HDR-Luigi-De-Luca-Example
type: Bundle
node role: treeRoot
id:
  v: HDR-Luigi-De-Luca-Example
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/bundle-eu-hdr
    l: bundle-eu-hdr
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: PRN
  system:
    v: https://hl7europe.org/example-identifier
    l: example-identifier
type:
  v: document
timestamp:
  v: 2025-04-29T14:00:00Z

urn:…
type: Composition
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr
    l: composition-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Composition b9dc409d-ec81-4556-9fac-4dc3f731c199 Profile: Composition (HDR) status: Final type: Hospital Discharge summary encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); serviceType = Diabetes mellitus screening (procedure); period = 2025-04-01 08:45:00+0000 --> 2025-04-10 11:00:00+0000; reasonCode = Prediabetes (finding) date: 2025-04-29 13:30:00+0100 author: PractitionerRole title: Hospital Discharge Report custodian: Organization Casa di cura Villa S. Giuliana
status:
  v: final
type:
  coding: https://loinc.org/rdf/34105-7
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 34105-7
    display:
      v: Hospital Discharge summary
date:
  v: 2025-04-29T13:30:00+01:00
title:
  v: Hospital Discharge Report
section:
  title:
    v: Admission evaluation
  code:
    coding: https://loinc.org/rdf/67851-6
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 67851-6
    coding: https://loinc.org/rdf/67852-4
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 67852-4
      display:
        v: Hospital Admission evaluation note
  text:
    status:
      v: additional
    div:
      v: 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. When Mr De Luca arrived in the morning we recorded a fasting blood glucose level at 180 mg/dL. His HbA1c level was 7.8%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.
section:
  title:
    v: Family History
  code:
    coding: https://loinc.org/rdf/10157-6
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 10157-6
      display:
        v: History of family member diseases Narrative
  text:
    status:
      v: additional
    div:
      v: Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).
section:
  title:
    v: Vital signs
  code:
    coding: https://loinc.org/rdf/8716-3
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 8716-3
      display:
        v: Vital signs
  text:
    status:
      v: additional
    div:
      v: Vital signs 1st April 10th April Body weight 109 kg 108 kg Body height 177 cm Blood Pressure 155 / 95 mmHg 150 / 90 mmHg
section:
  title:
    v: Tobacco use
  code:
    coding: https://loinc.org/rdf/11367-0
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 11367-0
      display:
        v: History of Tobacco use
  text:
    status:
      v: additional
    div:
      v: The patient smokes "a few" cigarettes per day.
section:
  title:
    v: Hospital Course
  code:
    coding: https://loinc.org/rdf/8648-8
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 8648-8
      display:
        v: Hospital Course
  text:
    status:
      v: additional
    div:
      v: During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment. 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.
section:
  title:
    v: Significant Observation Results
  code:
    coding: https://loinc.org/rdf/30954-2
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 30954-2
      display:
        v: Relevant diagnostic tests/laboratory data Narrative
  text:
    status:
      v: additional
    div:
      v: 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. Date Fasting glucose [Moles/volume] in Blood Range 1 April 2025 180 mg/dL 70 to 99 mg/dL 2 April 2025 140 mg/dL 70 to 99 mg/dL 3 April 2025 150 mg/dL 70 to 99 mg/dL 5 April 2025 140 mg/dL 70 to 99 mg/dL HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus. Date Hemoglobin A1c [Mass/volume] in Blood Range 1 April 2025 7.2% < 5.7% Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance. Date Glucose [Mass/volume] in Serum or Plasma --1 hour post dose glucose Range 2 April 2025 180 mg/dL 70 to 99 mg/dL
section:
  title:
    v: Significant procedures
  code:
    coding: https://loinc.org/rdf/10185-7
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 10185-7
      display:
        v: Hospital discharge procedures Narrative
  text:
    status:
      v: additional
    div:
      v: 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. 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. Starting Pharmacotherapy with Metformin.
section:
  title:
    v: Medications
  code:
    coding: https://loinc.org/rdf/87232-5
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 87232-5
      display:
        v: Medication administration.brief
  text:
    status:
      v: additional
    div:
      v: Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels. Medication administrations Dose/Frequency SNOMED Metformin, oral tbl 500 mg, twice / day 765507008 Multivitamines daily
section:
  title:
    v: Follow-up
  code:
    coding: https://loinc.org/rdf/18776-5
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 18776-5
      display:
        v: Plan of care note
  text:
    status:
      v: additional
    div:
      v: Follow-up Activity SNOMED Endocrinology Clinic Follow-up appointment in 2 weeks to assess response to treatment 306118006 Referral to endocrinology service (procedure) Dietitian Consultation Appointment in 1 month for further dietary planning 103699006 Referral to dietitian (procedure) Routine Blood tests Repeat HbA1c in 3 months 43396009 Hemoglobin A1c measurement (procedure)
section:
  title:
    v: Diagnosis at Discharge
  code:
    coding: https://loinc.org/rdf/11535-2
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 11535-2
      display:
        v: Hospital discharge Dx Narrative
  text:
    status:
      v: additional
    div:
      v: Discharge Diagnoses Codes Type 2 Diabetes Mellitus – Newly diagnosed. Type 2 diabetes mellitus E11 (ICD-10) Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)

