Generated Narrative: Composition 5e848ec9-b5bf-4c90-9d7e-6b0894208bfe Profile: Composition (HDR CZ) status: Final type: Hospital Discharge summary encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); priority = urgent; period = 2025-05-17 06:20:00+0200 --> 2025-05-20 11:30:00+0200 date: 2025-05-20 11:30:00+0200 author: Practitioner Eva Svobodova title: Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)
Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)
Hospitalizace pro spontánní porod v termínu, bez závažných komplikací.
Porod dne 18.05.2025 v 10:46, spontánní vaginální, bez indukce, analgezie EDA (ropivakain + fentanyl), novorozenec mužského pohlaví, 3210 g, 49 cm, Apgar 10-10-10. Mateřské poranění: epiziotomie mediolaterální.
Gynekologická anamnéza: prvorodička, gravidita/parita 1/1, gestační stáří při porodu 39+6.
Gestační stáří 39+6, prvorodička, gravidita 1, parita 1, singleton gravidita.
Health insurance and payment information
Payer: 111 (VZP), insurance number: 9355181234.
Allergies and adverse reactions Document
Alergie na penicilin, reakce: kožní vyrážka a otok rtů.
Porodní analgezie: epidurální podání ropivakainu s malou dávkou fentanylu během porodu.
Generated Narrative: Patient 6c4f4d2c-5f24-4a91-a75e-1b0e2a1f7731 Profile: Patient (CZ core) Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) Other Id: https://ncez.mzcr.cz/fhir/sid/rcis/9355181234 (use: official, ) Contact Detail +420777222333 Kvetna 12, 60200 Brno(home) Language: Czech (preferred) Registering provider: value: PractitionerRole Lekar category: General medical service Registering provider: value: PractitionerRole Lekar category: Obstetrics and gynecology service
Generated Narrative: Patient b7e6c8a1-4a8d-4d9f-8f69-df4f210cb2d7 Profile: Patient (CZ core) Jan Novak (official) Male, DoB: 2025-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9009876543 (use: official, )) Multiple Birth: false Contact Detail Kvetna 12, 60200 Brno(home) Language: Czech (preferred) mother: Jana Novakova +420777222333 Links: Also see: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567)
Generated Narrative: Encounter 7d7a6f19-5dfb-45ee-8bcf-0f63d9fe49f2 Profile: Encounter (HDR CZ) status: finished class: ActCode: IMP (inpatient encounter) priority: urgent subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) Participants - Type Individual * Admitter Practitioner Eva Svobodova period: 2025-05-17 06:20:00+0200 --> 2025-05-20 11:30:00+0200 Hospitalizations - AdmitSource DischargeDisposition * From outpatient department Home location location: Location Porodni oddeleni period: 2025-05-17 06:20:00+0200 --> 2025-05-18 09:00:00+0200 location location: Location Pokoj 3 period: 2025-05-18 09:00:00+0200 --> 2025-05-20 10:00:00+0200 location location: Location Luzko 01 period: 2025-05-18 09:10:00+0200 --> 2025-05-19 18:00:00+0200 serviceProvider: Organization Porodni oddeleni - Mestska nemocnice Brno
Generated Narrative: Coverage 8f9c2f14-1f69-4f2b-b4a8-8b7ca4db9f31 Profile: Coverage (CZ) identifier: https://ncez.mzcr.cz/fhir/sid/cislo-pojistence/9355181234 (use: official, ) status: Active beneficiary: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) payor: Organization Vseobecna zdravotni pojistovna Ceske republiky
Alergie na penicilin - kožní vyrážka, otok rtů.
Generated Narrative: Procedure GynNaturalBirthJana-DeliveryMethod Profile: Procedure: Method of Delivery (CZ) status: Completed code: Vaginal delivery subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) performed: 2025-05-18 10:46:00+0200 Performers - Actor * Practitioner Eva Svobodova
Epiziotomie mediolaterální během porodu.
