HL7 Czech Hospital Discharge Report Implementation Guide
0.0.2 - ci-build Czechia flag

HL7 Czech Hospital Discharge Report Implementation Guide, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.0.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/hdr/ and changes regularly. See the Directory of published versions

Artifacts

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Actors and Obligations (Informative)

Actors and Obligations used to describe the HDR functional requirements for the specified data elements. Informative for this version of the guide.

Actor HDR Consumer

HDR Consumer: a system receiving/querying and using a HDR.

Actor HDR Consumer

HDR Consumer: a system receiving/querying and using a HDR.

Actor HDR Consumer

HDR Consumer: a system receiving/querying and using a HDR.

Actor HDR Creator

HDR Creator: a system generating and sending/providing a HDR to a Consumer for report storage and sharing.

Actor HDR Creator

HDR Creator: a system generating and sending/providing a HDR to a Consumer for report storage and sharing.

Actor HDR Creator

HDR Creator: a system generating and sending/providing a HDR to a Consumer for report storage and sharing.

Patient: Obligations

This profile defines obligations for an human Patient in FHIR for the purpose of this guide.

Czech logical model (Informative)

Logical model in czech language. Informative for this version of the guide.

A - Propouštěcí zpráva

Nemocniční propouštěcí zpráva

A.1 – Hlavička dokumentu

Nemocniční propouštěcí zpráva - Struktura hlavičky propouštěcí zprávy podle tabulky části.

A.1.1 - Identifikace a A.1.2 - informace o pacientovi

Nemocniční propouštěcí zpráva - Informace o pacientovi.

A.1.9 - Digitální podpis

Nemocniční propouštěcí zpráva - Elektronický podpis dle zákona 327/2011 §54a

A.2.1 - Dříve vyslovená přání (cz)

Nemocniční propouštěcí zpráva - Dříve vyslovená přání

A.2.2 - Urgentní informace (cz)

Nemocniční propouštěcí zpráva - Urgentní informace

A.2.3 - Kontakt se zdravotními službami

Nemocniční propouštěcí zpráva - Záznam o hospitalizačním kontaktu v rámci propouštěcí zprávy.

A.2.4 - Stav při přijetí (cz)

Nemocniční propouštěcí zpráva - Stav při přijetí - A.2.4 CZ poznámka: Nepovinná sekce uvádět pouze v případě významu pro zajištění kontinuity péče.

A.2.6 - Anamnéza

Nemocniční propouštěcí zpráva - Anamnéza

A.2.7 - Průběh hospitalizace

Nemocniční propouštěcí zpráva - Průběh hospitalizace

A.2.7 Průběh hospitalizace

Nemocniční propouštěcí zpráva - Popis průběhu hospitalizace zahrnující diagnostické souhrny, výkony, léčbu, vyšetření i klinické shrnutí.

A.2.8.1 Objektivní nález

Nemocniční propouštěcí zpráva - Objektivní nález pacienta při propuštění.

A.2.8.2 - Funkční stav při propuštění

Nemocniční propouštěcí zpráva - Hodnocení funkčního stavu pacienta při propuštění.

A.2.9.1 Plán péče

Nemocniční propouštěcí zpráva - Plán péče po propuštění.

A.2.9.2 Souhrn medikace

Nemocniční propouštěcí zpráva - Souhrnná informace o medikaci doporučené na období po propuštění, včetně medikace změněné, nově zahájené nebo ukončené.

A.3 - Vizuální podoba dokumentu

Nemocniční propouštěcí zpráva - Zpráva z obrazového vyšetření čitelná lidským okem, je požadován PDF formát.

A.4 - Přílohy (cz)

Nemocniční propouštěcí zpráva - Přílohy

Structures: Logical Models

These define data models that represent the domain covered by this implementation guide in more business-friendly terms than the underlying FHIR resources.

A - Hospital Discharge Report (eHN)

Hospital Discharge Report

A.1 - Hospital Discharge Report header data element

Hospital Discharge Report - Hospital Discharge Report header data element - A.1 eHN

A.1.1 - Identification and A.1.2 - related contact information of the Patient/subject

Hospital Discharge Report - Hospital Discharge Report subject data element - A.1.1 and A.1.2 eHN

A.1.9 - Digital signature

Digital signature - Electronic signature or seal of a document according to Act 327/2011 §54a

A.2.1 - Advance Directives (eHN)

Hospital Discharge Report - Advance Directives - A.2.1 eHN

A.2.2 - Alerts (eHN)

Hospital Discharge Report - Alerts - A.2.2 eHN

A.2.3 - Encounter (eHN)

