{
  "resourceType" : "Composition",
  "id" : "b9dc409d-ec81-4556-9fac-4dc3f731c199",
  "meta" : {
    "profile" : ["http://hl7.eu/fhir/discharge-report/StructureDefinition/composition-eu-dr"]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition b9dc409d-ec81-4556-9fac-4dc3f731c199</b></p><a name=\"b9dc409d-ec81-4556-9fac-4dc3f731c199\"> </a><a name=\"hcb9dc409d-ec81-4556-9fac-4dc3f731c199\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-composition-eu-dr.html\">Composition (DR)</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/7.1.0/NamingSystem-uri.html\" title=\"As defined by RFC 3986 (http://www.ietf.org/rfc/rfc3986.txt)(with many schemes defined in many RFCs). For OIDs and UUIDs, use the URN form (urn:oid:(note: lowercase) and urn:uuid:). See http://www.ietf.org/rfc/rfc3001.txt and http://www.ietf.org/rfc/rfc4122.txt \r\n\r\nThis oid is used as an identifier II.root to indicate the the extension is an absolute URI (technically, an IRI). Typically, this is used for OIDs and GUIDs. Note that when this OID is used with OIDs and GUIDs, the II.extension should start with urn:oid or urn:uuid: \r\n\r\nNote that this OID is created to aid with interconversion between CDA and FHIR - FHIR uses urn:ietf:rfc:3986 as equivalent to this OID. URIs as identifiers appear more commonly in FHIR.\r\n\r\nThis OID may also be used in CD.codeSystem.\">Uniform Resource Identifier (URI)</a>/urn:uuid:3694ad44-910d-417a-837c-f48e78446f50</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 34105-7}\">Hospital Discharge summary</span></p><p><b>encounter</b>: <a href=\"Bundle-HDR-Luigi-De-Luca-Example.html#urn-uuid-7c9a2bf1-507f-4d43-b06e-d78e9670379d\">Encounter: status = finished; class = inpatient encounter (ActCode#IMP); serviceType = Diabetes mellitus screening (procedure); period = 2025-04-01 08:45:00+0000 --&gt; 2025-04-10 11:00:00+0000; reasonCode = Prediabetes (finding)</a></p><p><b>date</b>: 2025-04-29 13:30:00+0100</p><p><b>author</b>: <a href=\"Bundle-HDR-Luigi-De-Luca-Example.html#urn-uuid-74403dd8-bb1b-45f9-bb69-e843dfaf45e9\">Augusto Zucchero-Combattente at Casa di cura Villa S. Giuliana</a></p><p><b>title</b>: Hospital Discharge Report</p><p><b>custodian</b>: <a href=\"Bundle-HDR-Luigi-De-Luca-Example.html#urn-uuid-a61a91f8-b8f2-4947-9a64-5165ea380a38\">Casa di cura Villa S. Giuliana</a></p></div>"
  },
  "identifier" : {
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:uuid:3694ad44-910d-417a-837c-f48e78446f50"
  },
  "status" : "final",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "34105-7",
      "display" : "Hospital Discharge summary"
    }]
  },
  "subject" : {
    "reference" : "urn:uuid:b01a2623-e219-41d2-8e78-1fa1439751d0"
  },
  "encounter" : {
    "reference" : "urn:uuid:7c9a2bf1-507f-4d43-b06e-d78e9670379d"
  },
  "date" : "2025-04-29T13:30:00+01:00",
  "author" : [{
    "reference" : "urn:uuid:74403dd8-bb1b-45f9-bb69-e843dfaf45e9"
  }],
  "title" : "Hospital Discharge Report",
  "custodian" : {
    "reference" : "urn:uuid:a61a91f8-b8f2-4947-9a64-5165ea380a38"
  },
  "section" : [{
    "title" : "Admission evaluation",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "67851-6"
      },
      {
        "system" : "http://loinc.org",
        "code" : "67852-4",
        "display" : "Hospital Admission evaluation note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi De Luca, a 57-year-old male, was admitted on 1st April following a pre-diabetic episode characterized by episodes of fatigue, polyuria, and increased thirst. Recent routine blood tests showed elevated fasting blood glucose and HbA1c levels that required further investigation.<p/>When Mr De Luca arrived in the morning we recorded a fasting blood glucose level at 180 mg/dL. His HbA1c level was 7.2%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.</div>"
    }
  },
  {
    "title" : "Family History",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "10157-6",
        "display" : "History of family member diseases note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).</div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:635c22e7-d7f1-45ad-9b4d-d4fe35239085"
    },
    {
      "reference" : "urn:uuid:3fbdfbe1-9d70-47ec-ac05-3e30b063365a"
    }]
  },
  {
    "title" : "Vital signs note",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8716-3",
        "display" : "Vital signs note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Vital signs</th><th>1st April</th><th>10th April</th></tr></thead><tbody><tr><td>Body weight</td><td>109 kg</td><td>108 kg</td></tr><tr><td>Body height</td><td>177 cm</td><td></td></tr><tr><td>Blood Pressure</td><td>155 / 95 mmHg</td><td>150 / 90 mmHg</td></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:f0113857-b9b7-429b-8893-b645a38ae20a"
    },
    {
      "reference" : "urn:uuid:065c918f-730a-47f8-938a-7ad54618037b"
    },
    {
      "reference" : "urn:uuid:81783ae4-c36d-424f-8cea-fe7d3407a36b"
    },
    {
      "reference" : "urn:uuid:a19e48e1-2271-4cdb-9c76-b0626c7a5363"
    },
    {
      "reference" : "urn:uuid:fd7f7580-5788-45dd-88ec-dca615d69c7d"
    }]
  },
  {
    "title" : "Tobacco use",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11367-0",
