# Scope and content - HL7 Czech Hospital Discharge Report Implementation Guide v0.1.0

* [**Table of Contents**](toc.md)
* **Scope and content**

## Scope and content

### Overview

The European eHealth Network "GUIDELINE on the electronic exchange of health data under Cross-Border Directive 2011/24/EU Hospital Discharge Report" - Release 1.1 is addressed to the Member States of the European Union and applies to support the exchange of Hospital Discharge Report for continuity of care in a cross-border setting.

These guidelines could serve as a guiding principle for the national development and implementation of Hospital Discharge Reports.

### eHN Data Set

The eHN Hospital Discharge Report Guideline in section 4 specifies a HOSPITAL DISCHARGE REPORT DATASET, which records all clinically relevant information pertaining to the patient’s stay in a hospital, which are essential for the continuity of care.

The Hospital Discharge Report (HDR) has two main components:

* The header and
* The body.

The **header** contains essential administrative and identification data about the patient, healthcare providers, and other key participants in the patient's care.

The **body** consists of the core clinical details regarding the patient's stay, treatment, and discharge plan.

#### Header

The Hospital Discharge Report Header component provides documentation for the:

* **Identification of the patient/subject:** This includes critical identification information like the patient's **given name**, **family name**, **date of birth**, and **national healthcare patient ID**. It also covers **nationality**, **gender**, and the patient’s **country of affiliation**.
* **Patient/subject related contact information:** This involves the patient’s **address** and **telecommunication contact details** (e.g., phone numbers and email addresses). It may also include details of a **preferred healthcare professional** (name, identifier, role, organization).
* **Health insurance and payment information:** Key data related to health insurance, including the **insurance code**, **name of the health insurance provider**, and the **patient's health insurance number**.
* **Information recipient:** Refers to the intended recipient of the hospital discharge report. This includes **recipient's name**, **organization**, **address**, and **telecom details**.
* **Author:** Documents the **author of the report**, including their identifier (e.g., license number), name, and organizational information. The author is responsible for signing off on the content of the report.
* **Attester:** The healthcare professional who verifies the content of the report. This includes the **attester’s identifier**, **name**, **organization**, and the **date and time of attestation**.
* **Legal authenticator:** The person taking legal responsibility for the report. Includes the **identifier**, **name**, **organization**, and **date of authentication**.
* **Document metadata:** Contains the document's unique **identifier**, **type**, and metadata such as the **date and time** of creation or modification, ensuring proper tracking of the report.

#### Body

The Hospital Discharge Report Body component includes:

* **Presented form:** The Hospital Discharge Report in its narrative form; that is, in a printable representation.
* **Advance directives:** Legal documents like living wills or DNR orders guiding treatment decisions.
* **Alerts:** Important medical alerts like allergies or other critical patient conditions.
* **Encounter:** Details of the hospital encounter, including admission date, reason, and type (inpatient/outpatient).
* **Admission evaluation:** Key findings and diagnostic results from the admission process.
* **Patient history:** A comprehensive record of the patient’s medical history prior to the hospital stay.
* **Course of hospitalisation:** Progress of the patient during the hospital stay, including treatments and interventions.
* **Discharge details:** Information about the discharge date, destination, and post-discharge care instructions.
* **Care plan and other recommendations after discharge:** Detailed follow-up care plan, including medications and therapy recommendations.

#### eHN Data Set as HL7 FHIR logical models

The HL7 FHIR logical models used to represent the HOSPITAL DISCHARGE REPORT DATASET as defined in section 4 of that eHN guideline are documented in the [HL7 FHIR Models](logical-models.md) page.

