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/costateixeira/xt-ehr-common/ and changes regularly. See the Directory of published versions

## Logical Model: EHDSDischargeReportCore - Detailed Descriptions

Draft as of 2025-12-03

Definitions for the EHDSDischargeReportCore 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. EHDSDischargeReportCore
Definition | EHDS refined base model for Discharge Report 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. EHDSDischargeReportCore.header
Definition | Common header for all patient-related data
Short | Document header elements
Control | 1..1
Type | Base
4. EHDSDischargeReportCore.header.subject
Definition | Patient/subject information
Short | Patient/subject information
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient
6. EHDSDischargeReportCore.header.identifier
Definition | Business identifier for the object
Short | Unique identifier of the document
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSDischargeReportCore.header.authorship
Definition | Resource authoring details
Short | Resource authoring details
Control | 1..*
Type | Base
10. EHDSDischargeReportCore.header.authorship.author[x]
Definition | Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Short | Author(s) by whom the resource was/were authored. Multiple authors 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/EHDSOrganisation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
12. EHDSDischargeReportCore.header.authorship.datetime
Definition | Date and time of authoring/issuing
Short | Date and time of authoring/issuing
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
14. EHDSDischargeReportCore.header.lastUpdate
Definition | Date and time of the last update to the resource (may be used for technical corrections).
Short | Date and time of the last update to the resource (may be used for technical corrections).
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSDischargeReportCore.header.status
Definition | Status of the resource or document
Short | Status of the resource or document
Control | 1..1
Type | CodeableConcept
18. EHDSDischargeReportCore.header.statusReason[x]
Definition | Reason for the current status of the resource.
Short | Reason for the current status of the resource.
Control | 0..1
Type | Choice of: CodeableConcept, string
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSDischargeReportCore.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
22. EHDSDischargeReportCore.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
24. EHDSDischargeReportCore.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
26. EHDSDischargeReportCore.header.period
Definition | Time of service that is being documented
Short | Time of service that is being documented
Control | 0..1
Type | Period
28. EHDSDischargeReportCore.header.version
Definition | Business version of the document.
Short | Business version of the document.
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
30. EHDSDischargeReportCore.header.attestation
Definition | Document attestation details
Short | Document attestation details
Control | 0..*
Type | Base
32. EHDSDischargeReportCore.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]
34. EHDSDischargeReportCore.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
36. EHDSDischargeReportCore.header.legalAuthentication
Definition | Document legal authentication details
Short | Document legal authentication details
Control | 0..1
Type | Base
38. EHDSDischargeReportCore.header.legalAuthentication.legalAuthenticator[x]
Definition | The person or organization taking responsibility for the medical content of the document
Short | The person or organization taking responsibility for the medical content of the document
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]
40. EHDSDischargeReportCore.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
42. EHDSDischargeReportCore.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
44. EHDSDischargeReportCore.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
46. EHDSDischargeReportCore.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
48. EHDSDischargeReportCore.header.confidentiality
Definition | Level of confidentiality of the document. Implicit value is normal.
Short | Level of confidentiality of the document. Implicit value is normal.
Control | 0..1
Binding | hl7:Confidentiality
Type | CodeableConcept
50. EHDSDischargeReportCore.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
52. EHDSDischargeReportCore.header.intendedRecipient[x]
Definition | Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
Short | Intended recipient
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatientCore, 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, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
54. EHDSDischargeReportCore.header.healthInsuranceAndPaymentInformation
Definition | Health insurance and payment information
Short | Health insurance and payment information
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCoverage
56. EHDSDischargeReportCore.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
58. EHDSDischargeReportCore.body.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
60. EHDSDischargeReportCore.body.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
62. EHDSDischargeReportCore.body.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAdvanceDirective
64. EHDSDischargeReportCore.body.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
66. EHDSDischargeReportCore.body.alerts.description
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
68. EHDSDischargeReportCore.body.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSDischargeReportCore.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
72. EHDSDischargeReportCore.body.alerts.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAllergyIntoleranceCore
Requirements | eHN Guideline HDR (v1.1): A.2.2.1
74. EHDSDischargeReportCore.body.alerts.otherAlert
Definition | The warning can be entered in code (there are codes for frequently used alerts) but seeing the dynamic nature of the warnings, these alerts will often be entered as free text
Short | A warning, other than included in allergies.
