Generated Narrative: StructureDefinition cz-composition-hdr Name Flags Card. Type Description & Constraints <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition" title="Hospital Discharge Report composition. #xD;#xA;A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. #xD;#xA;While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.">Composition 0..* Composition Hospital Discharge Report composition This profile also imposes the profile Composition (HDR) #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:basedOn 0..* (Complex) Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn #xD; value[x] 1..1 Reference(Resource | ServiceRequest) Value of extension #xD; extension:presentedForm 1..* (Complex) Presented form URL: https://hl7.cz/fhir/core/StructureDefinition/presentedForm #xD; value[x] #xD; contentType 0..1 code Mime type of the content, with charset etc. Example pdf: application/pdf #xD; data 0..1 base64Binary B64 in-line data #xD; url 0..1 url URL of the document #xD; extension:compositionVersionR5 0..1 (Complex) An explicitly assigned identifer of a variation of the content in the Composition URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version #xD; value[x] 0..1 string Business version #xD; extension:information-recipient 0..* (Complex) Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient #xD; value[x] 0..1 Reference(Practitioner (CZ core) | Medical Device (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core)) Value of extension #xD; identifier 0..1 Identifier HDR business identifier #xD; status 1..1 code HDR status #xD; type 1..1 CodeableConceptIPS(2.0.0) Kind of composition ("Hospital Discharge Report") Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 34105-7 #xD; display 1..1 string Representation defined by the system Fixed Value: Hospital Discharge summary #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.subject" title="Who or what the composition is about. #xD;#xA;In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).#xD;#xA;For the hdr the subject is always the patient.">subject 1..1 Reference(Patient (CZ core)) Who and/or what the composition is about #xD; encounter 1..1 Reference(Encounter (HDR CZ)) Context of the Composition #xD; date 1..1 dateTime HDR date #xD; author 1..* Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Medical Device (CZ) | Organization (CZ core)) Who and/or what authored the Hospital Discharge Report #xD; title 1..1 string Hospital Discharge Report #xD; attester #xD; mode 1..1 code The type of attestation #xD; time 0..1 dateTime When the composition was attested. #xD; party 0..1 Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Organization (CZ core)) Who attested the composition. #xD; Slices for section 1..* BackboneElement Sections composing the Hospital Discharge Report Slice: Unordered, Open by value:code #xD; section:All Slices Content/Rules for all slices #xD; author 0..* Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core)) Who and/or what authored the section #xD; section:sectionAdmissionEvaluation 0..1 BackboneElement Composition is broken into sections #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 67851-6 #xD; Slices for section 0..* BackboneElement Objective findings Slice: Unordered, Open by value:code #xD; section:All Slices Content/Rules for all slices #xD; title 1..1 string Label for section (e.g. for ToC) #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; section 0..0 Nested Section #xD; section:sectionAnthropometry 0..1 BackboneElement Anthropometric observations #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://snomed.info/sct #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 248326004 #xD; entry 1..* Reference(Observation: Anthropometric Data (HDR CZ) - Abdominal Circumference | Observation: Anthropometric Data (HDR CZ) - Height | Observation: Anthropometric Data (HDR CZ) | Observation: Anthropometric Data (HDR CZ) - BMI | Observation: Anthropometric Data (HDR CZ) - Head Circumference | Observation: Anthropometric Data (HDR CZ) - Chest Circumference | Observation) Entry used to represent anthropometric measurements #xD; section 0..0 BackboneElement Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionAdmissionEvaluation.section:sectionVitalSigns" title="Slice sectionVitalSigns: The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included">section:sectionVitalSigns 0..1 BackboneElement Vital signs #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8716-3 #xD; entry 1..* Reference(Observation) Entry used to represent vital sign measurements #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionPhysicalExamination 0..1 BackboneElement Nested Section #xD; title 1..1 string Label for section (e.g. for ToC) Required Pattern: Somatické vyšetření­ #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://snomed.info/sct #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 425044008 #xD; display 1..1 string Representation defined by the system Fixed Value: Physical exam section (record artifact) #xD; entry 0..* Reference(ClinicalImpression | Observation | DocumentReference | QuestionnaireResponse) Optional entry used to represent physical examination findings #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionAdmissionEvaluation.section:sectionFunctionalStatus" title="Slice sectionFunctionalStatus: The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.