Hospital Discharge Report - Encounter - A.2.3 eHN

A.2.4 - Admission evaluation (eHN)

Hospital Discharge Report - Admission evaluation - A.2.4 eHN

A.2.5 - Patient history (eHN)

Hospital Discharge Report - Patient history - A.2.5 eHN

A.2.6 - Hospital stay (eHN)

Hospital Discharge Report - Hospital stay - A.2.6 eHN

A.2.7 - Discharge details (eHN)

Hospital Discharge Report - Discharge details - A.2.7 eHN

A.2.7.1 - Objective findings

Hospital Discharge Report - Objective Findings- A.2.7.1 eHN

A.2.8.1 - Care plan

Hospital Discharge Report - Care plan after discharge - A.2.8.1 eHN

A.2.8.2 - Functional status

Hospital Discharge Report - Functional status - A.2.8.2 eHN

A.2.8.2 - Medication summary

Hospital Discharge Report - Medication Summary after discharge - A.2.8.2 eHN

A.3 - Presented form

Presented form - Entire report as issued. Various formats could be provided, pdf format is recommended.

A.4 - Additional attachments

Discharge Report - additional attachments - A.4

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

Allergy Intolerance (HDR CZ)

This profile constrains the AllergyIntolerance resource for the purpose of this project.

Attachment: HDR (CZ)

Czech profile for attachment.

Bundle (HDR CZ)

Clinical document used to represent a Hospital Discharge Report for the scope of this guide.

Care Plan (HDR CZ)

This profile constrains the CarePlan resource for the purpose of this guide.

Composition (HDR CZ)

This profile defines how to represent Composition resource in HL7 FHIR for the scope of this guide.

Condition (HDR CZ)

This profile represents the constraint applied to the Condition in the scope of this guide. It supports the Diagnostic summary part of the eHN data model adding two additional categories: First category distinguishes conditions present at admission and acquired during hospital stay, while second category is used to indicate impact of the condition to the treatment during hospital stay (treated, untreated).

Consent (Advance Directives) (HDR CZ)

This profile constrains the Consent resource for the purpose of representing Advance Directives in this project.

DeviceUseStatement (HDR)

This profile represents the constraints applied to the DeviceUseStatement resource for the purpose of this guide. A device used by or implanted on the patient is described in the hospital discharge report as an instance of a Device resource constrained by this profile.

Encounter (HDR CZ)

This profile defines how to represent Inpatient Encounter in HL7 FHIR for the scope of this guide.

FamilyMemberHistory (HDR CZ)

This profile represents the constraints applied to the FamilyMemberHistory resource by this guide.

Flag (HDR CZ)

This profile constrains the Flag resource to represent alerts or warnings in FHIR for the purpose of this project.

Immunization (HDR CZ)

This profile constrains the Immunization resource for the purpose of this guide.

ImmunizationRecommendation (CZ HDR)

This profile defines how to represent Immunization Recommandations for the purpose of this guide.

MedicationDispense (HDR)

This profile constrains the MedicationDispense resource for the purpose of this guide, adapted from the MPD work.

MedicationRequest (HDR CZ)

This profile constrains the MedicationRequest resource for the purpose of this guide, adapted from the MPD work.

Observation: Anthropometric Data (HDR CZ)

This profile sets minimum expectations for the Observation resource to record, search, and fetch anthropometric measurements such as height, weight, BMI, and optional measurements like head, chest, and abdominal circumference.

Observation: Anthropometric Data (HDR CZ)

This profile sets minimum expectations for the Observation resource to record, search, and fetch anthropometric measurements such as height, weight, BMI, and optional measurements like head, chest, and abdominal circumference.

Observation: Anthropometric Data (HDR CZ)

This profile sets minimum expectations for the Observation resource to record, search, and fetch anthropometric measurements such as height, weight, BMI, and optional measurements like head, chest, and abdominal circumference.

Observation: Anthropometric Data (HDR CZ)

This profile sets minimum expectations for the Observation resource to record, search, and fetch anthropometric measurements such as height, weight, BMI, and optional measurements like head, chest, and abdominal circumference.

Observation: Anthropometric Data (HDR CZ)

This profile sets minimum expectations for the Observation resource to record, search, and fetch anthropometric measurements such as height, weight, BMI, and optional measurements like head, chest, and abdominal circumference.

Observation: Anthropometric Data (HDR CZ)

This profile sets minimum expectations for the Observation resource to record, search, and fetch anthropometric measurements such as height, weight, BMI, and optional measurements like head, chest, and abdominal circumference.

Observation: Infectious Contact (HDR CZ)

Infectious Contact profile represents potential patient exposure to an agent (exposure source).

