Example-Composition-Urgencias-a419331245c5
type: Composition
node role: treeRoot
id:
  v: Example-Composition-Urgencias-a419331245c5
text:
  status:
    v: generated
  div: Generated Narrative: Composition Example-Composition-Urgencias-a419331245c5 identifier: http://hospitalSystemInformation.example.org/Compositions/UR-20250505-01 (use: usual, ) status: Final type: Emergency department Note category: Summary of episode note encounter: Encounter: extension = Demanda espontánea (Vías de ingreso#01); identifier = http://HIS_Source/#Enc_ABC123 (use: usual, ); status = finished; class = Emergency (ActCode#EMER); type = Emergency Department Note; serviceType = SERVICIO DE URGENCIAS; priority = Nivel I; period = 2025-02-20 08:30:00+0000 --> 2025-02-20 10:00:00+0000 date: 2025-04-18 08:30:00+0000 author: Practitioner Carlos Andrés Gómez Pérez(official) title: REPORTE DE URGENCIAS confidentiality: very restricted Attesters - Mode Party * Legal Practitioner Carlos Andrés Gómez Pérez(official) custodian: Organization CLINICA IPS ATENCION SALUD
identifier:
  use:
    v: usual
  system:
    v: http://hospitalSystemInformation.example.org/Compositions
  value:
    v: UR-20250505-01
status:
  v: final
type:
  coding:
    system:
      v: https://loinc.org
    code:
      v: 34111-5
    display:
      v: Emergency department Note
category:
  coding:
    system:
      v: https://hl7.org/fhir/R4/valueset-document-classcodes.html
    code:
      v: 34133-9
    display:
      v: Summary of episode note
subject:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Patient/Example-Patient-Urgencias-bdb7a6003025
  reference:
    v: Patient/Example-Patient-Urgencias-bdb7a6003025
encounter:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Encounter/Example-Encounter-Urgencias-5e8d54e0dcb8
  reference:
    v: Encounter/Example-Encounter-Urgencias-5e8d54e0dcb8
date:
  v: 2025-04-18T08:30:00Z
author:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Practitioner/Example-Practitioner-Urgencias-8f6d2c3a5f6d
  reference:
    v: Practitioner/Example-Practitioner-Urgencias-8f6d2c3a5f6d
title:
  v: REPORTE DE URGENCIAS
confidentiality:
  v: V
attester:
  mode:
    v: legal
  party:
    link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Practitioner/Example-Practitioner-Urgencias-8f6d2c3a5f6d
    reference:
      v: Practitioner/Example-Practitioner-Urgencias-8f6d2c3a5f6d
custodian:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Organization/Example-Organization-2c3a5f6d1e4d
  reference:
    v: Organization/Example-Organization-2c3a5f6d1e4d
section:
  title:
    v: Contacto de emergencia
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 56796-6
      display:
        v: Emergency contact information
  entry:
    link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/RelatedPerson/Example-RelatedPerson-Urgencias-2c3a5f6d1e4a
    reference:
      v: RelatedPerson/Example-RelatedPerson-Urgencias-2c3a5f6d1e4a
section:
  title:
    v: Motivo de consulta
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 29299-5
      display:
        v: Reason for visit Narrative
section:
  title:
    v: Grupo Sanguineo
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 30954-2
      display:
        v: Relevant diagnostic tests/laboratory data Narrative
section:
  title:
    v: Datos de aseguramiento
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 48768-6
      display:
        v: Payment sources Document
section:
  title:
    v: Caracterización Poblacional
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 29762-2
      display:
        v: Social history Narrative
section:
  title:
    v: Motivo de ingreso
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 42349-1
      display:
        v: Reason for referral
section:
  title:
    v: Triage
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 54094-8
      display:
        v: Emergency department Triage note
section:
  title:
    v: Antecedentes Familiares
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 10157-6
      display:
        v: History of family member diseases Narrative
section:
  title:
    v: Antecedentes Personales
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 11348-0
      display:
        v: History of Past illness Narrative
  entry:
    link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Immunization/Example-Immunization-Urgencias-d35834cde568
    reference:
      v: Immunization/Example-Immunization-Urgencias-d35834cde568
  entry:
    link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/MedicationStatement/Example-MedicationStatement-Urgencias-bd2c49c9bb37
    reference:
      v: MedicationStatement/Example-MedicationStatement-Urgencias-bd2c49c9bb37
section:
  title:
    v: Revision por sistemas
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 10187-3
      display:
        v: Review of systems Narrative
section:
  title:
    v: Examen Físico
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 29545-1
      display:
        v: Physical findings Narrative
section:
  title:
    v: Signos Vitales
  code:
    coding:
      system:
        v: https://loinc.org
      code:
        v: 8716-3