        "display" : "History of Tobacco use"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">The patient smokes \"a few\" cigarettes per day.</div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6"
    }]
  },
  {
    "title" : "Hospital course note",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8648-8",
        "display" : "Hospital course note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment.<p></p>Throughout his hospital stay, Mr. De Luca was monitored closely. His blood sugar levels improved modestly with the introduction of Metformin, and no acute complications were observed.</div>"
    }
  },
  {
    "title" : "Significant Observation Results",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "30954-2",
        "display" : "Relevant diagnostic tests/laboratory data note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Blood Glucose Monitoring Regular monitoring of fasting blood glucose levels and random blood glucose levels. Fasting glucose levels consistently ranged between 140-180 mg/dL.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Fasting glucose [Moles/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>2 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>3 April 2025</td><td>150 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>5 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table>HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Hemoglobin A1c [Mass/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>7.2%</td><td>&lt; 5.7%</td></tr></tbody></table>Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Glucose [Mass/volume] in Serum or Plasma --1 hour post dose glucose</th><th>Range</th></tr></thead><tbody><tr><td>2 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table></div>"
    }
  },
  {
    "title" : "Significant procedures",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "10185-7",
        "display" : "Hospital discharge procedure note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Lifestyle Consultation: Mr. De Luca met with a dietitian to discuss necessary changes in his diet, focusing on a low glycemic index diet and the need to monitor carbohydrate intake. He was also advised to engage in regular physical activity.<p></p>Diabetes Education: Mr. De Luca attended educational sessions on diabetes management, including the importance of regular blood sugar monitoring, recognizing hypoglycemia and hyperglycemia symptoms, and foot care.<p></p>Starting Pharmacotherapy with Metformin.</div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0"
    },
    {
      "reference" : "urn:uuid:a74a3dca-92fa-4b71-8e70-89a07ac74bc3"
    },
    {
      "reference" : "urn:uuid:53a8c3c3-5d1b-4950-87bc-fddae2ebc079"
    }]
  },
  {
    "title" : "Medications",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "87232-5",
        "display" : "Medication administration.brief"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels.<table class=\"hl7__hdr\"><thead><tr><th>Medication administrations</th><th>Dose/Frequency</th><th>SNOMED</th></tr></thead><tbody><tr><td>Metformin, oral tbl</td><td>500 mg, twice / day</td><td>765507008</td></tr><tr><td>Multivitamines</td><td>daily</td><td></td></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:bda0b497-c9f2-47ca-8339-da1d379cb2f4"
    }]
  },
  {
    "title" : "Follow-up",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "18776-5",
        "display" : "Plan of care note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Follow-up</th><th>Activity</th><th>SNOMED</th></tr></thead><tbody><tr><td>Endocrinology Clinic</td><td>Follow-up appointment in 2 weeks to assess response to treatment</td><td>306118006 Referral to endocrinology service (procedure)</td></tr><tr><td>Dietitian Consultation</td><td>Appointment in 1 month for further dietary planning</td><td>103699006 Referral to dietitian (procedure)</td></tr><tr><td>Routine Blood tests</td><td>Repeat HbA1c in 3 months</td><td>43396009 Hemoglobin A1c measurement (procedure)</td></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:b84038f8-9541-4c5b-93b0-a7f1b8e55bd3"
    }]
  },
  {
    "title" : "Diagnosis at Discharge",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11535-2",
        "display" : "Hospital discharge diagnosis note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Discharge Diagnoses</th><th>Codes</th></tr></thead><tbody><tr><td>Type 2 Diabetes Mellitus – Newly diagnosed.</td><td><ul><li>Type 2 diabetes mellitus E11 (ICD-10)</li><li>Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)</li></ul></td></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:a5bf69e4-24db-48a8-9eda-71516dcaf1d9"
    }]
  },
  {
    "title" : "Hospital Discharge Instructions",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8653-8",
        "display" : "Hospital Discharge Instructions"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Instructions at Discharge to Mr. De Luca<ul><li>Continue home glucose monitoring and to maintain a log for review at follow-up appointments.</li><li>Continue with the prescribed medication and lifestyle changes.</li><li>Monitor blood sugar levels at home regularly.</li><li>Adhere to the diabetic diet plan.</li><li>Stay physically active, with at least 30 minutes of moderate exercise most days of the week.</li><li>Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).</li></ul></div>"
    }
  }]
}