Cross Border Data Exchange IG
1.0.0 - CI Build International flag

Cross Border Data Exchange IG, published by IEHR-Workgroup. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/InteropEHRate-project/cross-border-data-exchange/ and changes regularly. See the Directory of published versions

: HospitalDischargeReport Example - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="69208519"/>
  <meta>
    <profile
             value="http://interopehrate.eu/fhir/StructureDefinition/Composition-HospitalDischargeReport-IEHR"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Composition</b><a name="69208519"> </a><a name="hc69208519"> </a></p><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">Resource Composition &quot;69208519&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-Composition-HospitalDischargeReport-IEHR.html">HospitalDischargeReport-IEHR</a></p></div><p><b>ProvenanceExtension-IEHR</b>: <a href="Provenance-16.html">Provenance/16</a></p><p><b>status</b>: final</p><p><b>type</b>: Discharge Sum C-CDA R2.1 Sections <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#81218-0)</span></p><p><b>date</b>: 2022-05-31 11:16:01+0200</p><p><b>author</b>: <a href="Practitioner-21.html">Practitioner/21</a> &quot; ANTONIO&quot;</p><p><b>title</b>: Hospital discharge summary</p></div>
  </text>
  <extension
             url="http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR">
    <valueReference>🔗 
      <reference value="Provenance/16"/>
    </valueReference>
  </extension>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="81218-0"/>
      <display value="Discharge Sum C-CDA R2.1 Sections"/>
    </coding>
  </type>
  <date value="2022-05-31T11:16:01+02:00"/>
  <author>🔗 
    <reference value="Practitioner/21"/>
  </author>
  <title value="Hospital discharge summary"/>
  <section>
    <title value="Hospital Admission Dx"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="46241-6"/>
        <display value="Hospital admission Dx Reported"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Hospital Admission section</div>
    </text>
    <entry>🔗 
      <reference value="Condition/69208519"/>
    </entry>
  </section>
  <section>
    <title value="Hospital Admission History And Physical Note"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="47039-3"/>
        <display value="Hosp Admit H&amp;P note"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Hospital Admission History section</div>
    </text>
  </section>
  <section>
    <title value="History General"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11329-0"/>
        <display value="Hx general Reported"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the general history section</div>
    </text>
  </section>
  <section>
    <title value="Physical Examination"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29545-1"/>
        <display value="Phys find"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the physical examination section</div>
    </text>
  </section>
  <section>
    <title value="Medications On Admission"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="42346-7"/>
        <display value="Medications on admission (narrative)"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the medications on admission section</div>
    </text>
  </section>
  <section>
    <title value="Hospital Course"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8648-8"/>
        <display value="Hospital course"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the hospital course section</div>
    </text>
  </section>
  <section>
    <title value="Relevant Diagnostic Tests And/Or Laboratory Data"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="30954-2"/>
        <display value="Relevant Dx tests/lab data"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the laboratory data section</div>
    </text>
    <entry>🔗 
      <reference value="Observation/69208519"/>
    </entry>
  </section>
  <section>
    <title value="Hospital Discharge Studies Summary"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11493-4"/>
        <display value="Hospital discharge studies summary"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the studies summary section</div>
    </text>
  </section>
  <section>
    <title value="Selected Medicine Administered During Hospitalization"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8677-7"/>
        <display value="Hx of Medication use"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the medicine administered during hospitalisation section</div>
    </text>
  </section>
  <section>
    <title value="Hospital Discharge Dx"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11535-2"/>
        <display value="Hospital discharge Dx"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the hospital discharge Dx section</div>
    </text>
  </section>
  <section>
    <title value="Discharge Medications"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10183-2"/>
        <display value="Hospital discharge medications"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the discharge medications section</div>
    </text>
    <entry>🔗 
      <reference value="MedicationRequest/69208519"/>
    </entry>
  </section>
  <section>
    <title value="Treatment Plan"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
        <display value="Plan of care note"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the treatment plan section</div>
    </text>
  </section>
  <section>
    <title value="Allergies"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48765-2"/>
        <display value="Allergies &amp;or adverse reactions Doc"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the allergy section</div>
    </text>
  </section>
</Composition>