HL7 Europe Discharge Report
1.0.0-ci-build - ci-build 150

HL7 Europe Discharge Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/discharge-report/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Discharge Report

Discharge Report document profiles.

Bundle: obligations

This profile defines obligations for the Discharge Report for the scope of this guide.

Composition: obligations

This profile defines obligations for a Discharge Report (DR) for the scope of this guide.

Obligations (Informative)

Obligations used to describe the Discharge Report functional requirements for the specified data elements. Informative for this version of the guide.

AllergyIntolerance: obligations

This profile defines obligations for the AllergyIntolerance resource for the purpose of this guide.

CarePlan: obligations

This profile defines obligations for the CarePlan resource for the purpose of this guide.

Condition: obligations

This profile defines obligations for the Condition resource for the purpose of this guide.

Device: obligations

This profile defines obligations for the Device resource for the purpose of this guide.

DeviceUseStatement: obligations

This profile defines obligations for the DeviceUseStatement resource for the purpose of this guide.

Encounter: obligations

This profile defines obligations for the encounter documented by a Discharge Report in HL7 FHIR for the scope of this guide.

Flag: obligations

This profile defines obligations for the Flag resource to represent alerts or warnings in FHIR for the purpose of this guide.

Immunization: obligations

This profile defines obligations for the Immunization resource for the purpose of this guide.

Medication: obligations

This profile defines obligations for the Medication resource for the purpose of this guide, adapted from the MPD work.

MedicationAdministration: obligations

This profile defines obligations for the MedicationAdministration resource for the purpose of this guide, adapted from the MPD work.

MedicationDispense: obligations

This profile defines obligations for the MedicationDispense resource for the purpose of this guide, adapted from the MPD work.

MedicationRequest: obligations

This profile defines obligations for the MedicationRequest resource for the purpose of this guide, adapted from the MPD work.

MedicationStatement: obligations

This profile defines obligations for the MedicationStatement resource for the purpose of this guide, adapted from the MPD work.

Observation (laboratory): obligations

This profile defines obligations for laboratory observations in the scope of this guide.

Observation: obligations

This profile defines obligations for observations in the scope of this guide.

Organization: obligations

This profile defines obligations for an organisation in FHIR for the purpose of this guide.

Patient: obligations

This profile defines obligations for a human Patient in FHIR for the purpose of this guide.

Practitioner: obligations

This profile defines obligations for a health professional represented as a Practitioner in FHIR for the purpose of this guide.

PractitionerRole: obligations

This profile defines obligations for a health professional role in FHIR for the purpose of this guide.

Procedure: obligations

This profile defines obligations for the Procedure resource for the purpose of this guide.

RelatedPerson: obligations

This profile defines obligations for a related person in FHIR for the purpose of this guide.

Specimen: obligations

This profile defines obligations for Specimen in FHIR for the purpose of this guide.

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

Bundle (DR)

Clinical document used to represent a Discharge Report for the scope of this guide.

CarePlan (DR)

This profile constrains the CarePlan resource for the purpose of this guide.

Composition (DR)

Clinical document used to represent a Discharge Report (DR) for the scope of this guide. A Discharge Report summarises the care provided during a healthcare encounter - for example a hospital stay, an emergency department visit, a day-care episode, a rehabilitation stay or an ambulatory specialist episode - and the information needed to ensure continuity of care after discharge.

Device (DR)

This profile represents the constraints applied to the Device resource for the purpose of this guide. A device used by or implanted on the patient is described in the discharge report as an instance of a Device resource constrained by this profile.

DeviceUseStatement (DR)

This profile represents the constraints applied to the DeviceUseStatement resource for the purpose of this guide. The use of a device by the patient, or the presence of an implanted device, is described in the discharge report as an instance of a DeviceUseStatement resource constrained by this profile.

Encounter (DR)

This profile defines how to represent the encounter documented by a Discharge Report in HL7 FHIR for the scope of this guide. The encounter may be of any kind leading to a discharge, for example an inpatient hospital stay, an emergency department visit, a day-care episode, a rehabilitation stay or an ambulatory episode.

Goal (DR)

This profile constrains the Goal resource for the purpose of this guide. It represents the goals of the patient care plan, aligned with the EHDSCarePlan logical model, and is referenced by CarePlanEuDr.

MedicationAdministration (DR)

This profile constrains the MedicationAdministration resource for the purpose of this guide, adapted from the MPD work.

MedicationDispense (DR)

This profile constrains the MedicationDispense resource for the purpose of this guide, adapted from the MPD work.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Admission Urgency Value Set

Discharge Report Admission Urgency value set includes selected codes from HL7 v3-ActPriority code system.

Condition Value Set (DR)

Discharge Report Condition value set includes selected codes from recommended EU code systems for health conditions (WHO-ICD-10, SNOMED CT and Orphacodes).

Discharge Report Type Value Set

Discharge Report Type value set includes selected LOINC document type codes used to identify the kind of discharge report. The generic code 18842-5 (Discharge summary) is used when no more specific code applies, for example for reports produced at the end of a day-care, rehabilitation or ambulatory episode.

Encounter Class Value Set

Discharge Report Encounter Class value set includes codes from the HL7 v3-ActCode code system that are used to classify the general type of encounter the discharge report refers to (e.g. inpatient, emergency, ambulatory or home health encounters).

Encounter Status Value Set

Discharge Report Encounter Status value set includes codes from the FHIR R4 EncounterStatus code system that are used to represent the state of the encounter.

Encounter Type Value Set

Discharge Report Encounter Type value set includes concepts from SNOMED CT descendants of 225351009 (Care provision regime) that are used to classify the care provision regimen during the encounter.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

AllergyIntolerance: Critical Allergy to Penicillin

A high-priority allergy to Penicillin, with a specific reaction and severity.