#xD;#xA;Profiles to express disabilities and functional assessments will be specified by future versions of this guide.">section:sectionFunctionalStatus 0..1 BackboneElement Functional status #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 47420-5 #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionAdmissionEvaluation.section:sectionFunctionalStatus.entry" title="It describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.#xD;#xA;Profiles to express disabilities and functional assessments will be specified by future versions of this guide.">entry 0..* Reference(Condition (HDR CZ) | ClinicalImpression | Observation | DocumentReference | QuestionnaireResponse) Optional entry used to represent disabilities and functional assessments #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionPhysicalFindings 0..1 BackboneElement Physical findings #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29545-1 #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionPhysicalExamination 0..1 BackboneElement Physical examination #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 55286-9 #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionVitalSigns" title="Slice sectionVitalSigns: The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included">section:sectionVitalSigns 0..1 BackboneElement Vital signs #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8716-3 #xD; entry 1..* Reference(DocumentReference | Vital Signs Profile) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionFunctionalStatus" title="Slice sectionFunctionalStatus: The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.#xD;#xA;Profiles to express disabilities and functional assessments will be specified by future versions of this guide.">section:sectionFunctionalStatus 0..1 BackboneElement Functional status #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 47420-5 #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionFunctionalStatus.entry" title="It describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.#xD;#xA;Profiles to express disabilities and functional assessments will be specified by future versions of this guide.">entry 0..* Reference(Condition (HDR CZ) | ClinicalImpression | Observation | DocumentReference | QuestionnaireResponse) Optional entry used to represent disabilities and functional assessments #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionAllergies" title="Slice sectionAllergies: This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy.#xD;#xA;At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.#xD;#xA;If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.">section:sectionAllergies 0..1 BackboneElement Allergies and Intolerances Section #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 48765-2 #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionAllergies.entry" title="It lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy.#xD;#xA;At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.#xD;#xA; This entry shall be used to document that no information about allergies is available, or that no allergies are known .">Slices for entry 1..* Reference(Allergy Intolerance (HDR CZ) | DocumentReference | AllergyIntolerance) Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by type:resolve() #xD; entry:allergyIntolerance 0..* Reference(Allergy Intolerance (HDR CZ)) Allergy entry #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionAlert" title="Slice sectionAlert: // SHORT#xA; A warning, other than included in allergies.#xA; The warning can be entered in code there are codes for frequently used alerts but seeing the dynamic nature of the warnings, these alerts will often be entered as free text.#xA; Any clinical information that is imperative to know so that the life or health of the patient does not come under threat.#xA; Example 1: the patient has a rare disease that requires special treatment#xA; Example 2: Airway Alert / Difficult Intubation#xA; Example 3: Diagnoses such as malignant hyperthermia, porphyria, and bleeding disorders; special treatments like anticoagulants or immunosuppressants; implanted devices.#xA; Example 4: transplanted organs illustrate other information that has to be taken into account in a healthcare contact.#xA; Example 5: participation in a clinical trial that has to be taken into account in a healthcare contact.">section:sectionAlert 0..1 BackboneElement Alert Section #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 104605-1 #xD; Slices for entry 0..* Reference(Resource) Alerts Slice: Unordered, Open by type:resolve() #xD; entry:flag 0..* Reference(Flag) Flags #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionHospitalCourse 1..1 BackboneElement Significant information about course of hospital stay #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8648-8 #xD; Slices for section 0..* BackboneElement Nested Section Slice: Unordered, Open by value:code #xD; section:All Slices Content/Rules for all slices #xD; section 0..0 Nested Section #xD; section:sectionDelivery 0..1 BackboneElement Delivery / Porod #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 57074-7 #xD; Slices for entry 0..* Reference(Procedure (HDR CZ) | Procedure: Method of Delivery (CZ) | Procedure: Maternal - Induction of labor (CZ) | Observation | Condition (HDR CZ) | Patient (CZ core)) Delivery-related entries / Polozky vztahujici se k porodu Slice: Unordered, Open by type:resolve() #xD; entry:deliveryProcedure 0..* Reference(Procedure: Method of Delivery (CZ)) Delivery procedure / Vykon porodu #xD; entry:inductionProcedure 0..* Reference(Procedure: Maternal - Induction of labor (CZ)) Labour induction procedure / Indukce porodu #xD; entry:birthInjury 0..