A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs.

Common header for all patient-related data

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Resource authoring details. Multiple authors can be provided.

Author responsible for the provided information. The exact role of the responsible author varies across use cases and is often specified in individual models.

Date and time of authoring/issuing

Status of the resource or document

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document.

Document attestation details

Attester who validated the document. Multiple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication details

The person or organization taking responsibility for the medical content of the document

Date and time when the document was authorised.

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.

Structured body of the discharge report document

Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.

eHN Guideline HDR (v1.1): A.2.2

Narrative, potentially formatted, content of the whole section.

Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.

eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1

Section: Encounter information.

eHN Guideline HDR (v1.1): A.2.2

Narrative, potentially formatted, content of the whole section.

Encounter information

eHN Guideline HDR (v1.1): A.2.3

Free text notes by the health professional

Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.

eHN Guideline HDR (v1.1): A.2.4

Narrative, potentially formatted, content of the whole section.

Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination

eHN Guideline HDR (v1.1): A.2.4.1

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being

eHN Guideline HDR (v1.1): A.2.4.2

Free text notes by the evaluation performer

Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.

eHN Guideline HDR (v1.1): A.2.5

Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.

Free text notes by the health professional

Course of inpatient or outpatient encounter.

eHN Guideline HDR (v1.1): A.2.6

Narrative, potentially formatted, content of the whole section.

Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).

eHN Guideline HDR (v1.1): A.2.6.1

Procedures performed during encounter which are significant for continuity of care, e.g. surgeries and other instrumental interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. Diagnostic procedures are typically captured as observation results and not repeated here.

eHN Guideline HDR (v1.1): A.2.6.2

Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.

eHN Guideline HDR (v1.1): A.2.6.3

Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.

eHN Guideline HDR (v1.1): A.2.6.5

Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.

Free text notes by the health professional

Structured information should be provided, however if not available, at least a section narrative should be present.

eHN Guideline HDR (v1.1): A.2.7

Narrative, potentially formatted, content of the whole section.

Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination

eHN Guideline HDR (v1.1): A.2.7.1

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being

eHN Guideline HDR (v1.1): A.2.7.2

Free text notes by the health professional

Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.

eHN Guideline HDR (v1.1): A.2.8.1

Narrative, potentially formatted, content of the whole section.

Details about medication and dosaging

Free text notes by the health professional

Care plan and other recommendations after discharge.

eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)

Narrative, potentially formatted, content of the whole section.

Structured care plan after discharge. Multiple care plans could be provided.

Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.

eHN Guideline HDR (v1.1): A.2.8.3

Clinical synthesis (e.g. description of reasons and course of encounter) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

eHN Guideline HDR (v1.1): A.2.6.7

Report attachments data elements

A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs.

Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.

Structured body of the discharge report document

Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.

eHN Guideline HDR (v1.1): A.2.2

Narrative, potentially formatted, content of the whole section.

Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.

eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1

Section: Encounter information.

eHN Guideline HDR (v1.1): A.2.2

Narrative, potentially formatted, content of the whole section.

Encounter information

eHN Guideline HDR (v1.1): A.2.3

Free text notes by the health professional

Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.

eHN Guideline HDR (v1.1): A.2.4

Narrative, potentially formatted, content of the whole section.

Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination

eHN Guideline HDR (v1.1): A.2.4.1

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being

eHN Guideline HDR (v1.1): A.2.4.2

Free text notes by the evaluation performer

Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.

eHN Guideline HDR (v1.1): A.2.5

Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.

Free text notes by the health professional

Course of inpatient or outpatient encounter.

eHN Guideline HDR (v1.1): A.2.6

Narrative, potentially formatted, content of the whole section.

Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).

eHN Guideline HDR (v1.1): A.2.6.1

Procedures performed during encounter which are significant for continuity of care, e.g. surgeries and other instrumental interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. Diagnostic procedures are typically captured as observation results and not repeated here.

eHN Guideline HDR (v1.1): A.2.6.2

Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.

eHN Guideline HDR (v1.1): A.2.6.3

Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.

eHN Guideline HDR (v1.1): A.2.6.5

Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.

Free text notes by the health professional

Structured information should be provided, however if not available, at least a section narrative should be present.

eHN Guideline HDR (v1.1): A.2.7

Narrative, potentially formatted, content of the whole section.

Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination

eHN Guideline HDR (v1.1): A.2.7.1

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being

eHN Guideline HDR (v1.1): A.2.7.2

Free text notes by the health professional

Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.

eHN Guideline HDR (v1.1): A.2.8.1

Narrative, potentially formatted, content of the whole section.

Details about medication and dosaging

Free text notes by the health professional

Care plan and other recommendations after discharge.

eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)

Narrative, potentially formatted, content of the whole section.

Structured care plan after discharge. Multiple care plans could be provided.

Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.

eHN Guideline HDR (v1.1): A.2.8.3

Clinical synthesis (e.g. description of reasons and course of encounter) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

eHN Guideline HDR (v1.1): A.2.6.7

Report attachments data elements

A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs.

Common header for all patient-related data

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Resource authoring details. Multiple authors can be provided.

Author responsible for the provided information. The exact role of the responsible author varies across use cases and is often specified in individual models.

Date and time of authoring/issuing

Status of the resource or document

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document.

Document attestation details

Attester who validated the document. Multiple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication details

The person or organization taking responsibility for the medical content of the document

Date and time when the document was authorised.

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.

Structured body of the discharge report document

Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.

eHN Guideline HDR (v1.1): A.2.2

Narrative, potentially formatted, content of the whole section.

Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.

eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1

Section: Encounter information.

eHN Guideline HDR (v1.1): A.2.2

Narrative, potentially formatted, content of the whole section.

Encounter information

eHN Guideline HDR (v1.1): A.2.3

Free text notes by the health professional

Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.

eHN Guideline HDR (v1.1): A.2.4

Narrative, potentially formatted, content of the whole section.

Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination

eHN Guideline HDR (v1.1): A.2.4.1

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being

eHN Guideline HDR (v1.1): A.2.4.2

Free text notes by the evaluation performer

Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.

eHN Guideline HDR (v1.1): A.2.5

Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.

Free text notes by the health professional

Course of inpatient or outpatient encounter.

eHN Guideline HDR (v1.1): A.2.6

Narrative, potentially formatted, content of the whole section.

Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).

eHN Guideline HDR (v1.1): A.2.6.1

Procedures performed during encounter which are significant for continuity of care, e.g. surgeries and other instrumental interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. Diagnostic procedures are typically captured as observation results and not repeated here.

eHN Guideline HDR (v1.1): A.2.6.2

Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.

eHN Guideline HDR (v1.1): A.2.6.3

Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.

eHN Guideline HDR (v1.1): A.2.6.5

Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.

Free text notes by the health professional

Structured information should be provided, however if not available, at least a section narrative should be present.

eHN Guideline HDR (v1.1): A.2.7

Narrative, potentially formatted, content of the whole section.

Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination

eHN Guideline HDR (v1.1): A.2.7.1

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being

eHN Guideline HDR (v1.1): A.2.7.2

Free text notes by the health professional

Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.

eHN Guideline HDR (v1.1): A.2.8.1

Narrative, potentially formatted, content of the whole section.

Details about medication and dosaging

Free text notes by the health professional

Care plan and other recommendations after discharge.

eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)

Narrative, potentially formatted, content of the whole section.

Structured care plan after discharge. Multiple care plans could be provided.

Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.

eHN Guideline HDR (v1.1): A.2.8.3

Clinical synthesis (e.g. description of reasons and course of encounter) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

eHN Guideline HDR (v1.1): A.2.6.7

Report attachments data elements