EHDS Logical Information Models
0.2.1 - qa-preview

EHDS Logical Information Models, published by Xt-EHR. This guide is not an authorized publication; it is the continuous build for version 0.2.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Xt-EHR/xt-ehr-common/ and changes regularly. See the Directory of published versions

Logical Model: Discharge Report model

Official URL: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDischargeReport Version: 0.2.1
Draft as of 2026-02-01 Computable Name: EHDSDischargeReport

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.

Usages:

  • This Logical Model is not used by any profiles in this Implementation Guide

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSDischargeReport 0..* EHDSDocument Discharge Report model

Elements defined in Ancestors:header, header, presentedForm
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 0..* Base Resource authoring details. Multiple authors can be provided.
..... author[x] 1..1 Author responsible for the provided information. The exact role of the responsible author varies across use cases and is often specified in individual models.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... status 1..1 CodeableConcept Status of the resource or document
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented (typically the same as the time of encounter)
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester[x] 1..1 Attester who validated the document. Multiple attesters could be provided.
...... attesterEHDSHealthProfessional EHDSHealthProfessional
...... attesterEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator[x] 1..1 The person or organization taking responsibility for the medical content of the document
...... legalAuthenticatorEHDSHealthProfessional EHDSHealthProfessional
...... legalAuthenticatorEHDSOrganisation EHDSOrganisation
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
.... intendedRecipient[x] 0..* 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.
..... intendedRecipientEHDSPatient EHDSPatient
..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
..... intendedRecipientEHDSOrganisation EHDSOrganisation
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... body 0..1 Base Structured body of the discharge report document
.... alerts 0..1 Base Section: Alerts.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicalAlert 0..* EHDSAlert 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.
.... encounterInformation 1..1 Base Section: Encounter information.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... encounter 0..1 EHDSEncounter Encounter information
..... note 0..1 string Free text notes by the health professional
.... admissionEvaluation 0..1 Base Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the evaluation performer
.... patientHistory 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
..... note 0..1 string Free text notes by the health professional
.... courseOfEncounter 0..1 Base Course of inpatient or outpatient encounter.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... diagnosticSummary 0..* EHDSCondition 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).
..... procedures 0..* EHDSProcedure 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.
..... medicalDevicesAndImplants 0..* EHDSDeviceUse Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
..... pharmacotherapy 0..* EHDSMedicationStatement Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
..... testResults[x] 0..* 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.
...... testResultsEHDSObservation EHDSObservation
...... testResultsEHDSLaboratoryObservation EHDSLaboratoryObservation
..... note 0..1 string Free text notes by the health professional
.... dischargeDetails 0..1 Base Discharge details
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the health professional
.... medicationSummary 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
..... note 0..1 string Free text notes by the health professional
.... carePlan 0..1 Base Care plan and other recommendations after discharge.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided.
..... otherRecommendations 0..1 string Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
.... synthesis 0..1 string 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.
.... attachmentsEHDSAttachment EHDSAttachment
.... attachmentsEHDSMedia EHDSMedia

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
EHDSDischargeReport.​header.language Base preferred Not State Unknown
EHDSDischargeReport.​header.documentType Base preferred Not State Unknown
EHDSDischargeReport.​header.eventType Base preferred Not State Unknown
EHDSDischargeReport.​header.serviceSpecialty Base preferred Not State Unknown
EHDSDischargeReport.​header.confidentiality Base preferred Not State Unknown

This structure is derived from EHDSDocument

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSDischargeReport 0..* EHDSDocument Discharge Report model