* Reference(Condition (HDR CZ)) Birth injury condition / Porodni poraneni #xD; entry:fetalPresentation 0..* Reference(Observation: Fetal Presentation During Delivery (CZ)) Fetal presentation observation / Poloha plodu #xD; entry:birthWeight 0..* Reference(Observation: Birth Weight (CZ)) Birth weight observation / Porodni hmotnost #xD; entry:birthLength 0..* Reference(Observation: Birth Length (CZ)) Birth length observation / Porodni delka #xD; entry:apgarScore 0..* Reference(Observation: APGAR Score (CZ)) APGAR score observation / APGAR skore #xD; entry:deliveryObservation 0..* Reference(Observation) Other delivery observations / Ostatni pozorovani k porodu #xD; entry:newborn 0..* Reference(Patient (CZ core)) Newborn patient / Novorozenec #xD; section 0..0 BackboneElement Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionDiagnosticSummary" title="Slice sectionDiagnosticSummary: All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.">section:sectionDiagnosticSummary 0..1 BackboneElement Problem specification in narrative form #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11535-2 #xD; entry 0..* Reference(Condition (HDR CZ)) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionSignificantProcedures" title="Slice sectionSignificantProcedures: Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other "instrumental"interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others.#xD;#xA;This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.">section:sectionSignificantProcedures 0..1 BackboneElement Significant procedures #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10185-7 #xD; entry 1..* Reference(Procedure (HDR CZ)) A reference to data that supports this section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionMedicalDevices" title="Slice sectionMedicalDevices: Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system.">section:sectionMedicalDevices 0..1 BackboneElement Medical devices and implants #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 57080-4 #xD; entry 0..* Reference(DeviceUseStatement (HDR) | Procedure (HDR CZ)) A reference to data that supports this section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPharmacotherapy" title="Slice sectionPharmacotherapy: Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.#xA;Medicinal products, the administration of which was started during hospitalisation but is also recommended after discharge, will be listed in the summary table in the recommendation section.">section:sectionPharmacotherapy 0..1 BackboneElement Pharmacotherapy #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 87232-5 #xD; entry 0..* Reference(MedicationDispense (HDR) | Medication Statement (CZ) | MedicationRequest (HDR CZ) | Medication (CZ)) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionSignificantResults" title="Slice sectionSignificantResults: Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.">section:sectionSignificantResults 0..1 BackboneElement Significant Observation Results #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 30954-2 #xD; Slices for entry 0..* Reference(Observation | DiagnosticReport | DocumentReference) significant results Slice: Unordered, Open by type:resolve() #xD; entry:labResult 0..* Reference(Observation Laboratory (CZ)) Laboratory Result #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionSynthesis" title="Slice sectionSynthesis: This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.">section:sectionSynthesis 0..1 BackboneElement Synthesis #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 67781-5 #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionDischargeDetails 0..1 BackboneElement Discharge details #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8650-4 #xD; Slices for section 0..* BackboneElement Objective findings Slice: Unordered, Open by value:code #xD; section:All Slices Content/Rules for all slices #xD; title 1..1 string Label for section (e.g. for ToC) #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; section 0..0 Nested Section #xD; section:sectionAnthropometry 0..1 BackboneElement Anthropometric observations #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://snomed.info/sct #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 248326004 #xD; entry 1..* Reference(Observation: Anthropometric Data (HDR CZ) - Abdominal Circumference | Observation: Anthropometric Data (HDR CZ) - Height | Observation: Anthropometric Data (HDR CZ) | Observation: Anthropometric Data (HDR CZ) - BMI | Observation: Anthropometric Data (HDR CZ) - Head Circumference | Observation: Anthropometric Data (HDR CZ) - Chest Circumference | Observation) Entry used to represent anthropometric measurements #xD; section 0..0 BackboneElement Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionDischargeDetails.section:sectionVitalSigns" title="Slice sectionVitalSigns: The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included">section:sectionVitalSigns 0..1 BackboneElement Vital signs #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8716-3 #xD; entry 1..* Reference(Observation) Entry used to represent vital sign measurements #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionPhysicalExamination 0..1 BackboneElement Nested Section #xD; title 1..1 string Label for section (e.g. for ToC) Required Pattern: Somatické vyšetření­ #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://snomed.info/sct #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 425044008 #xD; display 1..1 string Representation defined by the system Fixed Value: Physical exam section (record artifact) #xD; entry 0..