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History Record

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DocumentReference "example" Version "1"

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This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

Generated Narrative

identifier: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234

status: current

docStatus: preliminary

type: Outpatient Note

category: History and Physical

subject: Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24

encounter: Generated Summary: id: 1234213.52345873 (OFFICIAL); status: completed; ambulatory

event: Arm

facilityType: Outpatient

practiceSetting: General Medicine

period: 23 Dec. 2004, 8:00:00 am --> 23 Dec. 2004, 8:01:00 am

date: 24 Dec. 2005, 9:43:41 am

author:

name: Gerald Smitty

Attesters

-ModeParty
*officialGenerated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); University Medical Hospital; name: Burgers University Medical Center; Phone: 022-655 2300

custodian: Generated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); University Medical Hospital; name: Burgers University Medical Center; Phone: 022-655 2300

RelatesTos

-CodeTarget
*appendsGenerated Summary: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234; status: current; docStatus: preliminary; Outpatient Note; History and Physical; Arm; Outpatient; General Medicine; period: 23 Dec. 2004, 8:00:00 am --> 23 Dec. 2004, 8:01:00 am; date: 24 Dec. 2005, 9:43:41 am; description: Physical; very restricted

description: Physical

securityLabel: very restricted

content

Attachments

-
*

format: History and Physical Specification

identifier: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7

sourcePatientInfo: Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24

related: Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24


{
  "resourceType" : "DocumentReference",
  "id" : "example",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-05-24T10:49:40.937Z",
    "tag" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code" : "HTEST",
        "display" : "test health data"
      }
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234</p><p><b>status</b>: current</p><p><b>docStatus</b>: preliminary</p><p><b>type</b>: <span>Outpatient Note</span></p><p><b>category</b>: <span>History and Physical</span></p><p><b>subject</b>: <a>Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24</a></p><p><b>encounter</b>: <a>Generated Summary: id: 1234213.52345873 (OFFICIAL); status: completed; <span>ambulatory</span></a></p><p><b>event</b>: <span>Arm</span></p><p><b>facilityType</b>: <span>Outpatient</span></p><p><b>practiceSetting</b>: <span>General Medicine</span></p><p><b>period</b>: 23 Dec. 2004, 8:00:00 am --&gt; 23 Dec. 2004, 8:01:00 am</p><p><b>date</b>: 24 Dec. 2005, 9:43:41 am</p><p><b>author</b>: </p><ul><li><a>Generated Summary: id: D234123 (OFFICIAL); Sherry Dopplemeyer ; john.doe@healthcare.example.org</a></li><li><a> </a></li></ul><blockquote><p><b>name</b>: Gerald Smitty </p></blockquote><h3>Attesters</h3><table><tr><td>-</td><td><b>Mode</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>official</td><td><a>Generated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); <span>University Medical Hospital</span>; name: Burgers University Medical Center; Phone: 022-655 2300</a></td></tr></table><p><b>custodian</b>: <a>Generated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); <span>University Medical Hospital</span>; name: Burgers University Medical Center; Phone: 022-655 2300</a></p><h3>RelatesTos</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Target</b></td></tr><tr><td>*</td><td>appends</td><td><a>Generated Summary: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234; status: current; docStatus: preliminary; <span>Outpatient Note</span>; <span>History and Physical</span>; <span>Arm</span>; <span>Outpatient</span>; <span>General Medicine</span>; period: 23 Dec. 2004, 8:00:00 am --&gt; 23 Dec. 2004, 8:01:00 am; date: 24 Dec. 2005, 9:43:41 am; description: Physical; <span>very restricted</span></a></td></tr></table><p><b>description</b>: Physical</p><p><b>securityLabel</b>: <span>very restricted</span></p><blockquote><p><b>content</b></p><h3>Attachments</h3><table><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>format</b>: <span>History and Physical Specification</span></p><p><b>identifier</b>: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7</p></blockquote><p><b>sourcePatientInfo</b>: <a>Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24</a></p><p><b>related</b>: <a>Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24</a></p></div>"
  },
  "contained" : [
    {
      "resourceType" : "Practitioner",
      "id" : "a2",
      "name" : [
        {
          "family" : "Smitty",
          "given" : [
            "Gerald"
          ]
        }
      ]
    }
  ],
  "identifier" : [
    {
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"
    }
  ],
  "status" : "current",
  "docStatus" : "preliminary",
  "type" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "34108-1",
        "display" : "Outpatient Note"
      }
    ]
  },
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://ihe.net/xds/connectathon/classCodes",
          "code" : "History and Physical",
          "display" : "History and Physical"
        }
      ]
    }
  ],
  "subject" : {
    "reference" : "Patient/xcda"
  },
  "encounter" : [
    {
      "reference" : "Encounter/xcda"
    }
  ],
  "event" : [
    {
      "coding" : [
        {
          "system" : "http://ihe.net/xds/connectathon/eventCodes",
          "code" : "T-D8200",
          "display" : "Arm"
        }
      ]
    }
  ],
  "facilityType" : {
    "coding" : [
      {
        "system" : "http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes",
        "code" : "Outpatient",
        "display" : "Outpatient"
      }
    ]
  },
  "practiceSetting" : {
    "coding" : [
      {
        "system" : "http://www.ihe.net/xds/connectathon/practiceSettingCodes",
        "code" : "General Medicine",
        "display" : "General Medicine"
      }
    ]
  },
  "period" : {
    "start" : "2004-12-23T08:00:00+11:00",
    "end" : "2004-12-23T08:01:00+11:00"
  },
  "date" : "2005-12-24T09:43:41+11:00",
  "author" : [
    {
      "reference" : "Practitioner/xcda1"
    },
    {
      "reference" : "#a2"
    }
  ],
  "attester" : [
    {
      "mode" : "official",
      "party" : {
        "reference" : "Organization/f001"
      }
    }
  ],
  "custodian" : {
    "reference" : "Organization/f001"
  },
  "relatesTo" : [
    {
      "code" : "appends",
      "target" : {
        "reference" : "DocumentReference/example"
      }
    }
  ],
  "description" : "Physical",
  "securityLabel" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
          "code" : "V",
          "display" : "very restricted"
        }
      ]
    }
  ],
  "content" : [
    {
      "attachment" : {
        "contentType" : "application/hl7-v3+xml",
        "language" : "en-US",
        "url" : "http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510",
        "size" : 3654,
        "hash" : "2jmj7l5rSw0yVb/vlWAYkK/YBwk=",
        "title" : "Physical",
        "creation" : "2005-12-24T09:35:00+11:00"
      },
      "format" : {
        "system" : "urn:oid:1.3.6.1.4.1.19376.1.2.3",
        "code" : "urn:ihe:pcc:handp:2008",
        "display" : "History and Physical Specification"
      },
      "identifier" : {
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:oid:1.3.6.1.4.1.21367.2005.3.7"
      }
    }
  ],
  "sourcePatientInfo" : {
    "reference" : "Patient/xcda"
  },
  "related" : [
    {
      "reference" : "Patient/xcda",
      "identifier" : {
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"
      }
    }
  ]
}

