Dental Data Exchange
1.0.0 - STU 1

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## : Dental Consultation Note example - XML Representation

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    <Composition xmlns="http://hl7.org/fhir">
      <id value="Dental-2-Med-Consult"/>
      <meta>
        <versionId value="24"/>
        <lastUpdated value="2021-08-24T23:27:45.426+00:00"/>
        <source value="#sBPqj3BhYLw4XXH8"/>
        <profile
                 value="http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult-note"/>
      </meta>
      <language value="en-US"/>
      <text>
        <status value="extensions"/>
        <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>
      </text>
      <extension
                 url="http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension">
        <valueReference>
          <reference value="ServiceRequest/example-dental-referral-1"/>
        </valueReference>
      </extension>
      <identifier>
        <system value="urn:ietf:rfc:3986"/>
        <value value="urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b"/>
      </identifier>
      <status value="final"/>
      <type>
        <coding>
          <system value="http://loinc.org"/>
          <code value="34756-7"/>
          <display value="Dentistry Consult note"/>
        </coding>
      </type>
      <subject>
        <reference value="Patient/example-dental"/>
        <display value="Patient A"/>
      </subject>
      <encounter>
        <reference value="Encounter/Dental-encounter"/>
        <display value="Dental Referral with patient A"/>
      </encounter>
      <date value="2020-02-16T09:10:14Z"/>
      <author>
        <reference value="Practitioner/practitioner-D"/>
        <display value="Dentist D, DMD"/>
      </author>
      <title value="Consultation Note"/>
      <attester>
        <mode value="legal"/>
        <time value="2020-03-28T09:10:14Z"/>
        <party>
          <reference value="Practitioner/practitioner-D"/>
          <display value="Dentist Dentist D, DMD"/>
        </party>
      </attester>
      <custodian>
        <reference value="Organization/GOHC-organization"/>
        <display value="Good Oral Health Clinic"/>
      </custodian>
      <event>
        <code>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActClass"/>
            <code value="PCPR"/>
            <display value="Care Provision"/>
          </coding>
        </code>
        <period>
          <start value="2020-02-16"/>
          <end value="2020-02-16"/>
        </period>
      </event>
      <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>Substance</b>
                            </td>
                            <td>
                                <b>Overall Severity</b>
                            </td>
                            <td>
                                <b>Reaction</b>
                            </td>
                            <td>
                                <b>Reaction Severity</b>
                            </td>
                            <td>
                                <b>Status</b>
                            </td>
                        </tr>
                        <tr>
                            <td>Penicillin G (Ingredient)</td>
                            <td>Mild</td>
                            <td>Skin rash</td>
                            <td>Mild</td>
                            <td>Active</td>
                        </tr>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="AllergyIntolerance/Allergy-example-dental"/>
        </entry>
      </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 fluoride treatments in the past four years while away at college</p>
                </div>
        </text>
      </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>Dental caries</p>
                    <p>Unable to chew</p>
                    <p>Teeth covered in plague</p>
                    <p>Toothache</p>
                    <p>Chronic periodontitis</p>
                    <p>Infection of tooth</p>
                    <p>At high risk for dental caries (finding)</p>
                </div>
        </text>
        <entry>
          <reference value="Condition/HTN-example"/>
        </entry>
        <entry>
          <reference value="Condition/DM1-example"/>
        </entry>
        <entry>
          <reference value="Condition/Dental-caries"/>
        </entry>
        <entry>
          <reference value="Condition/no-chew"/>
        </entry>
        <entry>
          <reference value="Condition/Dental-plaque-example"/>
        </entry>
        <entry>
          <reference value="Condition/toothache-example"/>
        </entry>
        <entry>
          <reference value="Condition/Chronic-periodontitis-example"/>
        </entry>
        <entry>
          <reference value="Condition/Tooth-infection18"/>
        </entry>
        <entry>
          <reference value="Condition/Caries-risk"/>
        </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>erythromycin 500 mg</td>
                            <td>Take 1 tablet every six hours X10 days</td>
                            <td/>
                            <td>Active</td>
                            <td/>
                            <td/>
                        </tr>
                        <tr>
                            <td>ibuprofen (OTC)  200 mg tab</td>
                            <td>Take 2-3 tablets every 8 hours as needed for pain</td>
                            <td>Take 2-3 tablets every 8 hours as needed for pain</td>
                            <td/>
                            <td>Active</td>
                            <td/>
                            <td/>
                        </tr>
                        <tr>
                            <td>acetaminophen (OTC) 325 mg</td>
                            <td>Take 2 tablets every 4-6 hours as needed for pain</td>
                            <td/>
                            <td>Active</td>
                            <td/>
                            <td/>
                        </tr>
                        <tr>
                            <td>Lisinopril 10 mg tab</td>
                            <td>1 tab once a day</td>
                            <td/>
                            <td>Active</td>
                            <td/>
                            <td/>
                        </tr>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="MedicationRequest/erythromycin-medreq-2"/>
        </entry>
        <entry>
          <reference value="MedicationRequest/Ibuprofen-medreq-2"/>
        </entry>
        <entry>
          <reference value="MedicationRequest/Tylenol-med-dental"/>
        </entry>
        <entry>
          <reference value="MedicationRequest/Lisinopril-medreq"/>
        </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 reports inability to chew on left side due to pain and
            sensitivity, a condition that has increased in severity in the two days
            since his medical appointment </p>
                    <p> Significant decay on the left lower second molar (tooth #18)
             with signs of infection  </p>
                    <p> Early signs of a caries lesion (decay) on the right upper
            lateral incisor (tooth #7) </p>
                    <p> Recommend an extraction of the left lower second molar(tooth
            #18) and a restoration on the right upper lateral incisor (tooth #7) due
            to a caries lesion </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="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">
                    <table border="1" width="100%">
                        <thead>
                            <tr>
                                <th>Date</th>
                                <th>Code</th>