* Reference(ClinicalImpression | Observation | DocumentReference | QuestionnaireResponse) Optional entry used to represent physical examination findings #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionDischargeDetails.section:sectionFunctionalStatus" title="Slice sectionFunctionalStatus: The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.#xD;#xA;Profiles to express disabilities and functional assessments will be specified by future versions of this guide.">section:sectionFunctionalStatus 0..1 BackboneElement Functional status #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 47420-5 #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionDischargeDetails.section:sectionFunctionalStatus.entry" title="It describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.#xD;#xA;Profiles to express disabilities and functional assessments will be specified by future versions of this guide.">entry 0..* Reference(Condition (HDR CZ) | ClinicalImpression | Observation | DocumentReference | QuestionnaireResponse) Optional entry used to represent disabilities and functional assessments #xD; section 0..0 BackboneElement Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPatientHx" title="Slice sectionPatientHx: This Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.">section:sectionPatientHx 0..1 BackboneElement Patient History Section #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 35090-0 #xD; Slices for section 0..* BackboneElement Patient History Slice: Unordered, Open by value:code #xD; section:All Slices Content/Rules for all slices #xD; title 1..1 string Label for section (e.g. for ToC) #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; section 0..0 Nested Section #xD; section:sectionInfectiousContacts 0..1 BackboneElement Infectious contacts #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://hl7.cz/fhir/hdr/CodeSystem/temporarySystem-hdr-cz #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: infection-contact #xD; entry 0..* Reference(Observation: Infectious Contact (HDR CZ)) Exposure to an infectious agent. #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionTravelHx 0..1 BackboneElement Travel History Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10182-4 #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionSocialHistory 0..1 BackboneElement Social History Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29762-2 #xD; entry 0..* Reference(Observation: SDOH (HDR CZ) | DocumentReference) A reference to data that supports this section #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionPastIllnessHx 0..1 BackboneElement HDR History of Past Illness Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Fixed Value: As shown (History of Past illness note) #xD; coding 1..1 Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11348-0 #xD; entry 1..* Reference(Condition (IPS)(2.0.0)) Conditions the patient suffered in the past. #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPatientHx.section:sectionProceduresHx" title="Slice sectionProceduresHx: The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document.#xD;#xA;Procedures may refer for example to:#xD;#xA;1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)#xD;#xA;2. Therapeutic procedure: e.g. dialysis;#xD;#xA;3. Surgical procedure: e.g. appendectomy">section:sectionProceduresHx 0..1 BackboneElement History of Procedures Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 47519-4 #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPatientHx.section:sectionProceduresHx.entry" title="It lists the patient past procedures that are pertinent to the scope of this document.#xD;#xA;Procedures may refer for example to:#xD;#xA;1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)#xD;#xA;2. Therapeutic procedure: e.g. dialysis;#xD;#xA;3. Surgical procedure: e.g. appendectomy. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known.">Slices for entry 1..* Reference(Procedure | DocumentReference) Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by type:resolve() #xD; entry:procedure 0..* Reference(Procedure (HDR CZ)) Past Procedure entry #xD; section 0..0 BackboneElement Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPatientHx.section:sectionImmunizations" title="Slice sectionImmunizations: The Immunizations Section defines a patient's current immunization status and pertinent immunization history.#xD;#xA;The primary use case for the Immunization Section is to enable communication of a patient's immunization status.#xD;#xA;The section includes current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.">section:sectionImmunizations 0..1 BackboneElement Immunizations Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11369-6 #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPatientHx.section:sectionImmunizations.entry" title="It defines the patient's current immunization status and pertinent immunization history.#xD;#xA;The primary use case for the Immunization Section is to enable communication of a patient's immunization status.#xD;#xA; It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known.">Slices for entry 1..* Reference(Immunization (HDR CZ) | ImmunizationRecommendation (HDR) | DocumentReference) Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() #xD; entry:immunization 0..* Reference(Immunization (HDR CZ)) Immunization entry #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionFamilyHistory 0..1 BackboneElement Family History Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10157-6 #xD; entry 0..