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Document-example-dischargesummary.xml

Structured Documents Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

Example of a discharge summary (id = "father")

<?xml version="1.0" encoding="UTF-8"?>

<Bundle xmlns="http://hl7.org/fhir">

  <id value="father"/> 
  <meta> 
    <lastUpdated value="2013-05-28T22:12:21Z"/> 
  </meta> 
  <identifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:uuid:0c3151bd-1cbf-4d64-b04d-cd9187a4c6e0"/> 
  </identifier> 
  <type value="document"/> 
<!--      The Composition resource      -->
  <entry> 
    <fullUrl value="http://fhir.healthintersections.com.au/open/Composition/180f219f-97a8-486d-99d9-ed631fe4fc57"/> 
    <resource> 
      <Composition> 
        <id value="180f219f-97a8-486d-99d9-ed631fe4fc57"/> 
        <meta> 
          <lastUpdated value="2013-05-28T22:12:21Z"/> 
        </meta> 
        <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : 180f219f-97a8-486d-99d9-ed631fe4fc57</p> <p> <b> meta</b> : </p> <p> <b> status</b> : final</p> <p> <b> type</b> : Discharge Summary from Responsible Clinician <span> (Details : {LOINC code '28655-9' = 'Physician attending Discharge summary)</span> </p> <p> <b> encounter</b> : <a> http://fhir.healthintersections.com.au/open/Encounter/doc-example</a> </p> <p> <b> date</b> : Feb 1, 2013 12:30:02 PM</p> <p> <b> author</b> : <a> Doctor Dave</a> </p> <p> <b> title</b> : Discharge Summary</p> <p> <b> confidentiality</b> : N</p> </div> </text> <status value="final"/> 
        <type> 
          <coding> 
            <system value="http://loinc.org"/> 
            <code value="28655-9"/> 
          </coding> 
          <text value="Discharge Summary from Responsible Clinician"/> 
        </type> 
        <subject> 
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/> 
          <display value="Eve Everywoman"/> 
        </subject> 
      <!--      The Encounter resource. Points directly to an Encounter resource. Contains the dates
         of admission, specialtyu etc.      -->
        <encounter> 
          <reference value="http://fhir.healthintersections.com.au/open/Encounter/doc-example"/> 
        </encounter> 
        <date value="2013-02-01T12:30:02Z"/> 
        <author> 
          <reference value="Practitioner/example"/> 
          <display value="Doctor Dave"/> 
        </author> 
        <title value="Discharge Summary"/> 
        <confidentiality value="N"/> 
        <section> 
          <title value="Reason for admission"/> 
          <code> 
            <coding> 
              <system value="http://loinc.org"/> 
              <code value="29299-5"/> 
              <display value="Reason for visit Narrative"/> 
            </coding> 
          </code> 
          <text> 
            <status value="additional"/> 
            <div xmlns="http://www.w3.org/1999/xhtml">

              <table> 

                <thead> 

                  <tr> 

                    <td> Details</td> 

                    <td/>  

                  </tr> 

                </thead> 

                <tbody> 

                  <tr> 

                    <td> Acute Asthmatic attack. Was wheezing for days prior to admission.</td> 

                    <td/>  

                  </tr> 

                </tbody> 

              </table> 

            </div> 
          </text> 
          <entry> 
            <reference value="urn:uuid:541a72a8-df75-4484-ac89-ac4923f03b81"/> 
          </entry> 
        </section> 
      <!--      Points to the  medications on discharge      -->
        <section> 
          <title value="Medications on Discharge"/> 
          <code> 
            <coding> 
              <system value="http://loinc.org"/> 
              <code value="10183-2"/> 
              <display value="Hospital discharge medications Narrative"/> 
            </coding> 
          </code> 
          <text> 
            <status value="additional"/> 
            <div xmlns="http://www.w3.org/1999/xhtml">

