| Name | Flags | Card. | Type | Description & Constraints |
|---|
  EHDSDischargeReport | | 0..* | EHDSDischargeReport | Discharge Report model |
 header | O | 1..1 | Base | Document header |
 subject | O | 1..1 | EHDSPatient | Patient/subject information |
| identifier | O | 1..* | Identifier | Unique identifier of the document |
| author[x] | O | 1..* | EHDSHealthProfessional, EHDSOrganisation, EHDSDevice | The author of the report. |
| date | O | 1..1 | dateTime | Date of finalising/issuing the document |
| status | O | 1..1 | CodeableConcept | Status of the document |
| language | O | 0..1 | CodeableConcept | Language in which the resource is written. Language is expressed by the IETF language tag. |
| documentType | O | 1..1 | CodeableConcept | Type of the document (e.g. '34105-7 Hospital discharge summary) |
| documentTitle | O | 1..1 | string | Title of the document, possibly autogenerated from the structured fields (e.g. 'Hospital discharge report. Jane Green. 07.10.2025-10.10.2025') |
| period | O | 0..1 | Period | Time of service that is being documented (typically the same as the time/period of encounter) |
| attestation | O | 0..* | Base | Document attestation details |
| attester[x] | O | 1..1 | EHDSHealthProfessional, EHDSDevice | Attester who validated the document |
 datetime | O | 1..1 | dateTime | Date and time of the approval of the document by Attester |
| legalAuthentication | O | 0..* | Base | Document legal authentication details |
| legalAuthenticator[x] | O | 1..1 | EHDSHealthProfessional, EHDSOrganisation | The person or organisation taking responsibility for the content of the document. |
| datetime | O | 1..1 | dateTime | Date and time when the document was authorised |
| eventType | O | 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. |
| serviceSpecialty | O | 0..* | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) |
| custodian | O | 0..1 | EHDSOrganisation | Organisation that is in charge of maintaining the document/report. |
| presentedForm | O | 0..* | EHDSAttachment | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document |
| body | O | 0..1 | Base | Structured body of the discharge report document |
 alerts | O | 0..1 | Base | Section: Alerts. |
| generatedNarrative | O | 0..1 | string | Narrative, potentially formatted, content of the whole section. |
| medicalAlert | O | 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 | O | 1..1 | Base | Section: Encounter information. |
| generatedNarrative | O | 0..1 | string | Narrative, potentially formatted, content of the whole section. |
| encounter | O | 0..1 | EHDSEncounter | Encounter information |
| note | O | 0..1 | string | Free text notes by the health professional |
| admissionEvaluation | O | 0..1 | Base | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care. |
| generatedNarrative | O | 0..1 | string | Narrative, potentially formatted, content of the whole section. |
| objectiveFindings | O | 0..* | EHDSObservation | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination |
| functionalStatus[x] | O | 0..* | EHDSCondition, EHDSObservation | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being |
| note | O | 0..1 | string | Free text notes by the evaluation performer |
| patientHistory | O | 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 | O | 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. |
| pastProblems | O | 0..* | EHDSCondition | A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report. |
| devicesAndImplants | O | 0..* | EHDSDeviceUse | Devices and implants in patient anamnesis. |
| procedures | O | 0..* | EHDSProcedure | Procedures in patient anamnesis. |
| note | O | 0..1 | string | Free text notes by the health professional |
| courseOfEncounter | O | 1..1 | Base | Course of inpatient or outpatient encounter. |
| generatedNarrative | O | 0..1 | string | Narrative, potentially formatted, content of the whole section. |
| diagnosticSummary | O | 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 | O | 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 | O | 0..* | EHDSDeviceUse | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter. |
| pharmacotherapy | O | 0..* | EHDSMedicationUse | 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] | O | 0..* | EHDSObservation, EHDSLaboratoryObservation | 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. |
| note | O | 0..1 | string | Free text notes by the health professional |
| dischargeDetails | O | 0..1 | Base | Discharge details |
| generatedNarrative | O | 0..1 | string | Narrative, potentially formatted, content of the whole section. |
| objectiveFindings | O | 0..* | EHDSObservation | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination |
| functionalStatus[x] | O | 0..* | EHDSCondition, EHDSObservation | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being |
| note | O | 0..1 | string | Free text notes by the health professional |
| medicationSummary | O | 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 | O | 0..1 | string | Narrative, potentially formatted, content of the whole section. |
| medicationUse | O | 0..* | EHDSMedicationUse | Details about medication and dosage |
| note | O | 0..1 | string | Free text notes by the health professional |
| carePlan | O | 0..1 | Base | Care plan and other recommendations after discharge. |
| generatedNarrative | O | 0..1 | string | Narrative, potentially formatted, content of the whole section. |
| otherRecommendations | O | 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 | O | 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. |
Documentation for this format |