Control | 0..*
Type | CodeableConcept
76. EHDSDischargeReportCore.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
78. EHDSDischargeReportCore.body.encounterInformation.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSDischargeReportCore.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
82. EHDSDischargeReportCore.body.encounterInformation.location
Definition | locations/departments where the patient stayed during the encounter
Short | locations/departments where the patient stayed during the encounter
Control | 0..*
Type | Base
84. EHDSDischargeReportCore.body.encounterInformation.location.period
Definition | Time period during which the patient was present at the location
Short | Time period during which the patient was present at the location
Control | 1..1
Type | Period
86. EHDSDischargeReportCore.body.encounterInformation.location.organisation
Definition | The organisation or part
Short | The organisation or part
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
88. EHDSDischargeReportCore.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
90. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary
Definition | The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Short | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
92. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.narrative
Definition | Problem description in narrative form.
Short | Problem description in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
94. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails
Definition | Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. 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 problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
Control | 0..*
Type | Base
96. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
Definition | Class of the problem (treated, other) in relation to the encounter.
Short | Class of the problem (treated, other) in relation to the encounter.
Control | 1..1
Type | CodeableConcept
98. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSConditionCore
100. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures
Definition | Significant surgical and non-surgical 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. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.
Short | Significant procedures section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
102. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
104. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedureCore
106. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Short | Medical devices and implants section
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
108. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUseCore
112. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy
Definition | Selected drug treatment during encounter. Medicinal products that were administered during encounter and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section. Medicinal products, the administration of which was started during encounter, but is also recommended after discharge, will be listed in the summary table in the recommendation section.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
114. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
116. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatementCore
118. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults
Definition | Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during encounter. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
Short | Significant Observation Results
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.6
120. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
122. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
124. EHDSDischargeReportCore.body.courseOfEncounter.synthesis
Definition | This section provides 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 | Synthesis
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
126. EHDSDischargeReportCore.body.courseOfEncounter.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
128. EHDSDischargeReportCore.body.courseOfEncounter.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
130. EHDSDischargeReportCore.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
132. EHDSDischargeReportCore.body.dischargeDetails.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
134. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
136. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
138. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.3
140. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.4
142. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.5
144. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person's abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one's own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
146. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
148. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus.functionalStatusAssessment
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/EHDSFunctionalStatusCore
150. EHDSDischargeReportCore.body.dischargeDetails.dischargeNote
Definition | Discharge Note
Short | Discharge Note
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
152. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary
Definition | Medication summary. 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 | Medication summary. 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
154. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
156. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry
Definition | Structured medication entry
Short | Structured medication entry
Control | 0..*
Type | Base
158. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.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/EHDSMedicationStatementCore
160. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.daysSupplied
Definition | Supply is intended to either hand over the medicine or write out a prescription. A 0 value indicates that the patient has not been provided with the drug (e.g. if the patient has a sufficient supply of the drug)
Short | Number of days for which the patient was provided with the drug at the time of discharge
Control | 0..1
Type | Quantity
162. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.reasonForChange
Definition | Reason for change in medication
Short | Reason for change in medication
Control | 0..1
Type | CodeableConcept
164. EHDSDischargeReportCore.body.dischargeDetails.carePlan
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
166. EHDSDischargeReportCore.body.dischargeDetails.carePlan.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
168. EHDSDischargeReportCore.body.dischargeDetails.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
170. EHDSDischargeReportCore.body.dischargeDetails.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
172. EHDSDischargeReportCore.body.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
174. EHDSDischargeReportCore.body.admissionEvaluation.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
176. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
178. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.2
180. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.3
182. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.physicalExaminationNote
Definition | Physical examination Observation note
Short | Physical examination Observation note
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
184. EHDSDischargeReportCore.body.patientHistory
Definition | Section: Patient health history (anamnesis).
Short | Section: Patient health history (anamnesis).
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
186. EHDSDischargeReportCore.body.patientHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
188. EHDSDischargeReportCore.body.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1
190. EHDSDischargeReportCore.body.patientHistory.medicalHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
192. EHDSDischargeReportCore.body.patientHistory.medicalHistory.pastProblems
Definition | 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.
