HL7 Europe Hospital Discharge Report
0.0.1-ci - ci-build 150

HL7 Europe Hospital Discharge Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 0.0.1-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

Logical Model: HospitalStayEhn - Detailed Descriptions

Draft as of 2024-11-21

Definitions for the HospitalStay logical model.

Guidance on how to interpret the contents of this table can be found here

0. HospitalStay
Definition

Hospital Discharge Report - Hospital stay - A.2.6 eHN

ShortA.2.6 - Hospital stay (eHN)
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. HospitalStay.diagnosticSummary
Definition

All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. 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.

ShortA.2.7.1 - Diagnostic summary
Control1..*
TypeBackboneElement
4. HospitalStay.diagnosticSummary.problemDescription
Definition

Problem specification in narrative form

ShortA.2.7.1.1 - Problem description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
6. HospitalStay.diagnosticSummary.problemDetails
Definition

Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.

ShortA.2.7.1.2 - Problem details
Control0..*
TypeBackboneElement
8. HospitalStay.diagnosticSummary.onsetDate
Definition

Onset date of a problem/condition

ShortA.2.7.1.3 - Onset date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
10. HospitalStay.diagnosticSummary.endDate
Definition

The date or estimated date that the condition resolved or went into remission.

ShortA.2.7.1.4 - End date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
12. HospitalStay.diagnosticSummary.category
Definition

Category of the problem allows flagging for conditions acquired during hospital stay.

ShortA.2.7.1.5 - Category
Control1..1
TypeCodeableConcept
14. HospitalStay.diagnosticSummary.treatmentClass
Definition

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital 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).

ShortA.2.7.1.6 - Treatment class
Control1..1
TypeCodeableConcept
16. HospitalStay.diagnosticSummary.clinicalStatus
Definition

Status of the condition/problem (active, resolved, inactive, ...)

ShortA.2.7.1.7 - Clinical status
Control0..1
TypeCodeableConcept
18. HospitalStay.diagnosticSummary.resolution
Definition

Describes the reason for which the status of the problem changed from current to inactive (e.g. surgical procedure, medical treatment, etc.). This field includes 'free text' if the resolution circumstances are not already included in other fields such as surgical procedure, medical device, etc., e.g. hepatic cystectomy (this will be the resolution circumstances for the problem 'hepatic cyst' and will be included in surgical procedures).

ShortA.2.7.1.8 - Resolution circumstances
Control0..1
TypeBackboneElement
20. HospitalStay.diagnosticSummary.severity
Definition

A subjective assessment of the severity of the condition as evaluated by the clinician.

ShortA.2.7.1.9 - Severity
Control0..1
TypeCodeableConcept
22. HospitalStay.diagnosticSummary.stage
Definition

Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.

ShortA.2.7.1.10 - Stage
Control0..*
TypeCodeableConcept
24. HospitalStay.significantProcedures
Definition

Significant surgical and non-surgical procedures performed during hospitalisation 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.

ShortA.2.7.2 - Significant procedures
Control1..*
TypeBackboneElement
26. HospitalStay.significantProcedures.procedureCode
Definition

Procedure code

ShortA.2.7.2.1 - Procedure code
Control0..*
TypeCodeableConcept
28. HospitalStay.significantProcedures.description
Definition

Narrative description of the procedure

ShortA.2.7.2.2 - Procedure description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
30. HospitalStay.significantProcedures.bodySite
Definition

Procedure target body site and laterality

ShortA.2.7.2.3 - Body site
Control0..1
TypeCodeableConcept
32. HospitalStay.significantProcedures.date
Definition

Date and time when procedure was performed

ShortA.2.7.2.4 - Procedure date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
34. HospitalStay.significantProcedures.reason
Definition

The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.

ShortA.2.7.2.5 - Procedure reason
Control0..*
TypeCodeableConcept
36. HospitalStay.significantProcedures.outcome
Definition

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

ShortA.2.7.2.6 - Outcome
Control0..1
TypeCodeableConcept
38. HospitalStay.significantProcedures.complication
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the procedure description, which will typically describe the procedure itself rather than any 'post procedure' issues.