urn:…
type: Patient
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Patient b01a2623-e219-41d2-8e78-1fa1439751d0 Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) Other Id: Medical record number/8121c77e7bf9 Contact Detail +39 0334 8920354 Via Zannoni 29 Serso 38057 Italy (home)
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: NI
  system:
    v: https://hl7europe.org/example-identifier
    l: example-identifier
  value:
    v: 3332-386800-1
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: MR
  system:
    v: https://hl7europe.org/example-identifier
    l: example-identifier
  value:
    v: 8121c77e7bf9
name:
  text:
    v: Luigi De Luca
  family:
    v: De Luca
  given:
    v: Luigi
telecom:
  system:
    v: phone
  value:
    v: +39 0334 8920354
gender:
  v: male
birth date:
  v: 1966-09-30
address:
  use:
    v: home
  type:
    v: physical
  line:
    v: Via Zannoni 29
  city:
    v: Serso
  postal code:
    v: 38057
  country:
    v: Italy

urn:…
type: Encounter
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/encounter-eu-hdr
    l: encounter-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Encounter 7c9a2bf1-507f-4d43-b06e-d78e9670379d Profile: Encounter (HDR) status: finished class: ActCode: IMP (inpatient encounter) serviceType: Diabetes mellitus screening (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) period: 2025-04-01 08:45:00+0000 --> 2025-04-10 11:00:00+0000 reasonCode: Prediabetes (finding) serviceProvider: Organization Casa di cura Villa S. Giuliana
status:
  v: finished
class:
  system:
    v: http://terminology.hl7.org/CodeSystem/v3-ActCode
    l: v3-ActCode
  code:
    v: IMP
service type:
  coding: http://snomed.info/id/171183004
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 171183004
    display:
      v: Diabetes mellitus screening (procedure)
period:
  start:
    v: 2025-04-01T08:45:00Z
  end:
    v: 2025-04-10T11:00:00Z
reason code:
  coding: http://snomed.info/id/714628002
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 714628002
    display:
      v: Prediabetes (finding)

urn:…
type: PractitionerRole
text:
  status:
    v: generated
  div:
    v: Generated Narrative: PractitionerRole 74403dd8-bb1b-45f9-bb69-e843dfaf45e9 practitioner: Practitioner Augusto Zucchero-Combattente organization: Organization Casa di cura Villa S. Giuliana

urn:…
type: Practitioner
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Practitioner 0710d9e7-3f1a-4e16-a9b3-5c991fe23c95 name: Augusto Zucchero-Combattente telecom: augusto@casasgiuliana.osp.venetia.it
name:
  family:
    v: Zucchero-Combattente
  given:
    v: Augusto
  prefix:
    v: dr
telecom:
  system:
    v: email