BodyStructure: Left Hip Joint

A left hip joint, expressed as a laterality-free structure code plus a separate laterality, so that consumers do not have to derive the side from a pre-coordinated code.

Bundle: Emergency Department Discharge Report, Chest Pain

HL7 FHIR Bundle example of an Emergency Department Discharge Report (HL7 Europe Discharge Report) for Maria Rossi, discharged home after an emergency department visit for chest pain.

Bundle: HDR Acute Respiratory Failure (Italian)

HL7 FHIR Bundle example of a Hospital Discharge Report (HL7 Europe Discharge Report) for Paolo Marcheschi.

Bundle: HDR Inguinal Hernia with Sub-sections (Czech)

HL7 FHIR Bundle example of a Hospital Discharge Report (HL7 Europe Discharge Report) for with structured composition for Czech patient Petr Novák.

Bundle: HDR Lower Leg Fracture

HL7 FHIR Bundle example of a Hospital Discharge Report (HL7 Europe Discharge Report) for Reijer Wolff.

Bundle: HDR Twin Delivery by Cesarean Section

HL7 FHIR Bundle example of a Hospital Discharge Report (HL7 Europe Discharge Report) for Fiona Swart.

Bundle: HDR Type 2 Diabetes Mellitus

HL7 FHIR Bundle example of a Hospital Discharge Report (HL7 Europe Discharge Report) for Luigi De Luca.

CarePlan: Diabetes Management Plan

Care plan for diabetes management, including referrals and HbA1c measurement.

Composition: HDR Type 2 Diabetes Mellitus

HL7 FHIR Composition example of a Hospital Discharge Report (HL7 Europe Discharge Report) for Luigi De Luca

Condition: Osteoarthritis of the Left Hip

Osteoarthritis whose body site, including the side of the body, is carried by a referenced BodyStructure rather than by a pre-coordinated bodySite code.

Condition: Type 2 Diabetes Mellitus

Condition representing type 2 diabetes mellitus, coded with ICD-10 and SNOMED CT.

Device: Implantable Pacemaker

A sample Device resource for an implantable pacemaker, referenced in a DeviceUseStatement.

Device: Total Hip Replacement Prosthesis

A sample Device resource for an implanted hip prosthesis, referenced in a DeviceUseStatement.

DeviceUseStatement: Implanted Pacemaker

A DeviceUseStatement documenting the use of an implanted pacemaker in the discharge report.

DeviceUseStatement: Total Hip Replacement Prosthesis

An implanted hip prosthesis whose body site, including the side of the body, is carried by a referenced BodyStructure. DeviceUseStatement.bodySite uses the R5 backport extension for DeviceUsage.bodySite, because the context of use of the generic bodySite extension does not cover DeviceUseStatement.

Encounter: Hospital admission and discharge, Reijer Wolff

A sample Encounter resource for a hospital admission and discharge.

FamilyMemberHistory: Type 2 Diabetes Mellitus - Mother

Mother has a history of type 2 diabetes mellitus.

Flag: Critical Allergy to Penicillin

A high-priority allergy alert referencing the specific AllergyIntolerance resource.

Flag: Do Not Use Left Arm

A clinical flag advising care teams to avoid using the patient's left arm for procedures.

Goal: Postoperative Mobilization

Goal profile example representing the goal of full postoperative mobilization after cesarean section.

Immunization: COVID-19 vaccine dose administered

An example record of an administered COVID-19 vaccine dose.

Medication: Cefuroxime 1500 mg, branded

1C. Cefuroxime 1500mg (1.5g) powder for solution in a vial (10 vials per package). Branded packaged product, defined by attributes.

Medication: Cefuroxime 1500 mg, generic

1A. Cefuroxime 1500mg (1.5g) powder for solution in a vial. Generic product, defined by attributes.

MedicationAdministration: Paracetamol

A sample MedicationAdministration resource for Paracetamol.

MedicationDispense: Cefuroxime 1500 mg, First Dispense

400D-1. Medication dispense fulfilling the first part of the order: 1 package containing 10 vials.

MedicationRequest: Cefuroxime 1500 mg, Single Line

400C. A prescription/request with one medication and changing dosage. Uses the 'actionable' tag. Cefuroxime sodium.

MedicationStatement: Enalapril

A sample MedicationStatement for a patient taking Enalapril, used in the context of the European Discharge Report.

Observation: ABO Group

ABO blood group type in blood.

Observation: Abdominal circumference

Example of an abdominal circumference vital-sign observation

Observation: Alcohol use

Example of Social History Observation - Alcohol Use

Observation: Blood pressure

Example of a blood pressure vital-sign observation (systolic and diastolic)

Observation: Body height

Example of a body height vital-sign observation

Observation: Body mass index

Example of a body mass index (BMI) vital-sign observation

Observation: Body weight, Fiona Swart

Vital signs observation representing the body weight of the patient.

Observation: Body weight, Petr Novák

Example of a body weight vital-sign observation

Observation: Chest circumference

Example of a chest circumference vital-sign observation

Observation: Head circumference

Example of a head circumference vital-sign observation

Observation: Smoking status

Example of Social History Observation - Smoking

Organization: Erasmus MC

Organization representing the Erasmus MC, Sophia kinderziekenhuis.

Patient: Dutch Patient

Patient resource representing Fiona Swart, a Dutch patient.

Procedure: Cesarean Section

A planned cesarean section procedure.

Procedure: Total Replacement of the Left Hip

A total hip replacement whose body site, including the side of the body, is carried by a referenced BodyStructure rather than by a pre-coordinated bodySite code.