                                <th>Description</th>
                                <th>Mouth Location</th>
                            </tr>
                        </thead>
                        <tbody>
                            <tr>
                                <td>Feb 23, 2020</td>
                                <td>D7140</td>
                                <td>Extraction, erupted tooth or exposed root (elevation and/or
                    forceps removal)</td>
                                <td>Tooth #18</td>
                            </tr>
                            <tr>
                                <td>Mar 3, 2020</td>
                                <td>D1352</td>
                                <td>Preventive resin restoration in a moderate to high caries
                    risk patient-permanent tooth</td>
                                <td>Tooth #7</td>
                            </tr>
                            <tr>
                                <td>Mar 10, 2020</td>
                                <td>D0150</td>
                                <td>comprehensive oral evaluation - new or established
                    patient</td>
                                <td>N/A</td>
                            </tr>
                            <tr>
                                <td>Mar 10, 2020</td>
                                <td>D1110</td>
                                <td>Prophylaxis - Adult</td>
                                <td>N/A</td>
                            </tr>
                            <tr>
                                <td>Mar 10, 2020</td>
                                <td>D0210</td>
                                <td>Full mouth radiographic survey</td>
                                <td>N/A</td>
                            </tr>
                        </tbody>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="ServiceRequest/Dental-extraction-example"/>
        </entry>
        <entry>
          <reference value="ServiceRequest/Resin-restore-example"/>
        </entry>
        <entry>
          <reference value="ServiceRequest/prophylaxis-example"/>
        </entry>
        <entry>
          <reference value="ServiceRequest/Radiograph-survey"/>
        </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">
                    <table border="1" width="100%">
                        <thead>
                            <tr>
                                <th>Date</th>
                                <th>Code</th>
                                <th>Description</th>
                                <th>Mouth Location</th>
                            </tr>
                        </thead>
                        <tbody>
                            <tr>
                                <td>Feb 16, 2020</td>
                                <td>D1206</td>
                                <td>topical application of fluoride varnish</td>
                                <td>N/A</td>
                            </tr>
                        </tbody>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="Procedure/Dental-flouride-tx-example"/>
        </entry>
      </section>
      <section>
        <title value="Reason for Visit Section"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="29299-5"/>
            <display value="Reason for visit"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                    <p>Patient referred for evaluation and treatment for toothache lower left</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 - Meaningful Use</td>
                            <td>Never smoked tobacco</td>
                            <td>Feb 14, 2020</td>
                        </tr>
                        <tr>
                            <td>Highest Education Level</td>
                            <td>College Education</td>
                            <td>2005/05/01 - 2010/02/28</td>
                        </tr>
                        <tr>
                            <td>Employment</td>
                            <td>Accountaint, Full Time</td>
                            <td>2005/05/01 - 2010/02/28</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 border="1" width="100%">
                        <thead>
                            <tr>
                                <th>Observation Type</th>
                                <th>Value</th>
                                <th>Units</th>
                            </tr>
                        </thead>
                        <tbody>
                            <tr>
                                <td>Body Temperature</td>
                                <td>99</td>
                                <td>[degF]</td>
                            </tr>
                            <tr>
                                <td>Heart Rate</td>
                                <td>82</td>
                                <td>/min</td>
                            </tr>
                            <tr>
                                <td>Blood Pressure - Diastolic</td>
                                <td>80</td>
                                <td>mmHg</td>
                            </tr>
                            <tr>
                                <td>Blood Pressure - Systolic</td>
                                <td>120</td>
                                <td>mmHg</td>
                            </tr>
                        </tbody>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="Observation/body-temperature"/>
        </entry>
        <entry>
          <reference value="Observation/heart-rate"/>
        </entry>
        <entry>
          <reference value="Observation/blood-pressure"/>
        </entry>
      </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>Patient educated on the benefits of using a fluoride toothpaste, daily
              flossing, and bi-annual routine dental cleaning visits.</p>
                </div>
        </text>
        <entry>
          <reference value="Communication/dental-education2"/>
        </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">
                    <table border="1" width="100%">
                        <thead>
                            <tr>
                                <th>Finding Type</th>
                                <th>Value</th>
                                <th>Location</th>
                            </tr>
                        </thead>
                        <tbody>
                            <tr>
                                <td>Problem</td>
                                <td>Dental Caries</td>
                                <td>Tooth #18</td>
                            </tr>
                            <tr>
                                <td>Problem</td>
                                <td>Infection of Tooth</td>
                                <td>Tooth #18</td>
                            </tr>
                            <tr>
                                <td>Problem</td>
                                <td>Dental Caries</td>
                                <td>Tooth #7</td>
                            </tr>
                            <tr>
                                <td>Result</td>
                                <td>Overjet</td>
                                <td>3mm</td>
                            </tr>
                        </tbody>
                    </table>
                </div>
        </text>
        <entry>
          <reference value="Condition/Mandibular-perm18-example"/>
        </entry>
        <entry>
          <reference value="Condition/Tooth-infection18"/>
        </entry>
        <entry>
          <reference value="Condition/Maxillary-perm7-example"/>
        </entry>
        <entry>
          <reference value="Observation/Overjet"/>
        </entry>
      </section>
    </Composition>