First degree perineal laceration during delivery
Generated Narrative: Observation GynNaturalBirthJana-FetalPresentation Profile: Observation: Fetal Presentation During Delivery (CZ) status: Final code: Fetal presentation at birth subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 10:46:00+0200 value: Vertex presentation
Generated Narrative: Observation GynNaturalBirthJana-BirthWeight Profile: Observation: Birth Weight (CZ) status: Final code: Birth weight measured subject: Jan Novak (official) Male, DoB: 2025-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9009876543 (use: official, )) value: 3210 g (Details: UCUM codeg = 'g')
Generated Narrative: Observation GynNaturalBirthJana-BirthLength Profile: Observation: Birth Length (CZ) status: Final code: Birth height measured subject: Jan Novak (official) Male, DoB: 2025-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9009876543 (use: official, )) value: 49 cm (Details: UCUM codecm = 'cm')
Generated Narrative: Observation GynNaturalBirthJana-Gravidity Profile: Observation: Maternal - Gravidity (CZ) status: Final code: [#] Pregnancies subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 10:46:00+0200 value: 1
Generated Narrative: Observation GynNaturalBirthJana-Parity Profile: Observation: Maternal - Parity (CZ) status: Final code: [#] Parity subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 10:46:00+0200 value: 1
Generated Narrative: Observation GynNaturalBirthJana-MultiplePregnancy Profile: Observation: Maternal - Multiple pregnancy and fetus count (CZ) status: Final code: Was this a multiple pregnancy [PhenX] subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 10:46:00+0200 value: false Components - Code Value[x] * Number of fetuses 1
Generated Narrative: Observation GynNaturalBirthJana-GestationalAgeAtDelivery status: Final code: Gestational age--at birth subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 10:46:00+0200 value: 39+6
Generated Narrative: Observation GynNaturalBirthJana-Apgar1 status: Final code: Apgar score 1 minute subject: Jan Novak (official) Male, DoB: 2025-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9009876543 (use: official, )) effective: 2025-05-18 10:47:00+0200 value: 10
Generated Narrative: Observation GynNaturalBirthJana-Apgar5 status: Final code: Apgar score 5 minute subject: Jan Novak (official) Male, DoB: 2025-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9009876543 (use: official, )) effective: 2025-05-18 10:51:00+0200 value: 10
Generated Narrative: Observation GynNaturalBirthJana-Apgar10 status: Final code: Apgar score 10 minute subject: Jan Novak (official) Male, DoB: 2025-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9009876543 (use: official, )) effective: 2025-05-18 10:56:00+0200 value: 10
Generated Narrative: Observation GynNaturalBirthJana-BirthOutcome status: Final code: Birth outcome subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 10:46:00+0200 value: Liveborn infant
Generated Narrative: Medication med-ropivacaine-epidural Profile: Medication (CZ) identifier: https://hl7.cz/fhir/core/CodeSystem/cz-dlplecivepripravky-cs/0299001 code: Ropivakain epiduralni roztok status: Active
Generated Narrative: Medication med-fentanyl-epidural Profile: Medication (CZ) identifier: https://hl7.cz/fhir/core/CodeSystem/cz-dlplecivepripravky-cs/0299002 code: Fentanyl pro epiduralni analgezii status: Active
Generated Narrative: MedicationStatement medstmt-ropivacaine-epidural-jana Profile: Medication Statement (CZ) identifier: https://hl7.cz/fhir/core/CodeSystem/cz-dlplecivepripravky-cs/0299001 status: completed category: Inpatient medication: Medication Ropivacaine subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 09:35:00+0200 --> 2025-05-18 11:10:00+0200 Dosages - Text Route * Epidurální podání ropivakainu během porodu Epidural route
Epidurální podání ropivakainu během porodu
Generated Narrative: MedicationStatement medstmt-fentanyl-epidural-jana Profile: Medication Statement (CZ) identifier: https://hl7.cz/fhir/core/CodeSystem/cz-dlplecivepripravky-cs/0299002 status: completed category: Inpatient medication: Medication Fentanyl subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) effective: 2025-05-18 09:40:00+0200 --> 2025-05-18 10:50:00+0200 Dosages - Text Route * Epidurální podání malé dávky fentanylu jako součást EDA Epidural route
Epidurální podání malé dávky fentanylu jako součást EDA
Generated Narrative: MedicationAdministration medadmin-ropivacaine-epidural-jana status: Completed medication: Medication Ropivacaine subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) context: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); priority = urgent; period = 2025-05-17 06:20:00+0200 --> 2025-05-20 11:30:00+0200 effective: 2025-05-18 09:35:00+0200 --> 2025-05-18 11:10:00+0200 Dosages - Route Dose * Epidural route 10 mg (Details: UCUM codemg = 'mg')