v: Vital signs

link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Observation/Example-Observation-Urgencias-VitalSigns-dbccfe96781c
reference:
  v: Observation/Example-Observation-Urgencias-VitalSigns-dbccfe96781c

title:
  v: Diagnóstico de ingreso
code:
  coding:
    system:
      v: https://loinc.org
    code:
      v: 42347-5
    display:
      v: Admission Diagnosis

title:
  v: Plan Manejo
code:
  coding:
    system:
      v: https://loinc.org
    code:
      v: 18776-5
    display:
      v: Care Plan
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/CarePlan/Example-CarePlan-AtencionCancer-bfccb5579642
  reference:
    v: CarePlan/Example-CarePlan-AtencionCancer-bfccb5579642
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/MedicationRequest/Example-MedicationRequest-Urgencias-52dbbee9eb19
  reference:
    v: MedicationRequest/Example-MedicationRequest-Urgencias-52dbbee9eb19
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/MedicationAdministration/Example-MedicationAdministration-Urgencias-03e6f360947f
  reference:
    v: MedicationAdministration/Example-MedicationAdministration-Urgencias-03e6f360947f
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Procedure/Example-Procedure-Urgencias-2008c9f37c2f
  reference:
    v: Procedure/Example-Procedure-Urgencias-2008c9f37c2f
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/ServiceRequest/Example-ServiceRequest-CancerCarePlan-0312bcb88c73
  reference:
    v: ServiceRequest/Example-ServiceRequest-CancerCarePlan-0312bcb88c73
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/ServiceRequest/Example-ServiceRequest-CancerCarePlan-5b366560c820
  reference:
    v: ServiceRequest/Example-ServiceRequest-CancerCarePlan-5b366560c820
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/ServiceRequest/Example-ServiceRequest-Laboratory-e5687676850c
  reference:
    v: ServiceRequest/Example-ServiceRequest-Laboratory-e5687676850c
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/ServiceRequest/Example-ServiceRequest-Urgencias-Cirugia-7be6824cc9
  reference:
    v: ServiceRequest/Example-ServiceRequest-Urgencias-Cirugia-7be6824cc9
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Medication/Example-Medication-7c0bfdb68885
  reference:
    v: Medication/Example-Medication-7c0bfdb68885
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Specimen/Example-Specimen-Laboratory-07ddf6801714
  reference:
    v: Specimen/Example-Specimen-Laboratory-07ddf6801714

title:
  v: Evolución Urgencias
code:
  coding:
    system:
      v: https://loinc.org
    code:
      v: 28626-0
    display:
      v: Physician History and physical note
entry:
  link: https://oh-modules.apps.indraclusterdes.eastus.aroapp.io/ehrserver/fhir/Observation/Example-Observation-Urgencias-Valoracion-1d1d1fb74a0b
  reference:
    v: Observation/Example-Observation-Urgencias-Valoracion-1d1d1fb74a0b

title:
  v: Diagnóstico de egreso
code:
  coding:
    system:
      v: https://loinc.org
    code:
      v: 78375-3
    display:
      v: Discharge Diagnosis

title:
  v: Plan Manejo Egreso
code:
  coding:
    system:
      v: https://loinc.org
    code:
      v: 58222-1
    display:
      v: Care Plan Discharge

title:
  v: Estado Egreso
code:
  coding:
    system:
      v: https://loinc.org
    code:
      v: 28626-0
    display:
      v: Physician History and physical note