              <table> 

                <thead> 

                  <tr> 

                    <td> Medication</td> 

                    <td> Last Change</td> 

                    <td> Last ChangeReason</td> 

                  </tr> 

                </thead> 

                <tbody> 

                  <tr> 

                    <td> Theophylline 200mg BD after meals</td> 

                    <td> continued</td> 

                  </tr> 

                  <tr> 

                    <td> Ventolin Inhaler</td> 

                    <td> stopped</td> 

                    <td> Getting side effect of tremor</td> 

                  </tr> 

                </tbody> 

              </table> 

            </div> 
          </text> 
          <mode value="working"/> 
          <!--      This is an entry that refers to a MedicationRequest resource in this document.
                It is a new medication (as indicated by the flag)     -->
          <entry> 
            <reference value="urn:uuid:124a6916-5d84-4b8c-b250-10cefb8e6e86"/> 
          </entry> 
          <entry> 
            <reference value="urn:uuid:673f8db5-0ffd-4395-9657-6da00420bbc1"/> 
          </entry> 
        </section> 
      <!--      Points to the  allergies      -->
        <section> 
          <title value="Known allergies"/> 
          <code> 
            <coding> 
              <system value="http://loinc.org"/> 
              <code value="48765-2"/> 
              <display value="Allergies and adverse reactions Document"/> 
            </coding> 
          </code> 
          <text> 
            <status value="additional"/> 
            <div xmlns="http://www.w3.org/1999/xhtml">

              <table> 

                <thead> 

                  <tr> 

                    <td> Allergen</td> 

                    <td> Reaction</td> 

                  </tr> 

                </thead> 

                <tbody> 

                  <tr> 

                    <td> Doxycycline</td> 

                    <td> Hives</td> 

                  </tr> 

                </tbody> 

              </table> 

            </div> 
          </text> 
          <entry> 
            <reference value="urn:uuid:47600e0f-b6b5-4308-84b5-5dec157f7637"/> 
          </entry> 
        </section> 
      </Composition> 
    </resource> 
  </entry> 
<!--      The Practitioner Resource. In this document they are the author of the document
    (There is a reference from the document resource). Note that, strictly, it doesn't
   need to be within the document as the
    recipient knows where to go and get it if they need it - assuming it is available
   on-line of course.     -->
  <entry> 
    <fullUrl value="http://fhir.healthintersections.com.au/open/Practitioner/example"/> 
    <resource> 
      <Practitioner> 
        <id value="example"/> 
        <meta> 
          <lastUpdated value="2013-05-05T16:13:03Z"/> 
        </meta> 
        <text> 
          <status value="generated"/> 
          <div xmlns="http://www.w3.org/1999/xhtml">

            <p> Dr Adam Careful</p> 

          </div> 
        </text> 
        <identifier> 
          <system value="http://www.acme.org/practitioners"/> 
          <value value="23"/> 
        </identifier> 
        <name> 
          <family value="Careful"/> 
          <given value="Adam"/> 
          <prefix value="Dr"/> 
        </name> 
      </Practitioner> 
    </resource> 
  </entry> 
<!--      The Patient who is the subject of the document. Same coments as practitioner.   
     -->
  <entry> 
    <fullUrl value="http://fhir.healthintersections.com.au/open/Patient/d1"/> 
    <resource> 
      <Patient> 
        <id value="d1"/> 
        <text> 
          <status value="generated"/> 
          <div xmlns="http://www.w3.org/1999/xhtml">

