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GET /DocumentReference/1002?access_token=6b5h9crwD1EP2zzNDifB5GNZi1rgmU3vmjsdJE9G9BfhQUL3Pm7stAUvJCgwSbAb 200 { "resourceType": "DocumentReference", "id": "1002", "meta": { "versionId": "1", "lastUpdated": "2021-03-23T19:36:17.299+00:00", "source": "#E1VolYkq84D3M96u", "profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference" ] }, "identifier": [ { "value": "1002" } ], "status": "current", "type": { "coding": [ { "system": "http://loinc.org", "code": "11506-3", "display": "Clinician Progress Note" } ] }, "category": [ { "coding": [ { "system": "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category", "code": "clinical-note", "display": "Clinical Note" } ] } ], "subject": { "reference": "Patient/1", "display": "Alice Newman" }, "date": "2022-11-29T02:51:52.000-05:00", "author": [ { "reference": "Practitioner/1008", "display": "Albert Davis" } ], "content": [ { "attachment": { "contentType": "text/html", "data": "<div class=\"doc-print\" style=\"width: 100%;\">\n <h3 style=\"margin-bottom:0;\">\n Clinician Progress Note (R) 08/29/2022\n </h3>\n <div class=\"cp-doc_header repeating_header\">\n <div id=\"patient-name\">malibu barbie MR# 20376 DOB: Gender: Status: Active</div>\n <div id=\"patient-address\">147 clark st malibu FL 37092 </div>\n <div id=\"patient-care_manager\">Care Manager: Not Assigned Allergies: Unknown </div>\n </div>\n\n <table style='width:100%'><tr>\n <td>\n <h5>ICD10 Diagnoses</h5>\n <ul class='cp-bullet_list'><li>No active codes</li></ul>\n </td>\n <td>\n <h5>ICD9 Diagnoses</h5>\n <ul class='cp-bullet_list'><li>300.02 Generalized Anxiety Disorder</li><li>309.81 Posttraumatic Stress Disorder</li></ul>\n </td>\n </tr></table> <div style=\"border: solid gray 1px; margin: 1em 0; padding:0 5px 5px 5px\">\n <div style='margin:0' class='sectionhead'>Service Information</div>\n <table style=\"width:100%\">\n <tbody>\n <tr>\n <td style=\"width:25%;padding:0 5px 0 0\">\n <span class=\"inputlabel\">Date</span><br>\n <span class=\"inputlabel\"></span>\n <div id=\"servicedate\">\n 08/29/2022\n </div>\n <input type=\"hidden\" id=\"servicedate\" name=\"servicedate\" value=\"20220829\">\n </td>\n <td style=\"width:25%;padding:0 5px 0 0\">\n <span class=\"inputlabel\">\n Time\n </span>\n <br>\n <span class=\"inputlabel\"></span>\n <div id=\"servicetime\">\n 3:19 PM\n </div>\n </td>\n <td style=\"width:25%;padding:0 5px 0 0\">\n <span class=\"inputlabel\">\n Actual Time In\n </span>\n <br>\n <span class=\"inputlabel\"></span>\n <div id=\"ActualTimeIn\">\n 12:00 PM\n </div>\n </td>\n <td style=\"width:25%;padding:0 5px 0 0\">\n <span class=\"inputlabel\">\n Actual Time Out\n </span>\n <br>\n <span class=\"inputlabel\"></span>\n <div id=\"ActualTimeOut\">\n 1:00 PM\n </div>\n </td>\n </tr>\n </tbody>\n </table>\n\n <div id=\"siteprogramkey\">\n \n </div>\n\n <div>\n <div class=\"ul\">Billing Codes</div>\n <table class=\"listtable\">\n <tbody>\n <tr>\n <th style=\"width: 10%\">Code</th>\n <th style=\"width: 10%\">Units</th>\n <th style=\"width: 80%\">Desc.</th>\n </tr>\n <tr>\n <td>90837</td>\n <td>1</td>\n <td>PSYTX W PT 60 MINUTES</td>\n </tr>\n\n </tbody>\n </table>\n </div>\n <table style=\"width:100%\">\n <tbody>\n <tr>\n <td style=\"width:25%; padding:0 5px 0 0\">\n <span class=\"inputlabel\">\n <span class=\"inputlabel\">Status</span>\n <br>\n </span>\n <div id=\"21043416servicestatus\">\n Completed\n </div>\n </td>\n <td style=\"width:50%; padding:0 5px 0 0\">\n <span class=\"inputlabel\">\n <span class=\"inputlabel\">Document Exception</span>\n <br>\n </span>\n <div id=\"document_exception\">\n No exceptions\n </div>\n </td>\n <td style=\"width:25%; padding:0 5px 0 0\">\n <span class=\"inputlabel\">Next Appt. Date</span>\n <br>\n <span class=\"inputlabel\"></span>\n <div id=\"ServiceNextDate\">\n \n </div>\n </td>\n </tr>\n </tbody>\n </table>\n\n \n </div>\n <span class=\"input-label\"><br>\r\nCurrent Symptoms, Summary of Session, and Current Medications</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nCurrent Symptoms</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nInterventions</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nSummary of Session</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <div class='prescriber-records-status'>\n <h4>Medications</h4>\n <div class='prescriber-medications-list-partial'>\n <table class='cp-index_table'>\n <tr>\n <th>Description</th>\n <th>Start</th>\n <th>Stop</th>\n <th>Status</th>\n <th>Qty/Refills</th>\n <th>Sig/Notes</th>\n </tr>\n \n </table>\n No records found.\n </div>\n\n <h4>Drug Allergies</h4>\n <div class='prescriber-allergies-list-partial'>\n <table class='cp-index_table'>\n <tr>\n <th>Allergen</th>\n <th>Status</th>\n <th>Reaction</th>\n <th>Onset Date</th>\n </tr>\n \n </table>\n No records found.\n </div>\n\n <h4>Notes</h4>\n <div id='record_prescriber_notes'>\n \n </div>\n </div>\n <span class=\"input-label\">Mental Status</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nAppearance</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nBehavior</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nMood</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nOrientation</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nAttitude</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nAffect</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nThought</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nSpeech</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nShort Term Memory</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nLong term memory</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nFund of Knowledge</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nIntellectual functioning</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nJudgement</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nInsight</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nRisk of self mutilation behaviors</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nRisk of suicide\r\n</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nRisk of violence towards others</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nPrognosis and Progress to Date</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nPrognosis</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n <span class=\"input-label\"><br>\r\nProgress to Date</span>\n <div class=\"form-field-print clearfix\">\n <div class='row'>\n \n </div>\n </div>\n\n </div>\n", "url": "/DocumentReference/" }, "format": { "system": "urn:oid:1.3.6.1.4.1.19376.1.2.3", "code": "urn:ihe:iti:xds:2017:mimeTypeSufficient", "display": "mimeType Sufficient" } } ], "context": { "encounter": [ { "reference": "Encounter/1009" } ], "period": { "start": "2021-08-01T00:00:00Z", "end": "2021-08-01T00:00:00Z" } } }
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