* Reference(FamilyMemberHistory (HDR CZ)) Family History #xD; section 0..0 BackboneElement Nested Section #xD; <a href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPatientHx.section:sectionPregnancyHx" title="Slice sectionPregnancyHx: This section SHALL summarize pregnancy history relevant for continuity of care in the hospital discharge report. For obstetric discharge this section SHALL support documenting key maternal pregnancy parameters used for post-discharge follow-up. / Tato sekce SHALL shrnovat tehotenskou anamnezu relevantni pro kontinuitu pece v propousteci zprave. Pro gynekologickou propousteci zpravu tato sekce SHALL podporovat zaznam klicovych parametru matky pro naslednou peci.">section:sectionPregnancyHx 0..1 BackboneElement HDR Pregnancy History Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10162-6 #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-cz-composition-hdr-definitions.html#Composition.section:sectionPatientHx.section:sectionPregnancyHx.entry" title="This section SHALL contain pregnancy status information. It MAY contain additional summarizing information about outcomes of earlier pregnancies and related obstetric parameters such as gravidity parity gestational age at delivery and multiple pregnancy. / Tato sekce SHALL obsahovat informaci o stavu tehotenstvi. MAY obsahovat i doplnujici souhrnne informace o vysledcich drivejsich tehotenstvi a souvisejicich porodnickych parametrech jako gravidita parita gestacni stari pri porodu a vicecetne tehotenstvi.">Slices for entry 0..* Reference(Resource) Current pregnancy status and where relevant information about the outcome of earlier pregnancies / Aktualni stav tehotenstvi a podle relevance informace o vysledku drivejsich tehotenstvi Slice: Unordered, Open by type:resolve() #xD; entry:pregnancyStatus 0..* Reference(Observation Pregnancy - Status (IPS)(2.0.0)) Current pregnancy status / Aktualni stav tehotenstvi #xD; entry:pregnancyOutcome 0..* Reference(Observation Pregnancy - Outcome (IPS)(2.0.0)) Information about the outcome of earlier pregnancies / Informace o vysledku drivejsich tehotenstvi #xD; entry:gestationalAge 0..* Reference(Observation) Gestational age at delivery / Gestacni stari pri porodu #xD; entry:gravidity 0..* Reference(Observation: Maternal - Gravidity (CZ)) Gravidity / Gravidita #xD; entry:parity 0..* Reference(Observation: Maternal - Parity (CZ)) Parity / Parita #xD; entry:multiplePregnancy 0..* Reference(Observation: Maternal - Multiple pregnancy and fetus count (CZ)) Multiple pregnancy and fetus count / Vicecetne tehotenstvi a pocet plodu #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionSubstanceUse 0..1 BackboneElement Use of Substances Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://hl7.cz/fhir/hdr/CodeSystem/temporarySystem-hdr-cz #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: substance-use #xD; entry 0..* Reference(Observation) A reference to data that supports this section #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionAlcoholUse 0..1 BackboneElement Alcohol use Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11331-6 #xD; entry 0..* Reference(Observation) A reference to data that supports this section #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionTobaccoUse 0..1 BackboneElement Tobacco use Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11367-0 #xD; entry 0..* Reference(Observation) A reference to data that supports this section #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionDrugUse 0..1 BackboneElement Drug use Section #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11343-1 #xD; entry 0..* Reference(Observation) A reference to data that supports this section #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionHistoryMedicalDevices 0..1 BackboneElement History of Medical devices and implants #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 46264-8 #xD; entry 0..* Reference(DeviceUseStatement (HDR) | Procedure (HDR CZ)) A reference to data that supports this section #xD; section 0..0 BackboneElement Nested Section #xD; section:sectionProblemList 0..1 BackboneElement Problem List Section #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11450-4 #xD; entry 0..* Reference(Condition (HDR)) Conditions the patient suffered in the past. #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionCareTeam 0..1 BackboneElement Care Team Section #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 85847-2 #xD; Slices for entry 0..* Reference(Resource) Care Teams Slice: Unordered, Open by type:resolve() #xD; entry:cteam 0..* Reference(CareTeam) Care Team #xD; section 0..0 Nested Section #xD; section:sectionPlanOfCare 0..1 BackboneElement Plan of Care Section #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 18776-5 #xD; entry 0..* Reference(Care Plan (HDR CZ) | DocumentReference) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionDischargeMedications 0..1 BackboneElement Hospital discharge medications #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 75311-1 #xD; entry 1..* Reference(Medication Statement (CZ) | MedicationRequest (HDR CZ) | Medication (CZ)) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionDischargeInstructions 0..1 BackboneElement Hospital Discharge instructions #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8653-8 #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionAdvanceDirectives 0..1 BackboneElement Advance Directives Section #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 42348-3 #xD; entry 0..* Reference(Consent (Advance Directives) (HDR CZ) | DocumentReference) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionAttachments 0..1 BackboneElement Attachments #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 77599-9 #xD; entry 1..* Reference(DocumentReference | Binary) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; section:sectionPayers 0..1 BackboneElement Health insurance and payment information. #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 48768-6 #xD; entry 0..* Reference(Coverage (CZ)) A reference to data that supports this section #xD; section 0..* BackboneElement Nested Section #xD; section 0..0 Nested Section #xD; Documentation for this format
