Generated Narrative: StructureDefinition EHDSDischargeReport Name Flags Card. Type Description & Constraints 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 #xD; header #xD; author[x] 1..* EHDSHealthProfessional, EHDSOrganisation, EHDSDevice The author of the report. #xD; status 1..1 CodeableConcept Status of the document #xD; period 0..1 Period Time of service that is being documented (typically the same as the time of encounter) #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.header.intendedRecipient[x]" title="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.">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. #xD; intendedRecipientEHDSPatient EHDSPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientEHDSHealthProfessional EHDSHealthProfessional #xD; intendedRecipientEHDSOrganisation EHDSOrganisation #xD; body 0..1 Base Structured body of the discharge report document #xD; alerts 0..1 Base Section: Alerts. #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; 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. #xD; encounterInformation 1..1 Base Section: Encounter information. #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; encounter 0..1 EHDSEncounter Encounter information #xD; note 0..1 string Free text notes by the health professional #xD; admissionEvaluation 0..1 Base Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care. #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination #xD; 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 #xD; note 0..1 string Free text notes by the evaluation performer #xD; 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. #xD; 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. #xD; note 0..1 string Free text notes by the health professional #xD; courseOfEncounter 0..1 Base Course of inpatient or outpatient encounter. #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary" title="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).">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). #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.courseOfEncounter.procedures" title="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.">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. #xD; medicalDevicesAndImplants 0..* EHDSDeviceUse Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter. #xD; 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. #xD; 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. #xD; testResultsEHDSObservation EHDSObservation #xD; testResultsEHDSLaboratoryObservation EHDSLaboratoryObservation #xD; note 0..1 string Free text notes by the health professional #xD; dischargeDetails 0..1 Base Discharge details #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; objectiveFindings 0..* EHDSObservation Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination #xD; 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 #xD; note 0..1 string Free text notes by the health professional #xD; 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. #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging #xD; note 0..1 string Free text notes by the health professional #xD; carePlan 0..1 Base Care plan and other recommendations after discharge. #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided. #xD; 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. #xD; 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. #xD; attachments[x] 0..* Report attachments data elements #xD; attachmentsEHDSAttachment EHDSAttachment #xD; attachmentsEHDSMedia EHDSMedia #xD; Documentation for this format
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.
Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Date and optionally time of authoring/issuing
Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.
Language in which the resource is written. Language is expressed by the IETF language tag.
Type of document at hand, e.g. 60591-5 Patient summary document.
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 (typically the same as the time of encounter)
Time of service that is being documented
Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.
Attester who validated the document. Multiple attesters could be provided.
Date and time of the approval of the document by Attester.
The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
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.
Additional details about where the content was created (e.g. clinical specialty)
Organisation that is in charge of maintaining the document/report.
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.
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.
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.
Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
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.
Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
Course of inpatient or outpatient encounter.
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 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.
Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
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.
Structured information should be provided, however if not available, at least a section narrative should be present.
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.
Care plan and other recommendations after discharge.
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.
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.