },
      "status" : "final",
      "type" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "57134-9",
            "display" : "Dentistry Referral note"
          }
        ]
      },
      "subject" : {
        "reference" : "Patient/example-dental",
        "display" : "Patient A"
      },
      "encounter" : {
        "reference" : "Encounter/Med-visit-1",
        "display" : "PCP visit"
      },
      "date" : "2020-01-14T03:10:14Z",
      "author" : [
        {
          "reference" : "Practitioner/practitioner-M",
          "display" : "Dr. John M, MD"
        }
      ],
      "title" : "Referral Note",
      "attester" : [
        {
          "mode" : "legal",
          "time" : "2020-03-14T09:10:14Z",
          "party" : {
            "reference" : "PractitionerRole/PractitionerRole-M",
            "display" : "Dr. John M, MD"
          }
        }
      ],
      "custodian" : {
        "reference" : "Organization/GHC-organization",
        "display" : "Good Health Clinic"
      },
      "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>Allergen</b>\n                        </td>\n                        <td>\n                            <b>Code</b>\n                        </td>\n                        <td>\n                            <b>Manifestation</b>\n                        </td>\n                        <td>\n                            <b>Severity</b>\n                        </td>\n                    </tr>\n                    <tr>\n                        <td>Penicillin G</td>\n                        <td>7908</td>\n                        <td>Skin rash</td>\n                        <td>mild</td>\n                    </tr>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "AllergyIntolerance/Allergy-example-dental"
            }
          ]
        },
        {
          "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>Lisinopril 10 mg tab</td>\n                        <td>1 tab once/day</td>\n                        <td/>\n                        <td>Active</td>\n                        <td/>\n                        <td>Generic substitution allowed</td>\n                    </tr>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "MedicationRequest/Lisinopril-medreq"
            }
          ]
        },
        {
          "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>Teeth covered in plague</p>\n                <p>Toothache</p>\n                <p>Swollen Gums</p>\n                <p>Bleeding Gums</p>\n                <p>At high risk for dental carries</p>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Condition/HTN-example"
            },
            {
              "reference" : "Condition/DM1-example"
            },
            {
              "reference" : "Condition/Dental-plaque-example"
            },
            {
              "reference" : "Condition/toothache-example"
            },
            {
              "reference" : "Condition/Swollen-gums-example"
            },
            {
              "reference" : "Condition/Bleeding-gums-example"
            },
            {
              "reference" : "Condition/Caries-risk"
            }
          ]
        },
        {
          "title" : "Reason for Referral Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "42349-1",
                "display" : "Reason for referral (narrative)"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>Toothache</p>\n                <p>Left lower quadrant pain</p>\n                <p>Bleeding gums</p>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "ServiceRequest/example-dental-referral-1"
            }
          ]
        },
        {
          "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                <p>D0150 - Comprehensive Oral Evaluation</p>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Encounter/Comp-oral-eval"
            }
          ]
        },
        {
          "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 has pain in his lower left jaw and occassional bleeding from his gums - referring for dental evaluation.</p>\n            </div>"
          }
        },
        {
          "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 flouride treatments in the past 4 years while away at college</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" : "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                <p>No Procedures performed</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</td>\n                        <td>NA</td>\n                        <td>2005/05/01 - 2020/03/28</td>\n                    </tr>\n                    <tr>\n                        <td>Highest Education Received</td>\n                        <td>Collect Education</td>\n                        <td>2010/05/01 - 2014/03/28</td>\n                    </tr>\n                    <tr>\n                        <td>Employment</td>\n                        <td>Full-time accountant</td>\n                        <td>2015/05/01 - current</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>\n                    <tr>\n                        <td>\n                            <b>Vital Sign</b>\n                        </td>\n                        <td>\n                            <b>Date</b>\n                        </td>\n                        <td>\n                            <b>Value</b>\n                        </td>\n                    </tr>\n                    <tr>\n                        <td>Temperature</td>\n                        <td>2020/04/15</td>\n                        <td>98.5</td>\n                    </tr>\n                    <tr>\n                        <td>Heart Rate</td>\n                        <td>2020/04/15</td>\n                        <td>78</td>\n                    </tr>\n                    <tr>\n                        <td>Respiration Rate</td>\n                        <td>2020/04/15</td>\n                        <td>20</td>\n                    </tr>\n                    <tr>\n                        <td>Blood Pressure</td>\n                        <td>2020/04/15</td>\n                        <td>120/80</td>\n                    </tr>\n                </table>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Observation/vitals-panel"
            }
          ]
        },
        {
          "title" : "Goals Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "61146-7",
                "display" : "Goals"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>No soda/sugary drinks/energy drinks</p>\n                <p>Use fluoride toothpaste</p>\n            </div>"
          }
        },
        {
          "title" : "Health Concerns Section",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "75310-3",
                "display" : "Health concerns Document"
              }
            ]
          },
          "text" : {
            "status" : "generated",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n                <p>Neuropathy due to diabetes mellitus</p>\n            </div>"
          }
        },
        {
          "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>Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride\n          toothpaste, floss</p>\n            </div>"
          },
          "entry" : [
            {
              "reference" : "Communication/dental-education"
            }
          ]
        },
        {
          "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                <p>No Information</p>\n            </div>"
          }
        }
      ]
    }