HL7 Europe Hospital Discharge Report
1.0.0-ci - draft
150
HL7 Europe Hospital Discharge Report
1.0.0-ci - draft
150
HL7 Europe Hospital Discharge Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ci built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/hdr/ and changes regularly. See the Directory of published versions
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
<http://hl7.org/fhir/Composition/b9dc409d-ec81-4556-9fac-4dc3f731c199> a fhir:Composition ;
fhir:nodeRole fhir:treeRoot ;
fhir:Resource.id [ fhir:value "b9dc409d-ec81-4556-9fac-4dc3f731c199"] ;
fhir:Resource.meta [
fhir:Meta.profile [
fhir:value "http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr" ;
fhir:index 0 ;
fhir:link <http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr>
]
] ;
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ] ;
fhir:Narrative.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-hdr.html\">Composition (HDR)</a></p></div><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 --> 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\">PractitionerRole</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\">Organization Casa di cura Villa S. Giuliana</a></p></div>"
] ;
fhir:Composition.status [ fhir:value "final"] ;
fhir:Composition.type [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:34105-7 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "34105-7" ] ;
fhir:Coding.display [ fhir:value "Hospital Discharge summary" ]
]
] ;
fhir:Composition.subject [
fhir:Reference.reference [ fhir:value "urn:uuid:b01a2623-e219-41d2-8e78-1fa1439751d0" ]
] ;
fhir:Composition.encounter [
fhir:Reference.reference [ fhir:value "urn:uuid:7c9a2bf1-507f-4d43-b06e-d78e9670379d" ]
] ;
fhir:Composition.date [ fhir:value "2025-04-29T13:30:00+01:00"^^xsd:dateTime] ;
fhir:Composition.author [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:74403dd8-bb1b-45f9-bb69-e843dfaf45e9" ]
] ;
fhir:Composition.title [ fhir:value "Hospital Discharge Report"] ;
fhir:Composition.custodian [
fhir:Reference.reference [ fhir:value "urn:uuid:a61a91f8-b8f2-4947-9a64-5165ea380a38" ]
] ;
fhir:Composition.section [
fhir:index 0 ;
fhir:Composition.section.title [ fhir:value "Admission evaluation" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:67851-6 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "67851-6" ]
], [
fhir:index 1 ;
a loinc:67852-4 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "67852-4" ] ;
fhir:Coding.display [ fhir:value "Hospital Admission evaluation note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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 7.8%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.</div>"
]
], [
fhir:index 1 ;
fhir:Composition.section.title [ fhir:value "Family History" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:10157-6 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "10157-6" ] ;
fhir:Coding.display [ fhir:value "History of family member diseases note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).</div>"
] ;
fhir:Composition.section.entry [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:635c22e7-d7f1-45ad-9b4d-d4fe35239085" ]
], [
fhir:index 1 ;
fhir:Reference.reference [ fhir:value "urn:uuid:3fbdfbe1-9d70-47ec-ac05-3e30b063365a" ]
]
], [
fhir:index 2 ;
fhir:Composition.section.title [ fhir:value "Vital signs note" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:8716-3 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "8716-3" ] ;
fhir:Coding.display [ fhir:value "Vital signs note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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/></tr><tr><td>Blood Pressure</td><td>155 / 95 mmHg</td><td>150 / 90 mmHg</td></tr></tbody></table></div>"
] ;
fhir:Composition.section.entry [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:f0113857-b9b7-429b-8893-b645a38ae20a" ]
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fhir:index 1 ;
fhir:Reference.reference [ fhir:value "urn:uuid:065c918f-730a-47f8-938a-7ad54618037b" ]
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fhir:index 2 ;
fhir:Reference.reference [ fhir:value "urn:uuid:81783ae4-c36d-424f-8cea-fe7d3407a36b" ]
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fhir:index 3 ;
fhir:Reference.reference [ fhir:value "urn:uuid:a19e48e1-2271-4cdb-9c76-b0626c7a5363" ]
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fhir:index 4 ;
fhir:Reference.reference [ fhir:value "urn:uuid:fd7f7580-5788-45dd-88ec-dca615d69c7d" ]
]
], [
fhir:index 3 ;