DocumentReference "xray" Version "1"

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This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

Xray of left hand for Patient Henry Levin (MRN 12345) 2016-03-15

{
  "resourceType" : "DocumentReference",
  "id" : "xray",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-05-24T10:49:40.891Z",
    "tag" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code" : "HTEST",
        "display" : "test health data"
      }
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Xray of left hand for Patient Henry Levin (MRN 12345) 2016-03-15</div>"
  },
  "status" : "current",
  "subject" : {
    "reference" : "Patient/example"
  },
  "encounter" : [
    {
      "reference" : "Encounter/example"
    },
    {
      "identifier" : {
        "system" : "http://someclinic.org/fhir/NamingSystem/imaging-orders",
        "value" : "111222",
        "assigner" : {
          "display" : "XYZ Medical Clinic"
        }
      }
    }
  ],
  "event" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "39714003",
          "display" : "Skeletal X-ray of wrist and hand"
        }
      ]
    },
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "85151006",
          "display" : "Structure of left hand (body structure)"
        }
      ]
    }
  ],
  "content" : [
    {
      "id" : "a1",
      "attachment" : {
        "contentType" : "image/jpeg",
        "url" : "http://someimagingcenter.org/fhir/Binary/A12345",
        "creation" : "2016-03-15",
        "height" : 432,
        "width" : 640
      }
    }
  ]
}

DocumentReference "sound" Version "1"

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This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

Sound recording of speech example for Patient Henry Levin (MRN 12345):
diagram

{
  "resourceType" : "DocumentReference",
  "id" : "sound",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-05-24T10:49:40.796Z",
    "tag" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code" : "HTEST",
        "display" : "test health data"
      }
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Sound recording of speech example for Patient Henry Levin (MRN 12345):<br/><img src=\"#11\" alt=\"diagram\"/></div>"
  },
  "status" : "current",
  "subject" : {
    "reference" : "Patient/xcda"
  },
  "author" : [
    {
      "reference" : "Practitioner/xcda-author"
    }
  ],
  "content" : [
    {
      "attachment" : {
        "contentType" : "audio/mpeg",
        "data" : "dG9vIGJpZyB0b28gaW5jbHVkZSB0aGUgd2hvbGU=",
        "duration" : 65
      }
    }
  ]
}

