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: EHDSDischargeReport - Detailed Descriptions

Draft as of 2026-02-05

Definitions for the EHDSDischargeReport logical model.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. EHDSDischargeReport
Definition | 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. Base definition for all types defined in FHIR type system.
Short | Discharge Report modelBase for all types and resources
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSDischargeReport.header
Definition | Basic metadata for this information
Short | Document header
Control | 1..1
Type | Base
4. EHDSDischargeReport.header.subject
Definition | Patient/subject information
Short | Patient/subject information
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient
6. EHDSDischargeReport.header.identifier
Definition | Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Short | Unique identifier of the document
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSDischargeReport.header.author[x]
Definition | The author of the report.
Short | The author of the report.
Control | 1..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
10. EHDSDischargeReport.header.date
Definition | Date and optionally time of authoring/issuing
Short | Date of finalising/issuing the document
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. EHDSDischargeReport.header.status
Definition | Status of the document
Short | Status of the document
Control | 1..1
Type | CodeableConcept
14. EHDSDischargeReport.header.source
Definition | 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.
Short | 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.
Control | 0..1
Type | CodeableConcept
16. EHDSDischargeReport.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language in which the resource is written. Language is expressed by the IETF language tag.
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
18. EHDSDischargeReport.header.documentType
Definition | Type of document at hand, e.g. 60591-5 Patient summary document.
Short | Type of document at hand, e.g. 60591-5 Patient summary document.
Control | 1..1
Binding | LOINC
Type | CodeableConcept
20. EHDSDischargeReport.header.documentTitle
Definition | 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'
Short | 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'
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. EHDSDischargeReport.header.period
Definition | Time of service that is being documented
Short | Time of service that is being documented (typically the same as the time of encounter)
Control | 0..1
Type | Period
24. EHDSDischargeReport.header.version
Definition | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.
Short | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. EHDSDischargeReport.header.attestation
Definition | Document attestation details
Short | Document attestation details
Control | 0..*
Type | Base
28. EHDSDischargeReport.header.attestation.attester[x]
Definition | Attester who validated the document. Multiple attesters could be provided.
Short | Attester who validated the document. Multiple attesters could be provided.
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
30. EHDSDischargeReport.header.attestation.datetime
Definition | Date and time of the approval of the document by Attester.
Short | Date and time of the approval of the document by Attester.
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
32. EHDSDischargeReport.header.legalAuthentication
Definition | Document legal authentication details
Short | Document legal authentication details
Control | 0..*
Type | Base
34. EHDSDischargeReport.header.legalAuthentication.legalAuthenticator[x]
Definition | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Short | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
36. EHDSDischargeReport.header.legalAuthentication.datetime
Definition | Date and time when the document was authorised.
Short | Date and time when the document was authorised.
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSDischargeReport.header.eventType
Definition | 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.
Short | 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.
Control | 0..*
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
40. EHDSDischargeReport.header.serviceSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Additional details about where the content was created (e.g. clinical specialty)
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
42. EHDSDischargeReport.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Organisation that is in charge of maintaining the document/report.
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
44. EHDSDischargeReport.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment
46. EHDSDischargeReport.header.intendedRecipient[x]
Definition | 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.
Short | 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.
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
48. EHDSDischargeReport.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
50. EHDSDischargeReport.body.alerts
Definition | Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
52. EHDSDischargeReport.body.alerts.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
54. EHDSDischargeReport.body.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert
Requirements | eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1
56. EHDSDischargeReport.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
58. EHDSDischargeReport.body.encounterInformation.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
60. EHDSDischargeReport.body.encounterInformation.encounter
Definition | Encounter information
Short | Encounter information
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSEncounter
Requirements | eHN Guideline HDR (v1.1): A.2.3
62. EHDSDischargeReport.body.encounterInformation.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
64. EHDSDischargeReport.body.admissionEvaluation
Definition | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
66. EHDSDischargeReport.body.admissionEvaluation.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
68. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
Definition | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Short | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1
70. EHDSDischargeReport.body.admissionEvaluation.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus
Requirements | eHN Guideline HDR (v1.1): A.2.4.2
72. EHDSDischargeReport.body.admissionEvaluation.note
Definition | Free text notes by the evaluation performer
Short | Free text notes by the evaluation performer
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSDischargeReport.body.patientHistory
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
76. EHDSDischargeReport.body.patientHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
Short | Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
78. EHDSDischargeReport.body.patientHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSDischargeReport.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
82. EHDSDischargeReport.body.courseOfEncounter.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
84. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
Definition | 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).
Short | 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).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
86. EHDSDischargeReport.body.courseOfEncounter.procedures
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
88. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
Short | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
90. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
Definition | Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
Short | Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
92. EHDSDischargeReport.body.courseOfEncounter.testResults[x]
Definition | 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.
Short | 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.
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
94. EHDSDischargeReport.body.courseOfEncounter.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSDischargeReport.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
98. EHDSDischargeReport.body.dischargeDetails.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSDischargeReport.body.dischargeDetails.objectiveFindings
Definition | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Short | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
102. EHDSDischargeReport.body.dischargeDetails.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
104. EHDSDischargeReport.body.dischargeDetails.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSDischargeReport.body.medicationSummary
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.1
108. EHDSDischargeReport.body.medicationSummary.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSDischargeReport.body.medicationSummary.medicationUse
Definition | Details about medication and dosaging
Short | Details about medication and dosaging
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement
112. EHDSDischargeReport.body.medicationSummary.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. EHDSDischargeReport.body.carePlan
Definition | Care plan and other recommendations after discharge.
Short | Care plan and other recommendations after discharge.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)
116. EHDSDischargeReport.body.carePlan.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
118. EHDSDischargeReport.body.carePlan.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan
120. EHDSDischargeReport.body.carePlan.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
122. EHDSDischargeReport.body.synthesis
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
124. EHDSDischargeReport.attachments[x]
Definition | Report attachments data elements
Short | Report attachments data elements
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedia
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]