Observation: SDOH (HDR CZ)

Profile for Social Determinants of Health (SDOH) observations that involve assessment (e.g., by a provider, payer, etc.) as opposed to being derived only from screening surveys (as is the case for the SDOHCC Screening Response Observation).

Observation: travel history (HDR CZ)

This profile sets minimum expectations for the Observation resource to record, search, and fetch travel history.

Procedure (HDR CZ)

This profile represents the constraints applied to the Procedure resource by this guide.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

CZ Consent Category

ValueSet for Consent Categories in the Czech HDR project.

CZ Provision Code

ValueSet for provision codes in the Czech HDR project, using ICD-10 and Orphacode.

Exposure of transmissible agents

HDR exposure agent value set. This value set includes codes from SNOMED Clinical Terms®: all descendants of 40733004 "Infectious disease (disorder)" and ICD-10 all descendants of chapter I: "Certain infectious and parasitic diseases"

eHDSI Condition Present On Admission

The Value Set is used to assert if a condition is Present on Admission

eHDSI Treatment Class

The Value set is used to encode category of treatment of the condition during encounter

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

Temporary HDR Code System

This is a temporary code system defined to collect concepts expected required by this project, but for which international coded concepts have not been identified yet.

Terminology: Concept Maps

These define transformations to convert between codes by systems conforming with this implementation guide.

CZ Advance Directives Model to this guide Map

eHN HDR Advance Directives Model to this guide mapping

CZ Alerts Model to this guide Map

eHN HDR Alerts Model to this guide mapping

CZ Attachment Model to this guide Map

CZ HDR Attachment Model to this guide mapping

CZ HDR Model to this guide Map

CZ Hospital Discharge Report Model to this guide mapping

CZ Header Model to this guide Map

CZ HDR Header Model to this guide mapping

CZ Patient History to this guide Map

CZ HDR Patient History Model to this guide Map

eHN Encounter Model to this guide Map

eHN HDR Encounter Model to this guide mapping

eHN Functional Status Model to this guide Map

eHN HDR Functional Status Model to this guide Map

eHN Hospital Stay Model to this guide Map

eHN HDR Hospital Stay Model to this guide Map

eHN Medication Summary Model to this guide Map

eHN HDR Medication Summary Model to this guide Map

eHN Objective Findings Model to this guide Map

eHN HDR Objective Findings Model to this guide Map

eHN Plan of Care Model to this guide Map

eHN HDR Plan of Care Model to this guide Map

eHN Subject Model to this guide Map

eHN HDR Subject Model to this guide mapping

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

AdvanceDirectives DNR

Czech hdr - example od advance directive

Allergy Information Unknown

No information is available regarding the patient’s allergy status.

AllergyIntolerance - No Known Allergies

Patient has no known allergies.

AllergyIntolerance - Penicillin

Patient experiences skin rash and lip swelling in response to penicillin.

AllergyIntolerance - Strawberry

Patient experiences itching and tongue swelling in response to strawberries.

AllergyIntolerance - Strawberry

Patient experiences itching and tongue swelling in response to strawberries.

AllergyIntolerance - cow's milk protein

Patient experiences rash and itching after ingestion of cow's milk protein due to intolerance.

Ambulance interního lékařství, MUDr. Jiří Zdvořilý

Example of ambulatory physician

CRP - Novák Petr

Czech HDR - example of CRP observation for Novák Petr

CZ-CarePlan-HDR Example

Czech HDR - example of a care plan

CZ-Condition-HDR Angiodysplasia

Example of a condition Angiodysplasia of colon

CZ-Condition-HDR Atrial Fibrillation

Example of a condition Persistent atrial fibrillation

CZ-Condition-HDR Example

Czech HDR - example of a condition (Heart Failure)

CZ-Condition-HDR Example 2

Czech HDR - example of a condition (Cardiac arrhythmia - Brugada Syndrome)

CZ-Condition-HDR Example 3

Czech HDR - example of a condition (Postoperative Hypothyroidism)

CZ-Condition-HDR Example 3

Czech HDR - example of a condition (Postoperative Hypothyroidism)

CZ-Condition-HDR Example K409

Example of a condition K409 with details on admission

CZ-Condition-HDR Hypercholesterolemia

Example of a condition Pure hypercholesterolaemia

CZ-Condition-HDR Hypothyroidism

Example of a condition Hypothyroidism

CZ-Condition-HDR Iron Deficiency Anemia

Example of a condition Iron deficiency anaemia secondary to blood loss (chronic)