This profile defines how to represent Composition resource in HL7 FHIR for the scope of this guide.
Hospital Discharge Report composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.
While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
A plan, proposal or order that is fulfilled in whole or in part by this event.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Source of the definition for the extension code - a logical name or a URL.
The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R5/extensibility.html) for a list).
Human readable representation of the entire document. Multiple formats are allowed but they SHALL be semantically equivalent.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R4/extensibility.html) for a list).
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Mime type of the content, with charset etc.
Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.
Processors of the data need to be able to know how to interpret the data.
The mime type of an attachment. Any valid mime type is allowed.
ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
The human language of the content. The value can be any valid value according to BCP 47.
Users need to be able to choose between the languages in a set of attachments.
The actual data of the attachment - a sequence of bytes, base64 encoded.
The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.
The data needs to able to be transmitted inline.
A location where the data can be accessed.
If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.
The data needs to be transmitted by reference.
RP.1+RP.2 - if they refer to a URL (see v2.6)
Number of bytes of content (if url provided)
The number of bytes of data that make up this attachment (before base64 encoding, if that is done).
The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.
Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.
The calculated hash of the data using SHA-1. Represented using base64.
The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](http://hl7.org/fhir/R4/provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.
Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).
A label or set of text to display in place of the data.
Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.
The date that the attachment was first created.
This is often tracked as an integrity issue for use of the attachment.
An explicitly assigned identifer of a variation of the content in the Composition
This cross-version extension represents Composition.version from http://hl7.org/fhir/StructureDefinition/Composition|5.0.0 for use in FHIR R4.
This extension applies to the Composition resource and is used to represent an intended recipient of the composition.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.
Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.
If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.
Need to be able to mark interim, amended, or withdrawn compositions or documents.
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
The workflow/clinical status of the composition.
interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
Kind of composition ("Hospital Discharge Report")
Specifies that this composition refer to a Hospital Discharge Report
For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.
Key metadata element describing the composition, used in searching/filtering.
A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.
This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).
Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.
High-level kind of a clinical document at a macro level.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
Who and/or what the composition is about
Who or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the hdr the subject is always the patient.
For clinical documents, this is usually the patient.
Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.
Describes the clinical encounter or type of care this documentation is associated with.
Provides context for the composition and supports searching.
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
The composition editing time, when the composition was last logically changed by the author.
The Last Modified Date on the composition may be after the date of the document was attested without being changed.
dateTime is used for tracking, organizing versions and searching. Note that this is the time of *authoring*. When packaged in a document, [Bundle.timestamp](http://hl7.org/fhir/R4/bundle-definitions.html#Bundle.timestamp) is the date of packaging.
DocumentReference.content.attachment.date, DocumentReference.created
Who and/or what authored the Hospital Discharge Report
Identifies who is responsible for the information in the Hospital Discharge Report, not necessarily who typed it in.
Identifies who is responsible for the content.