            <h1> Eve Everywoman</h1> 

          </div> 
        </text> 
        <active value="true"/> 
        <name> 
          <text value="Eve Everywoman"/> 
          <family value="Everywoman1"/> 
          <given value="Eve"/> 
        </name> 
        <telecom> 
          <system value="phone"/> 
          <value value="555-555-2003"/> 
          <use value="work"/> 
        </telecom> 
        <gender value="female"/> 
        <birthDate value="1955-01-06"/> 
        <address> 
          <use value="home"/> 
          <line value="2222 Home Street"/> 
        </address> 
      </Patient> 
    </resource> 
  </entry> 
<!--      The encounter that is being documented.     -->
  <entry> 
    <fullUrl value="http://fhir.healthintersections.com.au/open/Encounter/doc-example"/> 
    <resource> 
      <Encounter> 
        <id value="doc-example"/> 
        <meta> 
          <lastUpdated value="2013-05-05T16:13:03Z"/> 
        </meta> 
        <text> 
          <status value="generated"/> 
          <div xmlns="http://www.w3.org/1999/xhtml"> Admitted to Orthopedics Service,
                        Middlemore Hospital between Jan 20 and Feb ist 2013 </div> 
        </text> 
        <identifier> 
          <value value="S100"/> 
        </identifier> 
        <status value="completed"/> 
        <class> 
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> 
            <code value="IMP"/> 
            <display value="inpatient encounter"/> 
        </class> 
        <type> 
          <text value="Orthopedic Admission"/> 
        </type> 
        <subject> 
          <reference value="Patient/d1"/> 
        </subject> 
        <period> 
          <start value="2013-01-20T12:30:02Z"/> 
          <end value="2013-02-01T12:30:02Z"/> 
        </period> 
        <hospitalization> 
          <dischargeDisposition> 
            <text value="Discharged to care of GP"/> 
          </dischargeDisposition> 
        </hospitalization> 
      </Encounter> 
    </resource> 
  </entry> 
  <entry> 
    <fullUrl value="urn:uuid:541a72a8-df75-4484-ac89-ac4923f03b81"/> 
    <resource> 
      <Observation> 
        <meta> 
          <lastUpdated value="2013-05-05T16:13:03Z"/> 
        </meta> 
        <text> 
          <status value="additional"/> 
          <div xmlns="http://www.w3.org/1999/xhtml"> Acute Asthmatic attack. Was wheezing
                        for days prior to admission. </div> 
        </text> 
        <status value="final"/> 
        <code> 
          <coding> 
            <system value="http://loinc.org"/> 
            <code value="46241-6"/> 
          </coding> 
          <text value="Reason for admission"/> 
        </code> 
        <subject> 
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/> 
          <display value="Eve Everywoman"/> 
        </subject> 
        <encounter> 
          <reference value="http://fhir.healthintersections.com.au/open/Encounter/doc-example"/> 
        </encounter> 
        <valueString value="Acute Asthmatic attack. Was wheezing for days prior to admission."/> 
      </Observation> 
    </resource> 
  </entry> 
<!--      The first medication in the medications list      -->
  <entry> 
    <fullUrl value="urn:uuid:124a6916-5d84-4b8c-b250-10cefb8e6e86"/> 
    <resource> 
      <MedicationRequest> 
        <meta> 
          <lastUpdated value="2013-05-05T16:13:03Z"/> 
        </meta> 
      <!--      The Human readible version of the script      -->
        <text> 
          <status value="generated"/> 
          <div xmlns="http://www.w3.org/1999/xhtml">

            <p> Theophylline 200mg twice a day</p> 

          </div> 
        </text> 
      <!--      The patient details will generally be in the Document resource in the Document bundle,
         but could just as easily
        point to a patient resource on a server     -->
        <status value="unknown"/> 
        <intent value="order"/> 
        <medicationCodeableConcept> 
          <coding> 
            <system value="http://snomed.info/sct"/> 
            <code value="66493003"/> 
          </coding> 
          <text value="Theophylline 200mg"/> 
        </medicationCodeableConcept> 
     <subject> 
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/> 
          <display value="Peter Patient"/> 
        </subject> 
      <!--      The prescriber details could also be within the bundle, but has the same options
         as patient     -->
        <requester> 
          <reference value="Practitioner/example"/> 
          <display value="Peter Practitioner"/> 
        </requester> 
        <reasonCode> 
          <text value="Management of Asthma"/> 
        </reasonCode> 
      <!--      a reference to the medication being prescribed. As described earlier, this could
         be contained (as is the example here), separately
        within the document bundle or simply a reference to a remote server. See comment
         in the contained resource     -->
             <dosageInstruction> 
          <additionalInstruction> 
            <text value="Take with Food"/> 
          </additionalInstruction> 
        <!--      twice a day      -->
          <timing> 
            <repeat> 
              <frequency value="2"/> 
              <period value="1"/> 
              <periodUnit value="d"/> 
            </repeat> 
          </timing> 
        <!--      Orally      -->
          <route> 
            <coding> 
              <system value="http://snomed.info/sct"/> 
              <code value="394899003"/> 
              <display value="oral administration of treatment"/> 
            </coding> 
          </route> 
               <doseAndRate> 
                 <type> 
                   <coding> 
                     <system value="http://terminology.hl7.org/CodeSystem/dose-rate-type"/> 
                     <code value="ordered"/> 
                     <display value="Ordered"/> 
                   </coding> 
                 </type> 
                 <doseQuantity> 
                   <value value="1"/> 
                   <unit value="tablet"/> 
                   <system value="http://unitsofmeasure.org"/> 
                   <code value="tbl"/> 
                 </doseQuantity> 
               </doseAndRate> 

