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) - JSON Representation

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    {
      "resourceType" : "Composition",
      "id" : "5e848ec9-b5bf-4c90-9d7e-6b0894208bfe",
      "meta" : {
        "profile" : [
          🔗 "https://hl7.cz/fhir/hdr/StructureDefinition/cz-composition-hdr"
        ]
      },
      "text" : {
        "status" : "extensions",
        "div" : "<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>"
      },
      "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"
            }
          ]
        }
      ]
    }