Guidance on how to interpret the contents of this table can be foundhere

0. EHDSDischargeReport
Definition | 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.
Short | Discharge Report model
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSDischargeReport.header
4. EHDSDischargeReport.header.author[x]
Definition | The author of the report.
Short | The author of the report.
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
6. EHDSDischargeReport.header.status
Definition | Status of the document
8. EHDSDischargeReport.header.period
Short | Time of service that is being documented (typically the same as the time of encounter)
10. EHDSDischargeReport.header.intendedRecipient[x]
Definition | 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.
Short | 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.
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
12. EHDSDischargeReport.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
14. EHDSDischargeReport.body.alerts
Definition | Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
16. EHDSDischargeReport.body.alerts.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
18. EHDSDischargeReport.body.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert
Requirements | eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1
20. EHDSDischargeReport.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
22. EHDSDischargeReport.body.encounterInformation.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
24. EHDSDischargeReport.body.encounterInformation.encounter
Definition | Encounter information
Short | Encounter information
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSEncounter
Requirements | eHN Guideline HDR (v1.1): A.2.3
26. EHDSDischargeReport.body.encounterInformation.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
28. EHDSDischargeReport.body.admissionEvaluation
Definition | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
30. EHDSDischargeReport.body.admissionEvaluation.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
32. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
Definition | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Short | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1
34. EHDSDischargeReport.body.admissionEvaluation.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus
Requirements | eHN Guideline HDR (v1.1): A.2.4.2
36. EHDSDischargeReport.body.admissionEvaluation.note
Definition | Free text notes by the evaluation performer
Short | Free text notes by the evaluation performer
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSDischargeReport.body.patientHistory
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
40. EHDSDischargeReport.body.patientHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
Short | Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
42. EHDSDischargeReport.body.patientHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
44. EHDSDischargeReport.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
46. EHDSDischargeReport.body.courseOfEncounter.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
48. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
Definition | 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).
Short | 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).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
50. EHDSDischargeReport.body.courseOfEncounter.procedures
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
52. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
Short | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
54. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
Definition | Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
Short | Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
56. EHDSDischargeReport.body.courseOfEncounter.testResults[x]
Definition | 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.
Short | 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.
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
58. EHDSDischargeReport.body.courseOfEncounter.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
60. EHDSDischargeReport.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
62. EHDSDischargeReport.body.dischargeDetails.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
64. EHDSDischargeReport.body.dischargeDetails.objectiveFindings
Definition | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Short | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
66. EHDSDischargeReport.body.dischargeDetails.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
68. EHDSDischargeReport.body.dischargeDetails.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSDischargeReport.body.medicationSummary
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.1
72. EHDSDischargeReport.body.medicationSummary.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSDischargeReport.body.medicationSummary.medicationUse
Definition | Details about medication and dosaging
Short | Details about medication and dosaging
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement
76. EHDSDischargeReport.body.medicationSummary.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
78. EHDSDischargeReport.body.carePlan
Definition | Care plan and other recommendations after discharge.
Short | Care plan and other recommendations after discharge.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)
80. EHDSDischargeReport.body.carePlan.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
82. EHDSDischargeReport.body.carePlan.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan
84. EHDSDischargeReport.body.carePlan.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
86. EHDSDischargeReport.body.synthesis
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
88. EHDSDischargeReport.attachments[x]
Definition | Report attachments data elements
Short | Report attachments data elements
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedia
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]

