This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Structured Documents Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: 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> <security> <system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality"/> <code value="N"/> <display value="normal"/> </security> </meta> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:uuid:0c3151bd-1cbf-4d64-b04d-cd9187a4c6e0"/> </identifier> <type value="document"/> <timestamp value="2013-05-28T22:12:21Z"/> <!-- 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 class="res-header-id"><b> Generated Narrative: Composition 180f219f-97a8-486d-99d9-ed631fe4fc57</b> </p> <a name="180f219f-97a8-486d-99d9-ed631fe4fc57"> </a> <a name="hc180f219f-97a8-486d-99d9-ed631fe4fc57"> </a> <a name="180f219f-97a8-486d-99d9-ed631fe4fc57-en-US"> </a> <div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Last updated: 2013-05-28T22:12:21Z</p> </div> <p> <b> status</b> : final</p> <p> <b> type</b> : <span title="Codes:{http://loinc.org 28655-9}">Discharge Summary from Responsible Clinician</span> </p> <p> <b> encounter</b> : <a href="broken-link.html">??</a> </p> <p> <b> date</b> : 2013-02-01T12:30:02Z</p> <p> <b> author</b> : <a href="practitioner-example.html">Doctor Dave</a> </p> <p> <b> title</b> : Discharge Summary</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"/> <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> <!-- 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> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> <code value="IMP"/> <display value="inpatient encounter"/> </coding> </class> <type> <text value="Orthopedic Admission"/> </type> <subject> <reference value="Patient/d1"/> </subject> <actualPeriod> <start value="2013-01-20T12:30:02Z"/> <end value="2013-02-01T12:30:02Z"/> </actualPeriod> <admission> <dischargeDisposition> <text value="Discharged to care of GP"/> </dischargeDisposition> </admission> </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"/> <medication> <concept> <coding> <system value="http://snomed.info/sct"/> <code value="66493003"/> </coding> <text value="Theophylline 200mg"/> </concept> </medication> <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> <reason> <concept> <text value="Management of Asthma"/> </concept> </reason> <!-- 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://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/> <code value="TAB"/> </doseQuantity> </doseAndRate> </dosageInstruction> </MedicationRequest> </resource> </entry> <!-- The second medication in the medications list --> <entry> <fullUrl value="urn:uuid:673f8db5-0ffd-4395-9657-6da00420bbc1"/> <resource> <MedicationStatement> <!-- 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="recorded"/> <!-- 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 --> <medication> <concept> <text value="Ventolin Inhaler"/> </concept> </medication> <subject> <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/> <display value="Peter Patient"/> </subject> <dateAsserted value="2013-05-05T16:13:03Z"/> <reason> <concept> <text value="Management of Asthma"/> </concept> </reason> </MedicationStatement> </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> <coding> <system value="http://hl7.org/fhir/allergy-intolerance-type"/> <code value="allergy"/> <display value="Allergy"/> </coding> </type> <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> <concept> <coding> <system value="http://example.org/system"/> <code value="xxx"/> <display value="Hives"/> </coding> <text value="Hives"/> </concept> </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 a digital signature, but the publishing tools are not yet setup to produce a valid digital signature. 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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.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Tue, Dec 3, 2024 23:26+0000.
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