CZ-Condition-HDR Osteoporosis

Example of a condition Postmenopausal osteoporosis

CZ-Condition-HDR Presbycusis

Example of a condition Presbycusis

CZ-Condition-HDR TIA

Example of a condition Transient cerebral ischaemic attack, unspecified

CZ-Condition-HDR Varicose Veins

Example of a condition Varicose veins of lower extremities without ulcer or inflammation

CZ-Encounter-HDR Example

Czech HDR - example of an inpatient encounter

CZ-Encounter-HDR Example of encounter for Novak Petr

Czech HDR - example of encounter for Novak Petr

CZ-Encounter-HDR Example of encounter with emergency priority

Czech HDR - example of encounter with emergency priority

CZ-Encounter-HDR Example of finished hospital encounter

Czech HDR - example of finished hospital encounter

CZ-MedicationStatement-HDR Example of Atorvastatin

Czech HDR - example of Atorvastatin

CZ-MedicationStatement-HDR Example of Bisoprolol

Czech HDR - example of Bisoprolol

CZ-MedicationStatement-HDR Example of Calcium D3

Czech HDR - example of Calcium D3

CZ-MedicationStatement-HDR Example of Euthyrox

Czech HDR - example of Euthyrox

CZ-MedicationStatement-HDR Example of Ibalgin

Czech HDR - example of Ibalgin 400

CZ-MedicationStatement-HDR Example of Iron Supplement

Czech HDR - example of Iron Supplement

CZ-MedicationStatement-HDR Example of Levothyroxine

Czech HDR - example of Levothyroxine sodium

CZ-MedicationStatement-HDR Example of Paracetamol

Czech HDR - example of Paracetamol

CZ-MedicationStatement-HDR Example of Rivaroxaban

Czech HDR - example of Rivaroxaban

CZ-Procedure-HDR Example - Acute appendicitis

Czech HDR - example of a Procedure - Acute appendicitis.

CZ-Procedure-HDR Example - Appendectomy

Czech HDR - example of a Procedure - Appendectomy

CZ-Procedure-HDR Example - Colonoscopy

Czech HDR - example of a Procedure - Colonoscopy

CZ-Procedure-HDR Example - Inguinal hernia

Czech HDR - example of a Procedure - Repair of inguinal hernia

CZ-Procedure-HDR Example - No known procedures

Czech HDR - example of a Procedure - No known procedures.

CZ-Procedure-HDR Example - Pacemaker

Czech HDR - example of a Procedure - Pacemaker

CZ-Procedure-HDR Example - Pacemaker

Czech HDR - example of a Procedure - Pacemaker

CZObservationSdohHdrExample

Example instance for SDOH observation (assessment-based) using CZ_ObservationSdohHdr profile.

Cardiac Arrest Flag

A flag indicating that the patient has a history of cardiac arrest.

CarePlan-Novak-Petr

Czech HDR - example of a care plan

Device-Pacemaker

Heart pacemaker Medtronic W1DR01

Discharge Summary Document - Base64

DocumentReference for discharge summary, base64 encoded HTML

Discharge Summary Document - PDF

DocumentReference with Base64 PDF content directly inserted

DischargeBundle-Novak-Petr

Example Bundle for Hospital Discharge Report for patient Novák Petr

DischargeBundle-Novak-Petr-L1

Example Bundle for Hospital Discharge Report for patient Novák Petr

DischargeBundle-Novak-Petr-Subsections

Example Bundle for Hospital Discharge Report for patient Novák Petr

Dispense – Euthyrox

Euthyrox v tabletách

Dispense – Euthyrox

Výdej léčivého přípravku Euthyrox pacientovi Novákovi

Dispense – Ibalgin 400

Výdej léčivého přípravku Ibalgin 400 mg pacientovi Novákovi

Dispense – Paracetamol

Výdej léčivého přípravku Paracetamol pacientovi Novákovi

Dosažený stupeň vzdělání

Pacient má vysokoškolské vzdělání v oboru informatiky.

Erytrocyty

Příklad pro HDR - Počet erytrocytů v krvi

Example Czech Location

Example instance of a location conforming to the CZ_LocationCore profile.

ExampleAbdominalCircumference

Example instance for abdominal circumference observation using the CZ_ObservationAbdominalCircumferenceHdr profile.

ExampleBMI

Example instance for BMI observation using the CZ_ObservationBMIHdr profile.

ExampleBloodPressure

Example instance for blood pressure observation (systolic and diastolic).

ExampleChestCircumference

Example instance for chest circumference observation using the CZ_ObservationChestCircumferenceHdr profile.

ExampleHeadCircumference

Example instance for head circumference observation using the CZ_ObservationHeadCircumferenceHdr profile.

