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angshu/fixed-consultation-note-webemr

Created August 3, 2020 08:19
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fixed-consultation-note-webemr
{
"resourceType": "Bundle",
"id": "1eef1b16-f3c2-4e20-b32b-6e1edf103d5a",
"meta": {
"lastUpdated": "2020-07-09T15:32:26.605+05:30"
},
"identifier": {
"system": "https://www.max.in/bundle",
"value": "1eef1b16-f3c2-4e20-b32b-6e1edf103d5a"
},
"timestamp": "2020-07-09T15:32:26.605+05:30",
"type": "document",
"entry": [
{
"fullUrl": "Composition/44498b1a-e3cd-4612-be73-400012c58c75",
"resource": {
"resourceType": "Composition",
"id": "44498b1a-e3cd-4612-be73-400012c58c75",
"meta": {
"versionId": "1",
"lastUpdated": "2020-07-09T15:32:26.605+05:30",
"profile": [
"http://nrces.in/ndhm/fhir/r4/StructureDefinition/OPConsultRecord"
],
"security": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
"code": "V",
"display": "very restricted"
}
]
},
"language": "en-IN",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Consultation Report</div>"
},
"identifier": {
"system": "https://www.max.in/document",
"value": "645bb0c3-ff7e-4123-bef5-3852a4784813"
},
"status": "final",
"type": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "371530004",
"display": "Clinical Consultation report"
}
],
"text": "Clinical Consultation report"
},
"subject": {
"reference": "Patient/RVH1003",
"display": "Hina Patel"
},
"encounter": {
"reference": "Encounter/1"
},
"date": "2020-07-09T15:32:26.605+05:30",
"author": [
{
"reference": "Practitioner/MAX4321",
"display": "Dr Ramandeep Arora"
}
],
"title": "Consultation Report",
"custodian": {
"reference": "Organization/MaxSaket01",
"display": "Max Super Speciality Hospital, Saket"
},
"section": [
{
"title": "Allergy",
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "417662000",
"display": "History of clinical finding in subject"
}
]
},
"entry": [
{
"reference": "AllergyIntolerance/1"
}
]
},
{
"title": "Medical History",
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "417662000",
"display": "History of clinical finding in subject"
}
]
},
"entry": [
{
"reference": "Condition/1"
}
]
},
{
"title": "Symptoms",
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "417662000",
"display": "History of clinical finding in subject"
}
]
},
"entry": [
{
"reference": "Condition/2"
}
]
},
{
"title": "Observations",
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "223493006",
"display": "Documenting observations"
}
]
},
"entry": [
{
"reference": "Observation/cholesterol"
}
]
},
{
"title": "Final Diagnosis",
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "417662000",
"display": "History of clinical finding in subject"
}
]
},
"entry": [
{
"reference": "Condition/3"
}
]
},
{
"title": "Treatment Plan",
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "417662000",
"display": "History of clinical finding in subject"
}
]
},
"entry": [
{
"reference": "CarePlan/1"
}
]
},
{
"title": "Medications",
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "182816009",
"display": "Therapeutic prescription"
}
]
},
"entry": [
{
"reference": "MedicationRequest/1"
}
]
}
]
}
},
{
"fullUrl": "Practitioner/MAX4321",
"resource": {
"resourceType": "Practitioner",
"id": "MAX4321",
"meta": {
"versionId": "1",
"lastUpdated": "2020-07-09T15:32:26.605+05:30"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Dr. Parkash Sathe, MD (Medicine)</div>"
},
"identifier": [
{
"system": "https://ndhm.in/DigiDoc",
"value": "7601003178999"
}
],
"name": [
{
"text": "Dr Ramandeep Arora"
}
]
}
},
{
"fullUrl": "Organization/MaxSaket01",
"resource": {
"resourceType": "Organization",
"id": "MaxSaket01",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Medepolis Hospital. ph: +91 273 2139 3632, email:<a href=\"mailto:contact@facility.medepolis.org\">contact@facility.medepolis.org</a></div>"
},
"identifier": [
{
"system": "https://projecteka.in/facility",
"value": "4567823"
}
],
"name": "Max Super Speciality Hospital, Saket",
"telecom": [
{
"system": "phone",
"value": "+91 273 2139 3632",
"use": "work"
},
{
"system": "email",
"value": "contact@max.com",
"use": "work"
}
]
}
},
{
"fullUrl": "Patient/RVH1003",
"resource": {
"resourceType": "Patient",
"id": "RVH1003",
"meta": {
"versionId": "1",
"lastUpdated": "2020-07-09T14:58:58.181+05:30"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Dinesh Kale, 41 year, Male</div>"
},
"identifier": [
{
"system": "https://www.max.in/patient",
"value": "RVH1003"
},
{
"system": "https://projecteka.in/PHRID",
"value": "hinapatel79@ncg"
}
],
"name": [
{
"text": "Dinesh Kale"
}
],
"telecom": [
{
"system": "phone",
"value": "+919818512600",
"use": "home"
}
],
"gender": "female",
"birthDate": "1979-01-12"
}
},
{
"fullUrl": "Encounter/1",
"resource": {
"resourceType": "Encounter",
"id": "1",
"meta": {
"lastUpdated": "2020-07-09T14:58:58.181+05:30"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Out Patient Consultation Encounter</div>"
},
"identifier": [
{
"system": "https://max.in",
"value": "S100"
}
],
"status": "finished",
"class": {
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "AMB",
"display": "ambulatory"
},
"period": {
"start": "2020-07-09T14:58:58.181+05:30"
},
"hospitalization": {
"dischargeDisposition": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/discharge-disposition",
"code": "home",
"display": "Home"
}
],
"text": "Discharged to Home Care"
}
}
}
},
{
"fullUrl": "AllergyIntolerance/1",
"resource": {
"resourceType": "AllergyIntolerance",
"id": "1",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No Known Allergy</p>\n <p>recordedDate:2015-08-06</p>\n </div>"
},
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
"code": "active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
"code": "confirmed",
"display": "Confirmed"
}
]
},
"patient": {
"reference": "Patient/RVH1003"
},
"note": [
{
"text": "The patient reports no other known allergy."