Short | Past problems
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSConditionCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.1
194. EHDSDischargeReportCore.body.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUseCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.2
196. EHDSDischargeReportCore.body.patientHistory.medicalHistory.historyOfProcedures
Definition | Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
Short | History of procedures
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedureCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.3
198. EHDSDischargeReportCore.body.patientHistory.medicalHistory.device
Definition | Device
Short | Device
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
200. EHDSDischargeReportCore.body.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.2
202. EHDSDischargeReportCore.body.patientHistory.familyHistorySection.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
204. EHDSDischargeReportCore.body.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFamilyMemberHistory
206. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3
208. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
210. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.1
212. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
Short | Work situation
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
214. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
216. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient's social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
218. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.2
220. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
222. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
224. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.3
226. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
228. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Short | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
230. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
232. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.4
234. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
236. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient's home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
238. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person's marital status according to the terms and definition in the national civil code.
Short | Person's marital status according to the terms and definition in the national civil code.
Control | 0..1
Binding | hl7:marital-status
Type | CodeableConcept
240. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
242. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
244. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
246. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
248. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child's date of birth.
Short | Child's date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
250. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
252. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
254. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.4
256. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
258. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.1
260. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.2
262. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.3
264. EHDSDischargeReportCore.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. EHDSDischargeReportCore
Definition | EHDS refined base model for Discharge Report
Short | Discharge Report model
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSDischargeReportCore.header
4. EHDSDischargeReportCore.header.intendedRecipient[x]
Definition | Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
Short | Intended recipient
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatientCore, 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, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
6. EHDSDischargeReportCore.header.healthInsuranceAndPaymentInformation
Definition | Health insurance and payment information
Short | Health insurance and payment information
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCoverage
8. EHDSDischargeReportCore.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
10. EHDSDischargeReportCore.body.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
12. EHDSDischargeReportCore.body.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
14. EHDSDischargeReportCore.body.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAdvanceDirective
16. EHDSDischargeReportCore.body.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
18. EHDSDischargeReportCore.body.alerts.description
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSDischargeReportCore.body.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. EHDSDischargeReportCore.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
24. EHDSDischargeReportCore.body.alerts.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAllergyIntoleranceCore
Requirements | eHN Guideline HDR (v1.1): A.2.2.1
26. EHDSDischargeReportCore.body.alerts.otherAlert
Definition | The warning can be entered in code (there are codes for frequently used alerts) but seeing the dynamic nature of the warnings, these alerts will often be entered as free text
Short | A warning, other than included in allergies.
Control | 0..*
Type | CodeableConcept
28. EHDSDischargeReportCore.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
30. EHDSDischargeReportCore.body.encounterInformation.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
32. EHDSDischargeReportCore.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
34. EHDSDischargeReportCore.body.encounterInformation.location
Definition | locations/departments where the patient stayed during the encounter
Short | locations/departments where the patient stayed during the encounter
Control | 0..*
Type | Base
36. EHDSDischargeReportCore.body.encounterInformation.location.period
Definition | Time period during which the patient was present at the location
Short | Time period during which the patient was present at the location
Control | 1..1
Type | Period
38. EHDSDischargeReportCore.body.encounterInformation.location.organisation
Definition | The organisation or part
Short | The organisation or part
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
40. EHDSDischargeReportCore.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
42. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary
Definition | The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Short | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
44. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.narrative
Definition | Problem description in narrative form.
Short | Problem description in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
46. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails
Definition | Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. 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 problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
Control | 0..*
Type | Base
48. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
Definition | Class of the problem (treated, other) in relation to the encounter.
Short | Class of the problem (treated, other) in relation to the encounter.
Control | 1..1
Type | CodeableConcept
50. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSConditionCore
52. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures
Definition | Significant surgical and non-surgical 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. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.