Official human-readable label for the composition. For this document should be "Hospital Discharge Report" or any equivalent translation
For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
DocumentReference.description, DocumentReference.content.attachment.title
The code specifying the level of confidentiality of the Composition.
The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.
Codes specifying the level of confidentiality of the composition.
A participant who has attested to the accuracy of the composition/document.
Identifies responsibility for the accuracy of the composition content.
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
The type of attestation the authenticator offers.
Indicates the level of authority of the attestation.
The way in which a person authenticated a composition.
implied by .authenticator/.legalAuthenticator
When the composition was attested by the party.
Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
./time[type="TS" and isNormalDatatype()]
Who attested the composition in the specified way.
Identifies who has taken on the responsibility for accuracy of the composition content.
./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
Organization which maintains the composition
Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.
This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
Identifies where to go to find the current version, where to report issues, etc.
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
Relationships to other compositions/documents
Relationships that this composition has with other compositions or documents that already exist.
A document is a version specific composition.
The type of relationship that this composition has with anther composition or document.
If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
The type of relationship between documents.
The target composition/document of this relationship.
.target[classCode="DOC", moodCode="EVN"].id
The clinical service(s) being documented
The clinical service, such as a colonoscopy or an appendectomy, being documented.
The event needs to be consistent with the type element, though can provide further information if desired.
Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.
Code(s) that apply to the event being documented
This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.
An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.
This list of codes represents the main clinical acts being documented.
The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.
The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.
Sections composing the Hospital Discharge Report
The root of the sections that make up the Hospital Discharge Report composition.
A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
exists(f:text) or exists(f:entry) or exists(f:section)
A section can only have an emptyReason if it is empty
not(exists(f:emptyReason) and exists(f:entry))
./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
A code identifying the kind of content contained within the section. This must be consistent with the section title.
The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Provides computable standardized labels to topics within the document.
Classification of a section of a composition/document.
Identifies who is responsible for the information in this section, not necessarily who typed it in.
Who/what the section is about, when it is not about the subject of composition
The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
.subject? (CDA did not differentiate between subject and focus)
Text summary of the section, for human interpretation
A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Document profiles may define what content should be represented in the narrative to ensure clinical safety.
How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
The processing mode that applies to this section.
Specifies the order applied to the items in the section entries.
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
What order applies to the items in the entry.
.outboundRelationship[typeCode=COMP].sequenceNumber > 1
A reference to data that supports this section
A reference to the actual resource from which the narrative in the section is derived.
If there are no entries in the list, an emptyReason SHOULD be provided.
.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Allows capturing things like "none exist" or "not asked" which can be important for most lists.
A nested sub-section within this section.
Nested sections are primarily used to help human readers navigate to particular portions of the document.
The root of the sections that make up the composition.
Admission evaluation should be reported only exceptionally, if it is relevant to ensure continuity of care.
Findings made by healthcare practitioner
Entry used to represent anthropometric measurements
It describes findings from anthropometric measurements of the patient, such as height, weight, BMI, head circumference, chest circumference, abdominal circumference
The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included
Entry used to represent vital sign measurements
It describes findings from vital sign measurements of the patient. Profiles to express structured vital sign measurements will be specified by future versions of this guide.
Optional entry used to represent physical examination findings
It describes findings from physical examination of the patient. Profiles to express structured physical examination findings will be specified by future versions of this guide.
The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.
Optional entry used to represent disabilities and functional assessments
It describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.
Physical examination is the process of evaluating objective anatomical findings.
This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
Relevant allergies or intolerances (conditions) for that patient.
It lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. This entry shall be used to document that no information about allergies is available, or that no allergies are known .
// SHORT A warning, other than included in allergies. The warning can be entered in code there are codes for frequently used alerts but seeing the dynamic nature of the warnings, these alerts will often be entered as free text. Any clinical information that is imperative to know so that the life or health of the patient does not come under threat. Example 1: the patient has a rare disease that requires special treatment Example 2: Airway Alert / Difficult Intubation Example 3: Diagnoses such as malignant hyperthermia, porphyria, and bleeding disorders; special treatments like anticoagulants or immunosuppressants; implanted devices. Example 4: transplanted organs illustrate other information that has to be taken into account in a healthcare contact. Example 5: participation in a clinical trial that has to be taken into account in a healthcare contact.