Elements defined in Ancestors:header, header, presentedForm
Instances of this logical model can be the target of a Reference
... header
.... period 0..1 Period Time of service that is being documented (typically the same as the time of encounter)
.... intendedRecipient[x] 0..* 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.
..... intendedRecipientEHDSPatient EHDSPatient
..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
..... intendedRecipientEHDSOrganisation EHDSOrganisation
... body 0..1 Base Structured body of the discharge report document
.... alerts 0..1 Base Section: Alerts.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicalAlert 0..* EHDSAlert 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.
.... encounterInformation 1..1 Base Section: Encounter information.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... encounter 0..1 EHDSEncounter Encounter information
..... note 0..1 string Free text notes by the health professional
.... admissionEvaluation 0..1 Base Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the evaluation performer
.... patientHistory 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
..... note 0..1 string Free text notes by the health professional
.... courseOfEncounter 0..1 Base Course of inpatient or outpatient encounter.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... diagnosticSummary 0..* EHDSCondition 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).
..... procedures 0..* EHDSProcedure 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.
..... medicalDevicesAndImplants 0..* EHDSDeviceUse Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
..... pharmacotherapy 0..* EHDSMedicationStatement Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
..... testResults[x] 0..* 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.
...... testResultsEHDSObservation EHDSObservation
...... testResultsEHDSLaboratoryObservation EHDSLaboratoryObservation
..... note 0..1 string Free text notes by the health professional
.... dischargeDetails 0..1 Base Discharge details
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the health professional
.... medicationSummary 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
..... note 0..1 string Free text notes by the health professional
.... carePlan 0..1 Base Care plan and other recommendations after discharge.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided.
..... otherRecommendations 0..1 string Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
.... synthesis 0..1 string 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.
... attachments[x] 0..* Report attachments data elements
.... attachmentsEHDSAttachment EHDSAttachment
.... attachmentsEHDSMedia EHDSMedia

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSDischargeReport 0..* EHDSDocument Discharge Report model

Elements defined in Ancestors:header, header, presentedForm
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 0..* Base Resource authoring details. Multiple authors can be provided.
..... author[x] 1..1 Author responsible for the provided information. The exact role of the responsible author varies across use cases and is often specified in individual models.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... status 1..1 CodeableConcept Status of the resource or document
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented (typically the same as the time of encounter)
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester[x] 1..1 Attester who validated the document. Multiple attesters could be provided.
...... attesterEHDSHealthProfessional EHDSHealthProfessional
...... attesterEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator[x] 1..1 The person or organization taking responsibility for the medical content of the document
...... legalAuthenticatorEHDSHealthProfessional EHDSHealthProfessional
...... legalAuthenticatorEHDSOrganisation EHDSOrganisation
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
.... intendedRecipient[x] 0..* 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.
..... intendedRecipientEHDSPatient EHDSPatient
..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
..... intendedRecipientEHDSOrganisation EHDSOrganisation
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... body 0..1 Base Structured body of the discharge report document
.... alerts 0..1 Base Section: Alerts.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicalAlert 0..* EHDSAlert 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.
.... encounterInformation 1..1 Base Section: Encounter information.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... encounter 0..1 EHDSEncounter Encounter information
..... note 0..1 string Free text notes by the health professional
.... admissionEvaluation 0..1 Base Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the evaluation performer
.... patientHistory 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
..... note 0..1 string Free text notes by the health professional
.... courseOfEncounter 0..1 Base Course of inpatient or outpatient encounter.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... diagnosticSummary 0..* EHDSCondition 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).
..... procedures 0..* EHDSProcedure 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.
..... medicalDevicesAndImplants 0..* EHDSDeviceUse Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
..... pharmacotherapy 0..* EHDSMedicationStatement Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
..... testResults[x] 0..* 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.
...... testResultsEHDSObservation EHDSObservation
...... testResultsEHDSLaboratoryObservation EHDSLaboratoryObservation
..... note 0..1 string Free text notes by the health professional
.... dischargeDetails 0..1 Base Discharge details
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the health professional
.... medicationSummary 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
..... note 0..1 string Free text notes by the health professional
.... carePlan 0..1 Base Care plan and other recommendations after discharge.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided.
..... otherRecommendations 0..1 string Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
.... synthesis 0..1 string 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.
.... attachmentsEHDSAttachment EHDSAttachment
.... attachmentsEHDSMedia EHDSMedia

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
EHDSDischargeReport.​header.language Base preferred Not State Unknown
EHDSDischargeReport.​header.documentType Base preferred Not State Unknown
EHDSDischargeReport.​header.eventType Base preferred Not State Unknown
EHDSDischargeReport.​header.serviceSpecialty Base preferred Not State Unknown
EHDSDischargeReport.​header.confidentiality Base preferred Not State Unknown