Short | Significant procedures section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
54. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
56. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedureCore
58. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Short | Medical devices and implants section
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
60. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
62. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUseCore
64. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy
Definition | Selected drug treatment during encounter. Medicinal products that were administered during encounter and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section. Medicinal products, the administration of which was started during encounter, but is also recommended after discharge, will be listed in the summary table in the recommendation section.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
66. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
68. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatementCore
70. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults
Definition | Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during encounter. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
Short | Significant Observation Results
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.6
72. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
76. EHDSDischargeReportCore.body.courseOfEncounter.synthesis
Definition | This section provides 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 | Synthesis
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
78. EHDSDischargeReportCore.body.courseOfEncounter.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSDischargeReportCore.body.courseOfEncounter.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
82. EHDSDischargeReportCore.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
84. EHDSDischargeReportCore.body.dischargeDetails.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
86. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
88. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.3
92. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.4
94. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.5
96. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person's abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one's own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
98. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus.functionalStatusAssessment
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/EHDSFunctionalStatusCore
102. EHDSDischargeReportCore.body.dischargeDetails.dischargeNote
Definition | Discharge Note
Short | Discharge Note
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
104. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary
Definition | Medication summary. 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 | Medication summary. 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
106. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
108. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry
Definition | Structured medication entry
Short | Structured medication entry
Control | 0..*
Type | Base
110. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.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/EHDSMedicationStatementCore
112. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.daysSupplied
Definition | Supply is intended to either hand over the medicine or write out a prescription. A 0 value indicates that the patient has not been provided with the drug (e.g. if the patient has a sufficient supply of the drug)
Short | Number of days for which the patient was provided with the drug at the time of discharge
Control | 0..1
Type | Quantity
114. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.reasonForChange
Definition | Reason for change in medication
Short | Reason for change in medication
Control | 0..1
Type | CodeableConcept
116. EHDSDischargeReportCore.body.dischargeDetails.carePlan
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
118. EHDSDischargeReportCore.body.dischargeDetails.carePlan.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
120. EHDSDischargeReportCore.body.dischargeDetails.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
122. EHDSDischargeReportCore.body.dischargeDetails.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
124. EHDSDischargeReportCore.body.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
126. EHDSDischargeReportCore.body.admissionEvaluation.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
128. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
130. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.2
132. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.3
134. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.physicalExaminationNote
Definition | Physical examination Observation note
Short | Physical examination Observation note
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
136. EHDSDischargeReportCore.body.patientHistory
Definition | Section: Patient health history (anamnesis).
Short | Section: Patient health history (anamnesis).
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
138. EHDSDischargeReportCore.body.patientHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
140. EHDSDischargeReportCore.body.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1
142. EHDSDischargeReportCore.body.patientHistory.medicalHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
144. EHDSDischargeReportCore.body.patientHistory.medicalHistory.pastProblems
Definition | 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.
Short | Past problems
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSConditionCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.1
146. EHDSDischargeReportCore.body.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUseCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.2
148. EHDSDischargeReportCore.body.patientHistory.medicalHistory.historyOfProcedures
Definition | Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
Short | History of procedures
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedureCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.3
150. EHDSDischargeReportCore.body.patientHistory.medicalHistory.device
Definition | Device
Short | Device
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
152. EHDSDischargeReportCore.body.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.2
154. EHDSDischargeReportCore.body.patientHistory.familyHistorySection.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
156. EHDSDischargeReportCore.body.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFamilyMemberHistory
158. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3
160. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
162. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.1
164. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
Short | Work situation
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
166. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
168. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient's social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
170. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.2
172. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
174. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
176. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.3
178. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
180. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Short | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
182. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
184. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.4
186. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
188. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient's home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
190. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person's marital status according to the terms and definition in the national civil code.
Short | Person's marital status according to the terms and definition in the national civil code.
Control | 0..1
Binding | hl7:marital-status
Type | CodeableConcept
192. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
194. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
196. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
198. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
200. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child's date of birth.
Short | Child's date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
202. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
204. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
206. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.4
208. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
210. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.1
212. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.2
214. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.3
216. EHDSDischargeReportCore.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. EHDSDischargeReportCore
Definition | EHDS refined base model for Discharge Report
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. EHDSDischargeReportCore.header
Definition | Common header for all patient-related data
Short | Document header elements
Control | 1..1
Type | Base
4. EHDSDischargeReportCore.header.subject
Definition | Patient/subject information
Short | Patient/subject information
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient
6. EHDSDischargeReportCore.header.identifier
Definition | Business identifier for the object
Short | Unique identifier of the document
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSDischargeReportCore.header.authorship
Definition | Resource authoring details
Short | Resource authoring details
Control | 1..*
Type | Base
10. EHDSDischargeReportCore.header.authorship.author[x]
Definition | Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Short | Author(s) by whom the resource was/were authored. Multiple authors 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/EHDSOrganisation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
12. EHDSDischargeReportCore.header.authorship.datetime
Definition | Date and time of authoring/issuing
Short | Date and time of authoring/issuing
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
14. EHDSDischargeReportCore.header.lastUpdate
Definition | Date and time of the last update to the resource (may be used for technical corrections).
Short | Date and time of the last update to the resource (may be used for technical corrections).