Significant information about course of hospital stay
This section includes basic information about hospital staty (encounter), diagnostic summary in narrative form, pharmacotherapy, major procedures, medical devices, significant findings during hospital stay and clinical synthesis.
Information about labour, delivery and newborn outcome / Informace o prubehu porodu, porodu a stavu novorozence.
Delivery-related entries / Polozky vztahujici se k porodu
Structured entries for delivery method, induction, birth injury, newborn and related observations / Strukturovane polozky pro zpusob porodu, indukci, porodni poraneni, novorozence a souvisejici pozorovani.
Labour induction procedure / Indukce porodu
Birth injury condition / Porodni poraneni
Fetal presentation observation / Poloha plodu
Birth weight observation / Porodni hmotnost
Birth length observation / Porodni delka
Other delivery observations / Ostatni pozorovani k porodu
All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other "instrumental"interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.
Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system.
Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section. Medicinal products, the administration of which was started during hospitalisation but is also recommended after discharge, will be listed in the summary table in the recommendation section.
Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.
The hospital discharge status or disposition of the patient having a hospitalization.
This Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.
History reported by the patient or caregiver
Information about a suspected infectious agent or agents the person was exposed to.
This Section describes the travel history relevant for the Patient Summary, e.g.recent travel in a region of high prevalence of a specific infectious disease like Malaria
The social history section contains a description of the person Health related lifestyle factors or lifestyle observations. E.g. smoke habits; alcohol consumption; diets, risky habits.
The History of Past Illness section contains a narrative description and coded entries of the conditions the patient suffered in the past
Conditions the patient suffered in the past.
It contains a description of the conditions the patient suffered in the past.
The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to: 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy
Patient past procedures pertinent to the scope of this document.
It lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to: 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known.
The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
Patient's immunization status and pertinent history.
It defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known.
This section contains data defining the patient’s genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient’s healthcare risk profile.
This section SHALL summarize pregnancy history relevant for continuity of care in the hospital discharge report. For obstetric discharge this section SHALL support documenting key maternal pregnancy parameters used for post-discharge follow-up. / Tato sekce SHALL shrnovat tehotenskou anamnezu relevantni pro kontinuitu pece v propousteci zprave. Pro gynekologickou propousteci zpravu tato sekce SHALL podporovat zaznam klicovych parametru matky pro naslednou peci.
Current pregnancy status and where relevant information about the outcome of earlier pregnancies / Aktualni stav tehotenstvi a podle relevance informace o vysledku drivejsich tehotenstvi
This section SHALL contain pregnancy status information. It MAY contain additional summarizing information about outcomes of earlier pregnancies and related obstetric parameters such as gravidity parity gestational age at delivery and multiple pregnancy. / Tato sekce SHALL obsahovat informaci o stavu tehotenstvi. MAY obsahovat i doplnujici souhrnne informace o vysledcich drivejsich tehotenstvi a souvisejicich porodnickych parametrech jako gravidita parita gestacni stari pri porodu a vicecetne tehotenstvi.
Current pregnancy status / Aktualni stav tehotenstvi
Information about the outcome of earlier pregnancies / Informace o vysledku drivejsich tehotenstvi
Gestational age at delivery / Gestacni stari pri porodu
Gestational age at delivery format weeks and days for example 39-6 / Format gestacniho stari tydny a dny napr 39-6
Multiple pregnancy and fetus count / Vicecetne tehotenstvi a pocet plodu
The Use of Substances Section contains a description of the use abuse of substances E.g. tobacco; alcohol; drugs
The Alcohol use Section contains a description of the use abuse of alcohol
The Tobacco use Section contains a description of the use abuse of tobacco
The Drug use Section contains a description of the use abuse of drugs
The medical devices section contains narrative text and coded entries describing the patient history of medical device use.
The IPS derived problem section lists and describes clinical problems or conditions currently being monitored for the patient.
// SHORT The Care Team Section is used to share historical and current Care Team information.
The plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
Hospital discharge medications defines the medications that the patient is intended to take, or stop, after discharge
The advance directives section contains a narrative description of patient's advance directive.
This section lists documents and attachments associated to this report
Health insurance and payment information.
This section includes heath insurance and payment information.