This structure is derived from EHDSDocument

Summary

Mandatory: 0 element(2 nested mandatory elements)

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSDischargeReport 0..* EHDSDocument Discharge Report model

Elements defined in Ancestors:header, header, presentedForm
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 0..* Base Resource authoring details. Multiple authors can be provided.
..... author[x] 1..1 Author responsible for the provided information. The exact role of the responsible author varies across use cases and is often specified in individual models.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... status 1..1 CodeableConcept Status of the resource or document
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented (typically the same as the time of encounter)
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester[x] 1..1 Attester who validated the document. Multiple attesters could be provided.
...... attesterEHDSHealthProfessional EHDSHealthProfessional
...... attesterEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator[x] 1..1 The person or organization taking responsibility for the medical content of the document
...... legalAuthenticatorEHDSHealthProfessional EHDSHealthProfessional
...... legalAuthenticatorEHDSOrganisation EHDSOrganisation
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
.... intendedRecipient[x] 0..* 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.
..... intendedRecipientEHDSPatient EHDSPatient
..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
..... intendedRecipientEHDSOrganisation EHDSOrganisation
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... body 0..1 Base Structured body of the discharge report document
.... alerts 0..1 Base Section: Alerts.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicalAlert 0..* EHDSAlert 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.
.... encounterInformation 1..1 Base Section: Encounter information.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... encounter 0..1 EHDSEncounter Encounter information
..... note 0..1 string Free text notes by the health professional
.... admissionEvaluation 0..1 Base Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the evaluation performer
.... patientHistory 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
..... note 0..1 string Free text notes by the health professional
.... courseOfEncounter 0..1 Base Course of inpatient or outpatient encounter.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... diagnosticSummary 0..* EHDSCondition 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).
..... procedures 0..* EHDSProcedure 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.
..... medicalDevicesAndImplants 0..* EHDSDeviceUse Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
..... pharmacotherapy 0..* EHDSMedicationStatement Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
..... testResults[x] 0..* 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.
...... testResultsEHDSObservation EHDSObservation
...... testResultsEHDSLaboratoryObservation EHDSLaboratoryObservation
..... note 0..1 string Free text notes by the health professional
.... dischargeDetails 0..1 Base Discharge details
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the health professional
.... medicationSummary 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
..... note 0..1 string Free text notes by the health professional
.... carePlan 0..1 Base Care plan and other recommendations after discharge.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided.
..... otherRecommendations 0..1 string Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
.... synthesis 0..1 string 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.
.... attachmentsEHDSAttachment EHDSAttachment
.... attachmentsEHDSMedia EHDSMedia

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
EHDSDischargeReport.​header.language Base preferred Not State Unknown
EHDSDischargeReport.​header.documentType Base preferred Not State Unknown
EHDSDischargeReport.​header.eventType Base preferred Not State Unknown
EHDSDischargeReport.​header.serviceSpecialty Base preferred Not State Unknown
EHDSDischargeReport.​header.confidentiality Base preferred Not State Unknown

Differential View

This structure is derived from EHDSDocument

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSDischargeReport 0..* EHDSDocument Discharge Report model