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSDischargeReportCore.header.status
Definition | Status of the resource or document
Short | Status of the resource or document
Control | 1..1
Type | CodeableConcept
18. EHDSDischargeReportCore.header.statusReason[x]
Definition | Reason for the current status of the resource.
Short | Reason for the current status of the resource.
Control | 0..1
Type | Choice of: CodeableConcept, string
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSDischargeReportCore.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
22. EHDSDischargeReportCore.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
24. EHDSDischargeReportCore.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
26. EHDSDischargeReportCore.header.period
Definition | Time of service that is being documented
Short | Time of service that is being documented
Control | 0..1
Type | Period
28. EHDSDischargeReportCore.header.version
Definition | Business version of the document.
Short | Business version of the document.
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
30. EHDSDischargeReportCore.header.attestation
Definition | Document attestation details
Short | Document attestation details
Control | 0..*
Type | Base
32. EHDSDischargeReportCore.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]
34. EHDSDischargeReportCore.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
36. EHDSDischargeReportCore.header.legalAuthentication
Definition | Document legal authentication details
Short | Document legal authentication details
Control | 0..1
Type | Base
38. EHDSDischargeReportCore.header.legalAuthentication.legalAuthenticator[x]
Definition | The person or organization taking responsibility for the medical content of the document
Short | The person or organization taking responsibility for the medical content of the document
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]
40. EHDSDischargeReportCore.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
42. EHDSDischargeReportCore.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
44. EHDSDischargeReportCore.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
46. EHDSDischargeReportCore.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
48. EHDSDischargeReportCore.header.confidentiality
Definition | Level of confidentiality of the document. Implicit value is normal.
Short | Level of confidentiality of the document. Implicit value is normal.
Control | 0..1
Binding | hl7:Confidentiality
Type | CodeableConcept
50. EHDSDischargeReportCore.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
52. EHDSDischargeReportCore.header.intendedRecipient[x]
Definition | Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
Short | Intended recipient
Control | 0..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatientCore, 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, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
54. EHDSDischargeReportCore.header.healthInsuranceAndPaymentInformation
Definition | Health insurance and payment information
Short | Health insurance and payment information
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCoverage
56. EHDSDischargeReportCore.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
58. EHDSDischargeReportCore.body.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
60. EHDSDischargeReportCore.body.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
62. EHDSDischargeReportCore.body.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAdvanceDirective
64. EHDSDischargeReportCore.body.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
66. EHDSDischargeReportCore.body.alerts.description
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
68. EHDSDischargeReportCore.body.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSDischargeReportCore.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
72. EHDSDischargeReportCore.body.alerts.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAllergyIntoleranceCore
Requirements | eHN Guideline HDR (v1.1): A.2.2.1
74. EHDSDischargeReportCore.body.alerts.otherAlert
Definition | The warning can be entered in code (there are codes for frequently used alerts) but seeing the dynamic nature of the warnings, these alerts will often be entered as free text
Short | A warning, other than included in allergies.
Control | 0..*
Type | CodeableConcept
76. EHDSDischargeReportCore.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
78. EHDSDischargeReportCore.body.encounterInformation.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSDischargeReportCore.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
82. EHDSDischargeReportCore.body.encounterInformation.location
Definition | locations/departments where the patient stayed during the encounter
Short | locations/departments where the patient stayed during the encounter
Control | 0..*
Type | Base
84. EHDSDischargeReportCore.body.encounterInformation.location.period
Definition | Time period during which the patient was present at the location
Short | Time period during which the patient was present at the location
Control | 1..1
Type | Period
86. EHDSDischargeReportCore.body.encounterInformation.location.organisation
Definition | The organisation or part
Short | The organisation or part
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
88. EHDSDischargeReportCore.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
90. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary
Definition | The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Short | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
92. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.narrative
Definition | Problem description in narrative form.
Short | Problem description in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
94. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails
Definition | Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. 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 problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
Control | 0..*
Type | Base
96. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
Definition | Class of the problem (treated, other) in relation to the encounter.
Short | Class of the problem (treated, other) in relation to the encounter.
Control | 1..1
Type | CodeableConcept
98. EHDSDischargeReportCore.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSConditionCore
100. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures
Definition | Significant surgical and non-surgical 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. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.
