HL7 Czech Hospital Discharge Report Implementation Guide
0.1.0 - ci-build

HL7 Czech Hospital Discharge Report Implementation Guide, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/hdr/ and changes regularly. See the Directory of published versions

## : Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková) - XML Representation

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    <Composition xmlns="http://hl7.org/fhir">
      <id value="5e848ec9-b5bf-4c90-9d7e-6b0894208bfe"/>
      <meta>
        <profile
                 value="https://hl7.cz/fhir/hdr/StructureDefinition/cz-composition-hdr"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Composition 5e848ec9-b5bf-4c90-9d7e-6b0894208bfe</b></p><a name="5e848ec9-b5bf-4c90-9d7e-6b0894208bfe"> </a><a name="hc5e848ec9-b5bf-4c90-9d7e-6b0894208bfe"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-cz-composition-hdr.html">Composition (HDR CZ)</a></p></div><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 34105-7}">Hospital Discharge summary</span></p><p><b>encounter</b>: <a href="Encounter-7d7a6f19-5dfb-45ee-8bcf-0f63d9fe49f2.html">Encounter: status = finished; class = inpatient encounter (ActCode#IMP); priority = urgent; period = 2025-05-17 06:20:00+0200 --&gt; 2025-05-20 11:30:00+0200</a></p><p><b>date</b>: 2025-05-20 11:30:00+0200</p><p><b>author</b>: <a href="Practitioner-1ec5e355-648f-42b9-a316-3f056fbd04b5.html">Practitioner Eva Svobodova </a></p><p><b>title</b>: Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)</p></div>
      </text>
      <extension
                 url="https://hl7.cz/fhir/core/StructureDefinition/presentedForm"/>
      <status value="final"/>
      <type>
        <coding>
          <system value="http://loinc.org"/>
          <code value="34105-7"/>
          <display value="Hospital Discharge summary"/>
        </coding>
      </type>
      <subject>🔗
        <reference value="Patient/6c4f4d2c-5f24-4a91-a75e-1b0e2a1f7731"/>
      </subject>
      <encounter>🔗
        <reference value="Encounter/7d7a6f19-5dfb-45ee-8bcf-0f63d9fe49f2"/>
      </encounter>
      <date value="2025-05-20T11:30:00+02:00"/>
      <author>🔗
        <reference value="Practitioner/1ec5e355-648f-42b9-a316-3f056fbd04b5"/>
      </author>
      <title
             value="Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)"/>
      <section>
        <title value="Průběh hospitalizace"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="8648-8"/>
            <display value="Hospital course note"/>
          </coding>
        </code>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p>Hospitalizace pro spontánní porod v termínu, bez závažných komplikací.</p></div>
        </text>
        <section>
          <title value="Porod"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="57074-7"/>
              <display value="Delivery note"/>
            </coding>
          </code>
          <text>
            <status value="additional"/>
            <div xmlns="http://www.w3.org/1999/xhtml"><p>Porod dne 18.05.2025 v 10:46, spontánní vaginální, bez indukce, analgezie EDA (ropivakain + fentanyl), novorozenec mužského pohlaví, 3210 g, 49 cm, Apgar 10-10-10. Mateřské poranění: epiziotomie mediolaterální.</p></div>
          </text>
          <entry>🔗
            <reference value="Procedure/GynNaturalBirthJana-DeliveryMethod"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-FetalPresentation"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-BirthWeight"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-BirthLength"/>
          </entry>
          <entry>🔗
            <reference value="Condition/GynNaturalBirthJana-BirthInjury"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-BirthOutcome"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-Apgar1"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-Apgar5"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-Apgar10"/>
          </entry>
          <entry>🔗
            <reference value="Patient/b7e6c8a1-4a8d-4d9f-8f69-df4f210cb2d7"/>
          </entry>
        </section>
      </section>
      <section>
        <title value="Anamnéza"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="35090-0"/>
            <display value="Patient history note"/>
          </coding>
        </code>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p>Gynekologická anamnéza: prvorodička, gravidita/parita 1/1, gestační stáří při porodu 39+6.</p></div>
        </text>
        <section>
          <title value="Těhotenská anamnéza"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="10162-6"/>
              <display value="History of pregnancies"/>
            </coding>
          </code>
          <text>
            <status value="additional"/>
            <div xmlns="http://www.w3.org/1999/xhtml"><p>Gestační stáří 39+6, prvorodička, gravidita 1, parita 1, singleton gravidita.</p></div>
          </text>
          <entry>🔗
            <reference
                       value="Observation/GynNaturalBirthJana-GestationalAgeAtDelivery"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-Gravidity"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-Parity"/>
          </entry>
          <entry>🔗
            <reference value="Observation/GynNaturalBirthJana-MultiplePregnancy"/>
          </entry>
        </section>
      </section>
      <section>
        <title value="Health insurance and payment information"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="48768-6"/>
            <display value="Payment sources Document"/>
          </coding>
        </code>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p>Payer: 111 (VZP), insurance number: 9355181234.</p></div>
        </text>
        <entry>🔗
          <reference value="Coverage/8f9c2f14-1f69-4f2b-b4a8-8b7ca4db9f31"/>
        </entry>
      </section>
      <section>
        <title value="Alergie, intolerance a varování"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="48765-2"/>
            <display value="Allergies and adverse reactions Document"/>
          </coding>
        </code>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p>Alergie na penicilin, reakce: kožní vyrážka a otok rtů.</p></div>
        </text>
        <entry>🔗
          <reference value="AllergyIntolerance/Allergy-Penicillin-Novakova-Jana"/>
        </entry>
      </section>
      <section>
        <title value="Pharmacotherapy"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="87232-5"/>
            <display value="Medication administration brief"/>
          </coding>
        </code>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p>Porodní analgezie: epidurální podání ropivakainu s malou dávkou fentanylu během porodu.</p></div>
        </text>
        <entry>🔗
          <reference value="Medication/med-ropivacaine-epidural"/>
        </entry>
        <entry>🔗
          <reference value="Medication/med-fentanyl-epidural"/>
        </entry>
        <entry>🔗
          <reference
                     value="MedicationStatement/medstmt-ropivacaine-epidural-jana"/>
        </entry>
        <entry>🔗
          <reference value="MedicationStatement/medstmt-fentanyl-epidural-jana"/>
        </entry>
      </section>
    </Composition>