Generated Narrative: MedicationAdministration medadmin-fentanyl-epidural-jana status: Completed medication: Medication Fentanyl subject: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) context: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); priority = urgent; period = 2025-05-17 06:20:00+0200 --> 2025-05-20 11:30:00+0200 effective: 2025-05-18 09:40:00+0200 --> 2025-05-18 10:50:00+0200 Dosages - Route Dose * Epidural route 0.05 mg (Details: UCUM codemg = 'mg')
Generated Narrative: Practitioner 1ec5e355-648f-42b9-a316-3f056fbd04b5 Profile: Practitioner (CZ core) identifier: https://ncez.mzcr.cz/fhir/sid/nrzp/999111222 name: Eva Svobodova telecom: +420777888999
Generated Narrative: Practitioner practitioner-novakovajana-gp Profile: Practitioner (CZ core) identifier: https://ncez.mzcr.cz/fhir/sid/krzp/971234560 name: Pavel Kral telecom: +420725111222
Generated Narrative: Practitioner practitioner-novakovajana-gyn Profile: Practitioner (CZ core) identifier: https://ncez.mzcr.cz/fhir/sid/krzp/971234561 name: Petra Vesela telecom: +420725333444
Generated Narrative: PractitionerRole practitionerrole-novakovajana-gp Profile: Practitioner Role (CZ core) practitioner: Practitioner Pavel Kral organization: Organization MUDr. Jana Krásná code: Lekar specialty: Family practice (qualifier value)
Generated Narrative: PractitionerRole practitionerrole-novakovajana-gyn Profile: Practitioner Role (CZ core) practitioner: Practitioner Petra Vesela organization: Organization MUDr. Jana Kouzelná code: Lekar specialty: Gynecology service
Generated Narrative: Organization RegisteringProviderExample-gynecology Profile: Organization (CZ core) identifier: https://ncez.mzcr.cz/fhir/sid/ico/456789857, https://ncez.mzcr.cz/fhir/sid/icz/12345000, https://ncez.mzcr.cz/fhir/sid/icp/12345678 type: Samostatná ordinace PL - gynekologa name: MUDr. Jana Kouzelná telecom: +420603853227 address: Krátká 11, 70500 Ostrava Ostrava 70500 CZ
Samost. ordinace všeob. prakt. lékaře, MUDr. Stanislava Kubšová
Generated Narrative: Organization org-payer-111 Profile: Organization (CZ core) identifier: https://ncez.mzcr.cz/fhir/sid/zdravotni-pojistovna/111 name: Vseobecna zdravotni pojistovna Ceske republiky
Vseobecna zdravotni pojistovna Ceske republiky
Generated Narrative: Organization d4545f84-0d58-4f6f-a50a-2f2ea2ea4dc4 Profile: Organization (CZ core) identifier: https://ncez.mzcr.cz/fhir/sid/ico/27999911, https://ncez.mzcr.cz/fhir/sid/icz/62010000 name: Mestska nemocnice Brno telecom: +420543111222 address: Kvetna 15, 60200 Brno Brno 60200 CZ
Generated Narrative: Organization 2f823e1c-b1a5-42f8-9ba4-7df32768b2a7 Profile: Organization (CZ core) identifier: https://ncez.mzcr.cz/fhir/sid/icp/62010123 name: Porodni oddeleni - Mestska nemocnice Brno telecom: +420543111333 address: Kvetna 15, 60200 Brno Brno 60200 CZ partOf: Organization Mestska nemocnice Brno
Porodni oddeleni - Mestska nemocnice Brno
Generated Narrative: Location loc-brno-hospital Profile: Location (CZ core) status: Active name: Mestska nemocnice Brno description: Hlavni areal Mestske nemocnice Brno telecom: +420543111222 address: Kvetna 15, 60200 Brno, Ceska republika(work) physicalType: Building managingOrganization: Organization Mestska nemocnice Brno
Generated Narrative: Location loc-brno-maternity-ward Profile: Location (CZ core) status: Active name: Porodni oddeleni description: Porodni oddeleni - Mestska nemocnice Brno physicalType: Ward managingOrganization: Organization Porodni oddeleni - Mestska nemocnice Brno partOf: Mestska nemocnice Brno
Generated Narrative: Location loc-brno-maternity-room-3 Profile: Location (CZ core) status: Active name: Pokoj 3 description: Pokoj 3 na porodni oddeleni physicalType: Room managingOrganization: Organization Porodni oddeleni - Mestska nemocnice Brno partOf: Porodni oddeleni
Generated Narrative: Location loc-brno-maternity-room-3-bed-01 Profile: Location (CZ core) status: Active name: Luzko 01 description: Luzko 01, pokoj 3, porodni oddeleni physicalType: Bed managingOrganization: Organization Porodni oddeleni - Mestska nemocnice Brno partOf: Pokoj 3
Generated Narrative: RelatedPerson relatedperson-novak-petr-husband Profile: Related Person: HDR (CZ) identifier: https://ncez.mzcr.cz/fhir/sid/rid/1597778923 patient: Jana Novakova Female, DoB: 1993-05-18 ( https://ncez.mzcr.cz/fhir/sid/rid#9001234567) relationship: Manzel, otec ditete name: Petr Novak telecom: +420777111222