}
]
}
},
{
"fullUrl": "Condition/1",
"resource": {
"resourceType": "Condition",
"id": "2",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Foot has swollen</div>"
},
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code": "active"
}
]
},
"subject": {
"reference": "Patient/RVH1003"
},
"code": {
"coding": [
{
"system": "https://projecteka.in/sct",
"code": "297142003",
"display": "Foot swelling"
}
],
"text": "Foot swelling"
}
}
},
{
"fullUrl": "Condition/2",
"resource": {
"resourceType": "Condition",
"id": "2",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Past Medical Problem of Diabetes mellitus type 1</div>"
},
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code": "recurrence"
}
]
},
"subject": {
"reference": "Patient/RVH1003"
},
"code": {
"coding": [
{
"system": "https://ndhm.in/sct/condition",
"code": "46635009",
"display": "Diabetes mellitus type 1"
}
],
"text": "Diabetes mellitus type 1"
}
}
},
{
"fullUrl": "Condition/3",
"resource": {
"resourceType": "Condition",
"id": "3",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Past Medical Problem of Diabetes mellitus type 2</div>"
},
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code": "recurrence"
}
]
},
"subject": {
"reference": "Patient/RVH1003"
},
"code": {
"coding": [
{
"system": "https://ndhm.in/sct/condition",
"code": "44054006",
"display": "Diabetes mellitus type 2"
}
],
"text": "Diabetes mellitus type 2"
}
}
},
{
"fullUrl": "CarePlan/1",
"resource": {
"resourceType": "CarePlan",
"id": "1",
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Care Plan</div>"
},
"status": "active",
"intent": "plan",
"category": [
{
"coding": [
{
"system": "https://ndhm.in/sct/careplan",
"code": "736368003",
"display": "Coronary heart disease care plan"
}
]
}
],
"title": "Coronary heart disease care plan",
"description": "Treatment of coronary artery and related disease problems",
"subject": {
"reference": "Patient/RVH1003",
"display": "Hina Patel"
}
}
},
{
"fullUrl": "Observation/cholesterol",
"resource": {
"resourceType": "Observation",
"id": "cholesterol",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: cholesterol</p><p><b>status</b>: final</p><p><b>code</b>: Cholesterol <span>(Details : {LOINC code '35200-5' = 'Cholesterol [Mass or Moles/volume] in Serum or Plasma', given as 'Cholesterol [Moles/​volume] in Serum or Plasma'})</span></p><p><b>subject</b>: <a>Dinesh Kale</a></p><p><b>performer</b>: <a>Golwilkat Lab Pvt.Ltd.</a></p><p><b>value</b>: 6.3 mmol/L<span> (Details: UCUM code mmol/L = 'mmol/L')</span></p><h3>ReferenceRanges</h3><table><tr><td>-</td><td><b>High</b></td></tr><tr><td>*</td><td>4.5 mmol/L<span> (Details: UCUM code mmol/L = 'mmol/L')</span></td></tr></table></div>"
},
"status": "final",
"code": {
"coding": [
{
"system": "https://ndhm.in/loinc/test",
"code": "35200-5",
"display": "Cholesterol [Moles/​volume] in Serum or Plasma"
}
],
"text": "Cholesterol"
}
}
},
{
"fullUrl": "MedicationRequest/1",
"resource": {
"resourceType": "MedicationRequest",
"id": "1",
"subject": {
"reference": "Patient/RVH1003",
"display": "Hina Patel"
},
"status": "active",
"intent": "order",
"requester": {
"reference": "Practitioner/MAX4321",
"display": "Dr Ramandeep Arora"
},
"medicationCodeableConcept": {
"coding": [
{
"system": "https://ndhm.in/sct/CDCI",
"code": "353231006",
"display": "Neomycin 5 microgram/mg cutaneous ointment"
}
]
}
}
}
]
}
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