Guidance on how to interpret the contents of this table can be foundhere

0. EHDSDischargeReport
Definition | 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.
Short | Discharge Report model
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSDischargeReport.header
Definition | Basic metadata for this information
Short | Document header
Control | 1..1
Type | Base
4. EHDSDischargeReport.header.subject
Definition | Patient/subject information
Short | Patient/subject information
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient
6. EHDSDischargeReport.header.identifier
Definition | Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Short | Unique identifier of the document
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSDischargeReport.header.author[x]
Definition | The author of the report.
Short | The author of the report.
Control | 1..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
10. EHDSDischargeReport.header.date
Definition | Date and optionally time of authoring/issuing
Short | Date of finalising/issuing the document
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. EHDSDischargeReport.header.status
Definition | Status of the document
Short | Status of the document
Control | 1..1
Type | CodeableConcept
14. EHDSDischargeReport.header.source
Definition | 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.
Short | 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.
Control | 0..1
Type | CodeableConcept
16. EHDSDischargeReport.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language in which the resource is written. Language is expressed by the IETF language tag.
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
18. EHDSDischargeReport.header.documentType
Definition | Type of document at hand, e.g. 60591-5 Patient summary document.
Short | Type of document at hand, e.g. 60591-5 Patient summary document.
Control | 1..1
Binding | LOINC
Type | CodeableConcept
20. EHDSDischargeReport.header.documentTitle
Definition | 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'
Short | 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'
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. EHDSDischargeReport.header.period
Definition | Time of service that is being documented
Short | Time of service that is being documented (typically the same as the time of encounter)
Control | 0..1
Type | Period
24. EHDSDischargeReport.header.version
Definition | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.
Short | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. EHDSDischargeReport.header.attestation
Definition | Document attestation details
Short | Document attestation details
Control | 0..*
Type | Base
28. EHDSDischargeReport.header.attestation.attester[x]
Definition | Attester who validated the document. Multiple attesters could be provided.
Short | Attester who validated the document. Multiple attesters could be provided.
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
30. EHDSDischargeReport.header.attestation.datetime
Definition | Date and time of the approval of the document by Attester.
Short | Date and time of the approval of the document by Attester.
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
32. EHDSDischargeReport.header.legalAuthentication
Definition | Document legal authentication details
Short | Document legal authentication details
Control | 0..*
Type | Base
34. EHDSDischargeReport.header.legalAuthentication.legalAuthenticator[x]
Definition | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Short | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
36. EHDSDischargeReport.header.legalAuthentication.datetime
Definition | Date and time when the document was authorised.
Short | Date and time when the document was authorised.
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSDischargeReport.header.eventType
Definition | 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.
Short | 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.
Control | 0..*
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
40. EHDSDischargeReport.header.serviceSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Additional details about where the content was created (e.g. clinical specialty)
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
42. EHDSDischargeReport.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Organisation that is in charge of maintaining the document/report.
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
44. EHDSDischargeReport.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment
46. EHDSDischargeReport.header.intendedRecipient[x]
Definition | 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.
Short | 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.
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
48. EHDSDischargeReport.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
50. EHDSDischargeReport.body.alerts
Definition | Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
52. EHDSDischargeReport.body.alerts.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
54. EHDSDischargeReport.body.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert
Requirements | eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1
56. EHDSDischargeReport.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
58. EHDSDischargeReport.body.encounterInformation.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
60. EHDSDischargeReport.body.encounterInformation.encounter
Definition | Encounter information
Short | Encounter information
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSEncounter
Requirements | eHN Guideline HDR (v1.1): A.2.3
62. EHDSDischargeReport.body.encounterInformation.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
64. EHDSDischargeReport.body.admissionEvaluation
Definition | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
66. EHDSDischargeReport.body.admissionEvaluation.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
68. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
Definition | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Short | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1
70. EHDSDischargeReport.body.admissionEvaluation.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus
Requirements | eHN Guideline HDR (v1.1): A.2.4.2
72. EHDSDischargeReport.body.admissionEvaluation.note
Definition | Free text notes by the evaluation performer
Short | Free text notes by the evaluation performer
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSDischargeReport.body.patientHistory
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
76. EHDSDischargeReport.body.patientHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
Short | Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
78. EHDSDischargeReport.body.patientHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSDischargeReport.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
82. EHDSDischargeReport.body.courseOfEncounter.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
84. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
Definition | 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).
Short | 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).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
86. EHDSDischargeReport.body.courseOfEncounter.procedures
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
88. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
Short | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
90. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
Definition | Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
Short | Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
92. EHDSDischargeReport.body.courseOfEncounter.testResults[x]
Definition | 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.
Short | 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.
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
94. EHDSDischargeReport.body.courseOfEncounter.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSDischargeReport.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
98. EHDSDischargeReport.body.dischargeDetails.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSDischargeReport.body.dischargeDetails.objectiveFindings
Definition | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Short | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
102. EHDSDischargeReport.body.dischargeDetails.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
104. EHDSDischargeReport.body.dischargeDetails.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSDischargeReport.body.medicationSummary
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.1
108. EHDSDischargeReport.body.medicationSummary.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSDischargeReport.body.medicationSummary.medicationUse
Definition | Details about medication and dosaging
Short | Details about medication and dosaging
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement
112. EHDSDischargeReport.body.medicationSummary.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. EHDSDischargeReport.body.carePlan
Definition | Care plan and other recommendations after discharge.
Short | Care plan and other recommendations after discharge.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)
116. EHDSDischargeReport.body.carePlan.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
118. EHDSDischargeReport.body.carePlan.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan
120. EHDSDischargeReport.body.carePlan.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
122. EHDSDischargeReport.body.synthesis
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
124. EHDSDischargeReport.attachments[x]
Definition | Report attachments data elements
Short | Report attachments data elements
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedia
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]