ExampleHeight

Example instance for height observation using the CZ_ObservationHeightHdr profile.

ExampleSdohAlcohol

Example of Social History Observation - Alcohol Use

ExampleSdohAlcoholSporadic

Example of Social History Observation - Alcohol Use

ExampleSdohSmoking

Example of Social History Observation - Smoking

ExampleSdohSmokingEnded

Example of Social History Observation - Smoking history

ExampleWeight

Example instance for weight observation using the CZ_ObservationWeightHdr profile.

Goal for Hernia Treatment

Czech HDR - example of a goal for hernia treatment

Hematokrit

Příklad pro HDR - Hematokrit v krvi

Hematologická laboratoř Brno

Referenční laboratoř pro klinickou hematologii

Hemoglobin

Příklad pro HDR - Hladina hemoglobinu v krvi

Immunization example of Covid

Immunization of Covid

Immunization recommendation example

Immunization recommendation of vaccination

Infekční kontakt

Pacient byl v kontaktu s osobou nakaženou COVID-19

Koníčky

Pacient aktivně sportuje (jezdí na kole a běhá) a má zájem o fotografování.

Leukocyty

Příklad pro HDR - Počet leukocytů v krvi

Medication – Covid vaccine

Lek Covid vakcína

Medication – Ibalgin 400

Lek Ibalgin 400 v tabletách

Medication – Paracetamol

Lek Paracetamol v tabletách

Mracena2

Patient, contact information including registering practitioner

Observation - Travel History

Travel history observation

Organization-1

An example of the organization of a provider

Organization: Registering healthcare provider example

Example of registering healthcare provider

Organization: Registering healthcare provider example

Example of registering healthcare provider

Očkování Covid

Očkování proti COVID-19 u pacienta Novák Petr

Panel krevního obrazu

Panel obsahující základní hematologické hodnoty

Patient - Mracena

Patient, contact information and practitioner

Patient-Novak-Petr

Example of patient Petr Novak with identification by czech national identifiers (RID, RCIS), registrating healthcare provider and contact information

Pfizer výrobce vakcíny

Organizace Pfizer s.r.o. vyrábějící vakcínu Comirnaty proti COVID-19

Použití kardiostimulátoru

Záznam o implantaci kardiostimulátoru z důvodu bradykardie

Pracovní zapojení

Pacient pracuje na plný úvazek jako programátor.

Practitioner-2

Practitioner id(NRZP)=987654321

Practitioner-Admitter

Participant Admitter HDR

Practitioner-Author

Participant Referrer HDR

Practitioner-Author-detail

practitioner's detail

Practitioner-Referrer

Participant Referrer HDR

Practitioner-Referrer-detail

practitioner's detail

Practitioner-UZV

Participant UZV HDR

PractitionerRole1

General practitioner's office

Propouštěcí zpráva

Example Composition for Hospital Discharge Report for patient Novák Petr

Propouštěcí zpráva

Example Composition for Hospital Discharge Report for patient Novák Petr

Propouštěcí zpráva

Example Composition for Hospital Discharge Report for patient Novák Petr

Sample Czech Location 1

Example instance of a location conforming to the CZ_LocationCore profile.

Sample Czech Location 2

Example instance of a location conforming to the CZ_LocationCore profile.

Sample Czech Location 2

Example instance of a location conforming to the CZ_LocationCore profile.

Sample Czech Location 2

Example instance of a location conforming to the CZ_LocationCore profile.

Sample Czech Location 3

Example instance of a location conforming to the CZ_LocationCore profile.

Sample Czech Location 4

Example instance of a location conforming to the CZ_LocationCore profile.

Signature of image order

Czech national profile on Signature holds an electronic representation of a signature or timestamp and its supporting context in a FHIR accessible form.

Signature of image order

Czech national profile on Signature holds an electronic representation of a signature or timestamp and its supporting context in a FHIR accessible form.

Sociální síť

Pacient má aktivní sociální síť a pravidelně se setkává s přáteli.

Sova

Practitioner

Sovak

Practitioner

Společenské uplatnění

Pacient je aktivní v komunitních aktivitách a dobrovolnictví.

Stav při propuštění

Hodnocení celkového klinického stavu pacienta při propuštění

Střední podvýživa

Střední podvýživa – doporučení nutriční terapie u pacienta.

Trombocyty

Příklad pro HDR - Počet trombocytů v krvi

UZV - Novák Petr

Czech HDR - example of an ultrasound observation for Novák Petr

Vzdělání

Pacient má vysokoškolské vzdělání v oboru informatiky.

Vzorek krve – EDTA

Venous blood specimen