# Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková) - HL7 Czech Hospital Discharge Report Implementation Guide v0.1.0

* [**Table of Contents**](toc.md)
* [**Artifacts**](artifacts.md)
* **Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)**

## Example Composition: Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)

Profile: [Composition (HDR CZ)](StructureDefinition-cz-composition-hdr.md)

**status**: Final

**type**: Hospital Discharge summary

**encounter**: [Encounter: status = finished; class = inpatient encounter (ActCode#IMP); priority = urgent; period = 2025-05-17 06:20:00+0200 --> 2025-05-20 11:30:00+0200](Encounter-7d7a6f19-5dfb-45ee-8bcf-0f63d9fe49f2.md)

**date**: 2025-05-20 11:30:00+0200

**author**: [Practitioner Eva Svobodova ](Practitioner-1ec5e355-648f-42b9-a316-3f056fbd04b5.md)

**title**: Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)



## Resource Content

```json
{
  "resourceType" : "Composition",
  "id" : "5e848ec9-b5bf-4c90-9d7e-6b0894208bfe",
  "meta" : {
    "profile" : ["https://hl7.cz/fhir/hdr/StructureDefinition/cz-composition-hdr"]
  },
  "extension" : [{
    "url" : "https://hl7.cz/fhir/core/StructureDefinition/presentedForm"
  }],
  "status" : "final",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "34105-7",
      "display" : "Hospital Discharge summary"
    }]
  },
  "subject" : {
    "reference" : "Patient/6c4f4d2c-5f24-4a91-a75e-1b0e2a1f7731"
  },
  "encounter" : {
    "reference" : "Encounter/7d7a6f19-5dfb-45ee-8bcf-0f63d9fe49f2"
  },
  "date" : "2025-05-20T11:30:00+02:00",
  "author" : [{
    "reference" : "Practitioner/1ec5e355-648f-42b9-a316-3f056fbd04b5"
  }],
  "title" : "Gynekologická propouštěcí zpráva - spontánní vaginální porod (Jana Nováková)",
  "section" : [{
    "title" : "Průběh hospitalizace",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8648-8",
        "display" : "Hospital course note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Hospitalizace pro spontánní porod v termínu, bez závažných komplikací.</p></div>"
    },
    "section" : [{
      "title" : "Porod",
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "57074-7",
          "display" : "Delivery note"
        }]
      },
      "text" : {
        "status" : "additional",
        "div" : "<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>"
      },
      "entry" : [{
        "reference" : "Procedure/GynNaturalBirthJana-DeliveryMethod"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-FetalPresentation"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-BirthWeight"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-BirthLength"
      },
      {
        "reference" : "Condition/GynNaturalBirthJana-BirthInjury"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-BirthOutcome"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-Apgar1"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-Apgar5"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-Apgar10"
      },
      {
        "reference" : "Patient/b7e6c8a1-4a8d-4d9f-8f69-df4f210cb2d7"
      }]
    }]
  },
  {
    "title" : "Anamnéza",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "35090-0",
        "display" : "Patient history note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Gynekologická anamnéza: prvorodička, gravidita/parita 1/1, gestační stáří při porodu 39+6.</p></div>"
    },
    "section" : [{
      "title" : "Těhotenská anamnéza",
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "10162-6",
          "display" : "History of pregnancies"
        }]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Gestační stáří 39+6, prvorodička, gravidita 1, parita 1, singleton gravidita.</p></div>"
      },
      "entry" : [{
        "reference" : "Observation/GynNaturalBirthJana-GestationalAgeAtDelivery"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-Gravidity"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-Parity"
      },
      {
        "reference" : "Observation/GynNaturalBirthJana-MultiplePregnancy"
      }]
    }]
  },
  {
    "title" : "Health insurance and payment information",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "48768-6",
        "display" : "Payment sources Document"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Payer: 111 (VZP), insurance number: 9355181234.</p></div>"
    },
    "entry" : [{
      "reference" : "Coverage/8f9c2f14-1f69-4f2b-b4a8-8b7ca4db9f31"
    }]
  },
  {
    "title" : "Alergie, intolerance a varování",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "48765-2",
        "display" : "Allergies and adverse reactions Document"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Alergie na penicilin, reakce: kožní vyrážka a otok rtů.</p></div>"
    },
    "entry" : [{
      "reference" : "AllergyIntolerance/Allergy-Penicillin-Novakova-Jana"
    }]
  },
  {
    "title" : "Pharmacotherapy",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "87232-5",
        "display" : "Medication administration brief"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Porodní analgezie: epidurální podání ropivakainu s malou dávkou fentanylu během porodu.</p></div>"
    },
    "entry" : [{
      "reference" : "Medication/med-ropivacaine-epidural"
    },
    {
      "reference" : "Medication/med-fentanyl-epidural"
    },
    {
      "reference" : "MedicationStatement/medstmt-ropivacaine-epidural-jana"
    },
    {
      "reference" : "MedicationStatement/medstmt-fentanyl-epidural-jana"
    }]
  }]
}

```