urn:…
type: Organization
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Organization a61a91f8-b8f2-4947-9a64-5165ea380a38 name: Casa di cura Villa S. Giuliana address: Verona 37128 it
name:
  v: Casa di cura Villa S. Giuliana
address:
  city:
    v: Verona
  postal code:
    v: 37128
  country:
    v: it

urn:…
type: Condition
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/condition-eu-hdr
    l: condition-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Condition a5bf69e4-24db-48a8-9eda-71516dcaf1d9 Profile: Condition (HDR) clinicalStatus: Active code: Type 2 diabetes mellitus subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) onset: 2025-04-04
clinical status:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/condition-clinical
      l: condition-clinical
    code:
      v: active
code:
  coding:
    system:
      v: http://hl7.org/fhir/sid/icd-10
      l: icd-10
    code:
      v: E11
    display:
      v: Type 2 diabetes mellitus
  coding: http://snomed.info/id/44054006
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 44054006
    display:
      v: Diabetes mellitus type 2 (disorder)
onset: DateTime
  v: 2025-04-04

urn:…
type: CarePlan
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/carePlan-eu-hdr
    l: carePlan-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: CarePlan b84038f8-9541-4c5b-93b0-a7f1b8e55bd3 Profile: Care Plan (HDR) status: Active intent: Plan category: Diabetes clinical management plan title: Diabetes Management Plan subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) period: 2025-04-10 --> (ongoing) activity Details - Code Status * Referral to endocrinology service Not Started activity Details - Code Status * Referral to dietitian Not Started activity Details - Code Status * Hemoglobin A1c measurement Not Started
status:
  v: active
intent:
  v: plan
category:
  coding: http://snomed.info/id/736284000
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 736284000
    display:
      v: Diabetes clinical management plan
title:
  v: Diabetes Management Plan
period:
  start:
    v: 2025-04-10
activity:
  detail:
    code:
      coding: http://snomed.info/id/306118006
    status:
      v: not-started
activity:
  detail:
    code:
      coding: http://snomed.info/id/103699006
    status:
      v: not-started
activity:
  detail:
    code:
      coding: http://snomed.info/id/43396009
    status:
      v: not-started

urn:…
type: Procedure
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr
    l: procedure-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Procedure 92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0 Profile: Procedure (HDR) status: Completed code: Lifestyle education (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) performed: 2025-04-05
status:
  v: completed
code:
  coding: http://snomed.info/id/313204009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 313204009
    display:
      v: Lifestyle education (procedure)
performed: DateTime
  v: 2025-04-05

urn:…
type: Procedure
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr
    l: procedure-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Procedure a74a3dca-92fa-4b71-8e70-89a07ac74bc3 Profile: Procedure (HDR) status: Completed code: Diabetic education (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) performed: 2025-04-04
status:
  v: completed
code:
  coding: http://snomed.info/id/6143009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 6143009
    display:
      v: Diabetic education (procedure)
performed: DateTime
  v: 2025-04-04

urn:…
type: Procedure
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr
    l: procedure-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Procedure 53a8c3c3-5d1b-4950-87bc-fddae2ebc079 Profile: Procedure (HDR) status: In Progress code: Metformin therapy (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) performed: 2025-04-04
status:
  v: in-progress
code:
  coding: http://snomed.info/id/1340186004
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 1340186004
    display:
      v: Metformin therapy (procedure)
performed: DateTime
  v: 2025-04-04