Elements defined in Ancestors:header, header, presentedForm
Instances of this logical model can be the target of a Reference
... header
.... period 0..1 Period Time of service that is being documented (typically the same as the time of encounter)
.... intendedRecipient[x] 0..* 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.
..... intendedRecipientEHDSPatient EHDSPatient
..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
..... intendedRecipientEHDSOrganisation EHDSOrganisation
... body 0..1 Base Structured body of the discharge report document
.... alerts 0..1 Base Section: Alerts.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicalAlert 0..* EHDSAlert 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.
.... encounterInformation 1..1 Base Section: Encounter information.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... encounter 0..1 EHDSEncounter Encounter information
..... note 0..1 string Free text notes by the health professional
.... admissionEvaluation 0..1 Base Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the evaluation performer
.... patientHistory 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
..... note 0..1 string Free text notes by the health professional
.... courseOfEncounter 0..1 Base Course of inpatient or outpatient encounter.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... diagnosticSummary 0..* EHDSCondition 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).
..... procedures 0..* EHDSProcedure 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.
..... medicalDevicesAndImplants 0..* EHDSDeviceUse Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
..... pharmacotherapy 0..* EHDSMedicationStatement Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
..... testResults[x] 0..* 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.
...... testResultsEHDSObservation EHDSObservation
...... testResultsEHDSLaboratoryObservation EHDSLaboratoryObservation
..... note 0..1 string Free text notes by the health professional
.... dischargeDetails 0..1 Base Discharge details
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the health professional
.... medicationSummary 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
..... note 0..1 string Free text notes by the health professional
.... carePlan 0..1 Base Care plan and other recommendations after discharge.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided.
..... otherRecommendations 0..1 string Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
.... synthesis 0..1 string 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.
... attachments[x] 0..* Report attachments data elements
.... attachmentsEHDSAttachment EHDSAttachment
.... attachmentsEHDSMedia EHDSMedia

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSDischargeReport 0..* EHDSDocument Discharge Report model

Elements defined in Ancestors:header, header, presentedForm
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 0..* Base Resource authoring details. Multiple authors can be provided.
..... author[x] 1..1 Author responsible for the provided information. The exact role of the responsible author varies across use cases and is often specified in individual models.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... status 1..1 CodeableConcept Status of the resource or document
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented (typically the same as the time of encounter)
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester[x] 1..1 Attester who validated the document. Multiple attesters could be provided.
...... attesterEHDSHealthProfessional EHDSHealthProfessional
...... attesterEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator[x] 1..1 The person or organization taking responsibility for the medical content of the document
...... legalAuthenticatorEHDSHealthProfessional EHDSHealthProfessional
...... legalAuthenticatorEHDSOrganisation EHDSOrganisation
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
.... intendedRecipient[x] 0..* 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.
..... intendedRecipientEHDSPatient EHDSPatient
..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
..... intendedRecipientEHDSOrganisation EHDSOrganisation
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... body 0..1 Base Structured body of the discharge report document
.... alerts 0..1 Base Section: Alerts.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicalAlert 0..* EHDSAlert 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.
.... encounterInformation 1..1 Base Section: Encounter information.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... encounter 0..1 EHDSEncounter Encounter information
..... note 0..1 string Free text notes by the health professional
.... admissionEvaluation 0..1 Base Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the evaluation performer
.... patientHistory 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
..... note 0..1 string Free text notes by the health professional
.... courseOfEncounter 0..1 Base Course of inpatient or outpatient encounter.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... diagnosticSummary 0..* EHDSCondition 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).
..... procedures 0..* EHDSProcedure 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.
..... medicalDevicesAndImplants 0..* EHDSDeviceUse Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
..... pharmacotherapy 0..* EHDSMedicationStatement Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
..... testResults[x] 0..* 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.
...... testResultsEHDSObservation EHDSObservation
...... testResultsEHDSLaboratoryObservation EHDSLaboratoryObservation
..... note 0..1 string Free text notes by the health professional
.... dischargeDetails 0..1 Base Discharge details
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
..... functionalStatus 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
..... note 0..1 string Free text notes by the health professional
.... medicationSummary 0..1 Base 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.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
..... note 0..1 string Free text notes by the health professional
.... carePlan 0..1 Base Care plan and other recommendations after discharge.
..... generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section.
..... carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided.
..... otherRecommendations 0..1 string Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
.... synthesis 0..1 string 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.
.... attachmentsEHDSAttachment EHDSAttachment
.... attachmentsEHDSMedia EHDSMedia

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
EHDSDischargeReport.​header.language Base preferred Not State Unknown
EHDSDischargeReport.​header.documentType Base preferred Not State Unknown
EHDSDischargeReport.​header.eventType Base preferred Not State Unknown
EHDSDischargeReport.​header.serviceSpecialty Base preferred Not State Unknown
EHDSDischargeReport.​header.confidentiality Base preferred Not State Unknown

This structure is derived from EHDSDocument

Summary

Mandatory: 0 element(2 nested mandatory elements)

 

Other representations of profile: CSV, Excel