Short | Significant procedures section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
102. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
104. EHDSDischargeReportCore.body.courseOfEncounter.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedureCore
106. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Short | Medical devices and implants section
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
108. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSDischargeReportCore.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUseCore
112. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy
Definition | Selected drug treatment during encounter. Medicinal products that were administered during encounter and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section. Medicinal products, the administration of which was started during encounter, but is also recommended after discharge, will be listed in the summary table in the recommendation section.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
114. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
116. EHDSDischargeReportCore.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatementCore
118. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults
Definition | Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during encounter. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
Short | Significant Observation Results
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.6
120. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
122. EHDSDischargeReportCore.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
124. EHDSDischargeReportCore.body.courseOfEncounter.synthesis
Definition | This section provides 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 | Synthesis
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
126. EHDSDischargeReportCore.body.courseOfEncounter.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
128. EHDSDischargeReportCore.body.courseOfEncounter.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
130. EHDSDischargeReportCore.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
132. EHDSDischargeReportCore.body.dischargeDetails.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
134. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
136. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
138. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.3
140. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.4
142. EHDSDischargeReportCore.body.dischargeDetails.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.5
144. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person's abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one's own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
146. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
148. EHDSDischargeReportCore.body.dischargeDetails.functionalStatus.functionalStatusAssessment
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/EHDSFunctionalStatusCore
150. EHDSDischargeReportCore.body.dischargeDetails.dischargeNote
Definition | Discharge Note
Short | Discharge Note
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
152. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary
Definition | Medication summary. 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 | Medication summary. 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
154. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
156. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry
Definition | Structured medication entry
Short | Structured medication entry
Control | 0..*
Type | Base
158. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.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/EHDSMedicationStatementCore
160. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.daysSupplied
Definition | Supply is intended to either hand over the medicine or write out a prescription. A 0 value indicates that the patient has not been provided with the drug (e.g. if the patient has a sufficient supply of the drug)
Short | Number of days for which the patient was provided with the drug at the time of discharge
Control | 0..1
Type | Quantity
162. EHDSDischargeReportCore.body.dischargeDetails.medicationSummary.entry.reasonForChange
Definition | Reason for change in medication
Short | Reason for change in medication
Control | 0..1
Type | CodeableConcept
164. EHDSDischargeReportCore.body.dischargeDetails.carePlan
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
166. EHDSDischargeReportCore.body.dischargeDetails.carePlan.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
168. EHDSDischargeReportCore.body.dischargeDetails.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
170. EHDSDischargeReportCore.body.dischargeDetails.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
172. EHDSDischargeReportCore.body.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
174. EHDSDischargeReportCore.body.admissionEvaluation.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
176. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
178. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.2
180. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservationCore
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.3
182. EHDSDischargeReportCore.body.admissionEvaluation.objectiveFindings.physicalExaminationNote
Definition | Physical examination Observation note
Short | Physical examination Observation note
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
184. EHDSDischargeReportCore.body.patientHistory
Definition | Section: Patient health history (anamnesis).
Short | Section: Patient health history (anamnesis).
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
186. EHDSDischargeReportCore.body.patientHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
188. EHDSDischargeReportCore.body.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1
190. EHDSDischargeReportCore.body.patientHistory.medicalHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
192. EHDSDischargeReportCore.body.patientHistory.medicalHistory.pastProblems
Definition | 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.
Short | Past problems
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSConditionCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.1
194. EHDSDischargeReportCore.body.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUseCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.2
196. EHDSDischargeReportCore.body.patientHistory.medicalHistory.historyOfProcedures
Definition | Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
Short | History of procedures
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedureCore
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.3
198. EHDSDischargeReportCore.body.patientHistory.medicalHistory.device
Definition | Device
Short | Device
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
200. EHDSDischargeReportCore.body.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.2
202. EHDSDischargeReportCore.body.patientHistory.familyHistorySection.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
204. EHDSDischargeReportCore.body.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFamilyMemberHistory
206. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3
208. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
210. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.1
212. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
Short | Work situation
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
214. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
216. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient's social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
218. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.2
220. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
222. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
224. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.3
226. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
228. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Short | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
230. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
232. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.4
234. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
236. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient's home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
238. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person's marital status according to the terms and definition in the national civil code.
Short | Person's marital status according to the terms and definition in the national civil code.
Control | 0..1
Binding | hl7:marital-status
Type | CodeableConcept
240. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
242. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
244. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
246. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
248. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child's date of birth.
Short | Child's date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
250. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
252. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
254. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.4
256. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
258. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.1
260. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.2
262. EHDSDischargeReportCore.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.3
264. EHDSDischargeReportCore.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]