urn:…
type: FamilyMemberHistory
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/familyMemberHistory-eu-hdr
    l: familyMemberHistory-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: FamilyMemberHistory 635c22e7-d7f1-45ad-9b4d-d4fe35239085 Profile: FamilyMemberHistory (HDR) status: Completed patient: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) relationship: mother Conditions - Code * Family history of diabetes mellitus type 2 (situation)
status:
  v: completed
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-RoleCode
      l: v3-RoleCode
    code:
      v: MTH
    display:
      v: mother
condition:
  code:
    coding: http://snomed.info/id/430679000
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 430679000
      display:
        v: Family history of diabetes mellitus type 2 (situation)

urn:…
type: FamilyMemberHistory
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/familyMemberHistory-eu-hdr
    l: familyMemberHistory-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: FamilyMemberHistory 3fbdfbe1-9d70-47ec-ac05-3e30b063365a Profile: FamilyMemberHistory (HDR) status: Completed patient: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) relationship: maternal grandmother Conditions - Code * Family history of diabetes mellitus type 2 (situation)
status:
  v: completed
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-RoleCode
      l: v3-RoleCode
    code:
      v: MGRMTH
    display:
      v: maternal grandmother
condition:
  code:
    coding: http://snomed.info/id/430679000
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 430679000
      display:
        v: Family history of diabetes mellitus type 2 (situation)

urn:…
type: Observation
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Observation f0113857-b9b7-429b-8893-b645a38ae20a status: Final category: Vital Signs code: Body weight subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 value: 109 kg (Details: UCUM codekg = 'kg')
status:
  v: final
category:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/observation-category
      l: observation-category
    code:
      v: vital-signs
    display:
      v: Vital Signs
code:
  coding: https://loinc.org/rdf/29463-7
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 29463-7
    display:
      v: Body weight
effective: DateTime
  v: 2025-04-01
value: Quantity
  value:
    v: 109
  unit:
    v: kg
  system:
    v: http://unitsofmeasure.org
    l: unitsofmeasure.org
  code:
    v: kg

urn:…
type: Observation
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Observation 065c918f-730a-47f8-938a-7ad54618037b status: Final category: Vital Signs code: Body weight subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-19 value: 108 kg (Details: UCUM codekg = 'kg')
status:
  v: final
category:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/observation-category
      l: observation-category
    code:
      v: vital-signs
    display:
      v: Vital Signs
code:
  coding: https://loinc.org/rdf/29463-7
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 29463-7
    display:
      v: Body weight
effective: DateTime
  v: 2025-04-19
value: Quantity
  value:
    v: 108
  unit:
    v: kg
  system:
    v: http://unitsofmeasure.org
    l: unitsofmeasure.org
  code:
    v: kg

urn:…
type: Observation
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Observation 81783ae4-c36d-424f-8cea-fe7d3407a36b status: Final category: Vital Signs code: Body height subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 value: 177 cm (Details: UCUM codecm = 'cm')
status:
  v: final
category:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/observation-category
      l: observation-category
    code:
      v: vital-signs
    display:
      v: Vital Signs
code:
  coding: https://loinc.org/rdf/8302-2
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 8302-2
    display:
      v: Body height
effective: DateTime
  v: 2025-04-01
value: Quantity
  value:
    v: 177
  unit:
    v: cm
  system:
    v: http://unitsofmeasure.org
    l: unitsofmeasure.org
  code:
    v: cm

urn:…
type: Observation
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Observation a19e48e1-2271-4cdb-9c76-b0626c7a5363 status: Final category: Vital Signs code: Blood pressure panel with all children optional subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 component code: Systolic blood pressure value: 155 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') component code: Diastolic blood pressure value: 95 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
status:
  v: final
category:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/observation-category
      l: observation-category
    code:
      v: vital-signs
    display:
      v: Vital Signs
code:
  coding: https://loinc.org/rdf/85354-9
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 85354-9
    display:
      v: Blood pressure panel with all children optional
effective: DateTime
  v: 2025-04-01
component:
  code:
    coding: https://loinc.org/rdf/8480-6
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 8480-6
      display:
        v: Systolic blood pressure
  value: Quantity
    value:
      v: 155
    unit:
      v: mmHg
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: mm[Hg]
component:
  code:
    coding: https://loinc.org/rdf/8462-4
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 8462-4
      display:
        v: Diastolic blood pressure
  value: Quantity
    value:
      v: 95
    unit:
      v: mmHg
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: mm[Hg]