        </dosageInstruction> 
      </MedicationRequest> 
    </resource> 
  </entry> 
<!--      The second medication in the medications list      -->
  <entry> 
    <fullUrl value="urn:uuid:673f8db5-0ffd-4395-9657-6da00420bbc1"/> 
    <resource> 
      <MedicationUsage> 
      <!--      The Human readible version of the medication statement     -->
        <text> 
          <status value="generated"/> 
          <div xmlns="http://www.w3.org/1999/xhtml">

            <p> Ventolin inhaler discontinued</p> 

          </div> 
        </text> 
      <!--      The patient details will generally be in the Document resource in the Document bundle,
         but could just as easily
        point to a patient resource on a server     -->
        <status value="active"/> 
  <!--      a reference to the medication being prescribed. As described earlier, this could
         be contained (as is the example here), separately
        within the document bundle or simply a reference to a remote server. See comment
         in the contained resource     -->
        <statusReason> 
          <text value="Management of Asthma"/> 
        </statusReason> 
        <medicationCodeableConcept> 
          <text value="Ventolin Inhaler"/> 
        </medicationCodeableConcept> 
        <subject> 
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/> 
          <display value="Peter Patient"/> 
        </subject> 
        <dateAsserted value="2013-05-05T16:13:03Z"/> 




       </MedicationUsage> 
    </resource> 
  </entry> 
<!--      The Allergy.     -->
  <entry> 
    <fullUrl value="urn:uuid:47600e0f-b6b5-4308-84b5-5dec157f7637"/> 
    <resource> 
      <AllergyIntolerance> 
        <meta> 
          <lastUpdated value="2013-05-05T16:13:03Z"/> 
        </meta> 
        <text> 
          <status value="generated"/> 
          <div xmlns="http://www.w3.org/1999/xhtml">Sensitivity to Doxycycline :
                        Hives</div> 
        </text> 
        <clinicalStatus> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"/> 
        <code value="active"/> 
        <display value="Active"/> 
      </coding> 
      </clinicalStatus> 

      <verificationStatus> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/allergyintolerance-verification"/> 
        <code value="confirmed"/> 
        <display value="Confirmed"/> 
      </coding> 
      </verificationStatus> 
        <type value="allergy"/> 
        <criticality value="high"/> 
        <code> 
          <text value="Doxycycline"/> 
        </code> 
        <patient> 
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/> 
          <display value="Eve Everywoman"/> 
        </patient> 
        <recordedDate value="2012-09-17"/> 
        <reaction> 
          <manifestation> 
            <coding> 
              <system value="http://example.org/system"/> 
              <code value="xxx"/> 
              <display value="Hives"/> 
            </coding> 
            <text value="Hives"/> 
          </manifestation> 
        </reaction> 
      </AllergyIntolerance> 
    </resource> 
  </entry> 
  <signature> 
    <type> 
      <system value="urn:iso-astm:E1762-95:2013"/> 
      <code value="1.2.840.10065.1.12.1.1"/> 
      <display value="Author's Signature"/> 
    </type> 
    <when value="2015-08-31T07:42:33+10:00"/> 
    <who> 
      <reference value="Device/software"/> 
    </who> 
    <onBehalfOf> 
      <reference value="Organization/example"/> 
    </onBehalfOf> 
    <!--    a real document would typically have an digital signature, but
      the publishing tools are not yet setup to produce a valid digital
      signature. For now, an image of a signature    -->
    <sigFormat value="image/jpg"/> 
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  </signature> 
</Bundle> 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.