DocumentReference "1.2.840.11361907579238403408700.3.1.04.19970327150033" Version "1"

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This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

Ultrasound Image on patient "James Chalmers":
WADO reference to image

{
  "resourceType" : "DocumentReference",
  "id" : "1.2.840.11361907579238403408700.3.1.04.19970327150033",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-05-24T10:49:40.718Z",
    "tag" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code" : "HTEST",
        "display" : "test health data"
      }
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n Ultrasound Image on patient \"James Chalmers\":<br/>\n <img src=\"http://imaging.acme.com/wado/server?requestType=WADO&amp;contentType=application%2Fdicom&amp;studyUid=1.2.840.113619.2.21.848.34082.0.538976288.3&amp;seriesUid=1.2.840.113619.2.21.3408.700.0.757923840.3.0&amp;objectUid=1.2.840.11361907579238403408700.3.1.04.19970327150033\" alt=\"WADO reference to image\"/>\n\n </div>"
  },
  "extension" : [
    {
      "url" : "http://nema.org/fhir/extensions#0002-0010",
      "valueUri" : "urn:oid:1.2.840.10008.1.2.1"
    }
  ],
  "identifier" : [
    {
      "type" : {
        "text" : "accessionNo"
      },
      "system" : "http://acme-imaging.com/accession/2012",
      "value" : "1234567"
    },
    {
      "type" : {
        "text" : "studyId"
      },
      "system" : "urn:dicom:uid",
      "value" : "urn:oid:1.2.840.113619.2.21.848.34082.0.538976288.3"
    },
    {
      "type" : {
        "text" : "seriesId"
      },
      "system" : "urn:dicom:uid",
      "value" : "urn:oid:1.2.840.113619.2.21.3408.700.0.757923840.3.0"
    }
  ],
  "status" : "current",
  "subject" : {
    "reference" : "Patient/example"
  },
  "event" : [
    {
      "coding" : [
        {
          "system" : "http://dicom.nema.org/resources/ontology/DCM",
          "code" : "US"
        }
      ]
    },
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "399067008",
          "display" : "Lateral projection"
        }
      ]
    }
  ],
  "author" : [
    {
      "display" : "G.E. Medical Systems"
    }
  ],
  "content" : [
    {
      "attachment" : {
        "contentType" : "application/dicom",
        "url" : "http://imaging.acme.com/wado/server?requestType=WADO&contentType=application%2Fdicom&studyUid=1.2.840.113619.2.21.848.34082.0.538976288.3&seriesUid=1.2.840.113619.2.21.3408.700.0.757923840.3.0&objectUid=1.2.840.11361907579238403408700.3.1.04.19970327150033",
        "height" : 480,
        "width" : 640
      },
      "identifier" : {
        "use" : "official",
        "type" : {
          "text" : "InstanceUID"
        },
        "system" : "urn:dicom:uid",
        "value" : "urn:oid:1.2.840.11361907579238403408700.3.1.04.19970327150033"
      }
    }
  ]
}

DocumentReference "example-diagram" Version "1"

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This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

Generated Narrative

status: current

type: Image

subject: Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24

date: 18 Dec. 2017, 1:56:18 am

author:

content

Attachments

-
*

{
  "resourceType" : "DocumentReference",
  "id" : "example-diagram",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-05-24T10:49:40.656Z",
    "tag" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code" : "HTEST",
        "display" : "test health data"
      }
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>status</b>: current</p><p><b>type</b>: <span>Image</span></p><p><b>subject</b>: <a>Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24</a></p><p><b>date</b>: 18 Dec. 2017, 1:56:18 am</p><p><b>author</b>: </p><ul><li><a>Generated Summary: Harold Hippocrates </a></li><li><span>Acme Camera</span></li></ul><blockquote><p><b>content</b></p><h3>Attachments</h3><table><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></div>"
  },
  "status" : "current",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/media-type",
        "code" : "image",
        "display" : "Image"
      }
    ]
  },
  "subject" : {
    "reference" : "Patient/xcda"
  },
  "date" : "2017-12-17T14:56:18Z",
  "author" : [
    {
      "reference" : "Practitioner/xcda-author"
    },
    {
      "display" : "Acme Camera"
    }
  ],
  "content" : [
    {
      "id" : "a1",
      "attachment" : {
        "contentType" : "image/gif",
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}