fhir:Composition.section.title [ fhir:value "Tobacco use" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:11367-0 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "11367-0" ] ;
fhir:Coding.display [ fhir:value "History of Tobacco use" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">The patient smokes \"a few\" cigarettes per day.</div>"
] ;
fhir:Composition.section.entry [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6" ]
]
], [
fhir:index 4 ;
fhir:Composition.section.title [ fhir:value "Hospital course note" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:8648-8 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "8648-8" ] ;
fhir:Coding.display [ fhir:value "Hospital course note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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/>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>"
]
], [
fhir:index 5 ;
fhir:Composition.section.title [ fhir:value "Significant Observation Results" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:30954-2 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "30954-2" ] ;
fhir:Coding.display [ fhir:value "Relevant diagnostic tests/laboratory data note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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>< 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>"
]
], [
fhir:index 6 ;
fhir:Composition.section.title [ fhir:value "Significant procedures" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:10185-7 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "10185-7" ] ;
fhir:Coding.display [ fhir:value "Hospital discharge procedure note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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/>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/>Starting Pharmacotherapy with Metformin.</div>"
] ;
fhir:Composition.section.entry [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0" ]
], [
fhir:index 1 ;
fhir:Reference.reference [ fhir:value "urn:uuid:a74a3dca-92fa-4b71-8e70-89a07ac74bc3" ]
], [
fhir:index 2 ;
fhir:Reference.reference [ fhir:value "urn:uuid:53a8c3c3-5d1b-4950-87bc-fddae2ebc079" ]
]
], [
fhir:index 7 ;
fhir:Composition.section.title [ fhir:value "Medications" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:87232-5 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "87232-5" ] ;
fhir:Coding.display [ fhir:value "Medication administration.brief" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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/></tr></tbody></table></div>"
] ;
fhir:Composition.section.entry [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:bda0b497-c9f2-47ca-8339-da1d379cb2f4" ]
]
], [
fhir:index 8 ;
fhir:Composition.section.title [ fhir:value "Follow-up" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:18776-5 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "18776-5" ] ;
fhir:Coding.display [ fhir:value "Plan of care note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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>"
] ;
fhir:Composition.section.entry [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:b84038f8-9541-4c5b-93b0-a7f1b8e55bd3" ]
]
], [
fhir:index 9 ;
fhir:Composition.section.title [ fhir:value "Diagnosis at Discharge" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:11535-2 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "11535-2" ] ;
fhir:Coding.display [ fhir:value "Hospital discharge diagnosis note" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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>"
] ;
fhir:Composition.section.entry [
fhir:index 0 ;
fhir:Reference.reference [ fhir:value "urn:uuid:a5bf69e4-24db-48a8-9eda-71516dcaf1d9" ]
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], [
fhir:index 10 ;
fhir:Composition.section.title [ fhir:value "Hospital Discharge Instructions" ] ;
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0 ;
a loinc:8653-8 ;
fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
fhir:Coding.code [ fhir:value "8653-8" ] ;
fhir:Coding.display [ fhir:value "Hospital Discharge Instructions" ]
]
] ;
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "additional" ] ;
fhir:Narrative.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>"
]
] .
# - ontology header ------------------------------------------------------------
<http://hl7.org/fhir/Composition/b9dc409d-ec81-4556-9fac-4dc3f731c199.ttl> a owl:Ontology ;
owl:imports fhir:fhir.ttl ;
owl:versionIRI <http://build.fhir.org/Composition/b9dc409d-ec81-4556-9fac-4dc3f731c199.ttl> .
IG © 2024+ HL7 Europe. Package hl7.fhir.eu.hdr#1.0.0-ci based on FHIR 4.0.1. Generated 2026-06-26