urn:…
type: Observation
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Observation fd7f7580-5788-45dd-88ec-dca615d69c7d status: Final category: Vital Signs code: Blood pressure panel with all children optional subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-10 component code: Systolic blood pressure value: 150 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') component code: Diastolic blood pressure value: 90 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
status:
  v: final
category:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/observation-category
      l: observation-category
    code:
      v: vital-signs
    display:
      v: Vital Signs
code:
  coding: https://loinc.org/rdf/85354-9
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 85354-9
    display:
      v: Blood pressure panel with all children optional
effective: DateTime
  v: 2025-04-10
component:
  code:
    coding: https://loinc.org/rdf/8480-6
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 8480-6
      display:
        v: Systolic blood pressure
  value: Quantity
    value:
      v: 150
    unit:
      v: mmHg
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: mm[Hg]
component:
  code:
    coding: https://loinc.org/rdf/8462-4
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 8462-4
      display:
        v: Diastolic blood pressure
  value: Quantity
    value:
      v: 90
    unit:
      v: mmHg
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: mm[Hg]

urn:…
type: Observation
text:
  status:
    v: generated
  div:
    v: Generated Narrative: Observation 67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6 status: Final category: Social History code: History of Tobacco use subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 value: Current smoker note: Patient smokes a few cigarettes a day
status:
  v: final
category:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/observation-category
      l: observation-category
    code:
      v: social-history
    display:
      v: Social History
code:
  coding: https://loinc.org/rdf/11367-0
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 11367-0
    display:
      v: History of Tobacco use
effective: DateTime
  v: 2025-04-01
value: CodeableConcept
  coding: http://snomed.info/id/77176002
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 77176002
    display:
      v: Current smoker
note:
  text:
    v: Patient smokes a few cigarettes a day

urn:…
type: MedicationAdministration
meta:
  profile:
    v: http://hl7.eu/fhir/hdr/StructureDefinition/medicationAdministration-eu-hdr
    l: medicationAdministration-eu-hdr
text:
  status:
    v: generated
  div:
    v: Generated Narrative: MedicationAdministration bda0b497-c9f2-47ca-8339-da1d379cb2f4 Profile: MedicationAdministration (HDR) status: In Progress medication: Product containing precisely metformin hydrochloride 500 milligram/1 each prolonged-release oral tablet (clinical drug) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-03 --> (ongoing) Dosages - Text Route Dose * 500 mg, twice a day Oral route 500 mg
status:
  v: in-progress
medication: CodeableConcept
  coding: http://snomed.info/id/765507008
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 765507008
    display:
      v: Product containing precisely metformin hydrochloride 500 milligram/1 each prolonged-release oral tablet (clinical drug)
effective: Period
  start:
    v: 2025-04-03
dosage:
  text:
    v: 500 mg, twice a day
  route:
    coding: http://snomed.info/id/26643006
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 26643006
      display:
        v: Oral route
  dose:
    value:
      v: 500
    unit:
      v: mg

title:
  v: Hospital Discharge Instructions
code:
  coding: https://loinc.org/rdf/8653-8
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 8653-8
    display:
      v: Hospital Discharge Instructions
text:
  status:
    v: additional
  div:
    v: Instructions at Discharge to Mr. De Luca Continue home glucose monitoring and to maintain a log for review at follow-up appointments. Continue with the prescribed medication and lifestyle changes. Monitor blood sugar levels at home regularly. Adhere to the diabetic diet plan. Stay physically active, with at least 30 minutes of moderate exercise most days of the week. Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).

v: 306118006

v: Referral to endocrinology service

v: 103699006

v: Referral to dietitian

v: 43396009

v: Hemoglobin A1c measurement