ShortA.2.7.2.7 - Complication
Control0..*
TypeCodeableConcept
40. HospitalStay.significantProcedures.focalDevice
Definition

A reference to the device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

ShortA.2.7.2.8 - Focal device
Control0..*
TypeBackboneElement
42. HospitalStay.medicalDevices
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 hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system

ShortA.2.7.3 - Medical devices and implants
Control1..*
TypeBackboneElement
44. HospitalStay.medicalDevices.description
Definition

Describes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

ShortA.2.7.3.1 - Device and implant description
Control1..1
TypeCodeableConcept
46. HospitalStay.medicalDevices.identifier
Definition

Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745

ShortA.2.7.3.2 - Device ID
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
48. HospitalStay.medicalDevices.implantDate
Definition

The date and time the device was implanted or when its use began.

ShortA.2.7.3.3 - Implant date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. HospitalStay.medicalDevices.endDate
Definition

Date and time when the device was explanted from the patient or the external device was no longer in use; likewise when the device is planned to be explanted

ShortA.2.7.3.4 - End date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
52. HospitalStay.medicalDevices.reason
Definition

The medical reason for use of the medical device.

ShortA.2.7.3.5 - Reason
Control0..*
TypeCodeableConcept
54. HospitalStay.pharmacotherapy
Definition

Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation 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 hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.

ShortA.2.7.5 - Pharmacotherapy
Control0..*
TypeBackboneElement
56. HospitalStay.pharmacotherapy.reason
Definition

The reason why the medication is or was prescribed or used. It provides a link to the Past or current health conditions or problems that the patient has had or has.

ShortA.2.7.5.1 - Medication reason
Control0..1
TypeCodeableConcept
58. HospitalStay.pharmacotherapy.productCode
Definition

Product code

ShortA.2.7.5.2 - Code
Control1..1
TypeCodeableConcept
60. HospitalStay.pharmacotherapy.intendedUse
Definition

Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.

ShortA.2.7.5.3 - Intended use
Control0..*
TypeCodeableConcept
62. HospitalStay.pharmacotherapy.productName
Definition

Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)

ShortA.2.7.5.4 - Brand name
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
64. HospitalStay.pharmacotherapy.activeIngredient
Definition

Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: 'paracetamol'

ShortA.2.7.5.5 - Active ingredient list
Control0..*
TypeCodeableConcept
66. HospitalStay.pharmacotherapy.strength
Definition

The content of the active ingredient expressed quantifiably per dosage unit, per unit of volume or per unit of weight, according to the pharmaceutical dose form. Example: 500 mg per tablet

ShortA.2.7.5.6 - Strength
Control0..*
TypeRatio
68. HospitalStay.pharmacotherapy.doseForm
Definition

The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)

ShortA.2.7.5.7 - Pharmaceutical dose form
Control0..1
TypeCodeableConcept
70. HospitalStay.pharmacotherapy.dosageRegimen
Definition

Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days

ShortA.2.7.5.8 - Dosage Regimen
Control0..*
TypeBackboneElement
72. HospitalStay.pharmacotherapy.route
Definition

Path by which the pharmaceutical product is taken into or makes contact with the body.

ShortA.2.7.5.9 - Route of administration
Control0..1
TypeCodeableConcept
74. HospitalStay.pharmacotherapy.period
Definition

The time interval when the patient was, or was not, given the medication.

ShortA.2.7.5.10 - Period of treatment
Control0..1
TypePeriod
76. HospitalStay.significantResults
Definition

Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.

ShortA.2.7.6 - Significant Observation Results
Control0..*
TypeBackboneElement
78. HospitalStay.significantResults.date
Definition

Date and time of the observation

ShortA.2.7.6.1 - Date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
80. HospitalStay.significantResults.status
Definition

Status of the observation (e.g. registered, preliminary, final)

ShortA.2.7.6.2 - Observation status
Control1..1
TypeCodeableConcept
82. HospitalStay.significantResults.description
Definition

Narrative representation of the observation result and findings.

ShortA.2.7.6.3 - Result description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
84. HospitalStay.significantResults.details
Definition

Observation details include code that identifies observation, specification of the observed body structure or specimen, date and time of the specimen collection, observation method or protocol used and other aspects of the observation.

ShortA.2.7.6.4 - Observation details
Control1..1
TypeBackboneElement
86. HospitalStay.significantResults.result
Definition

Result of the observation including numeric and coded results of the measurement, details about how the tests were done to get the result values, information about reference ranges and result interpretation. Content of the observation result will vary according to the type of the observation.

ShortA.2.7.6.5 - Observation result
Control0..1
TypeBackboneElement
88. HospitalStay.significantResults.reporter
Definition

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

ShortA.2.7.6.7 - Reporter
Control0..*
TypeBackboneElement
90. HospitalStay.synthesis
Definition

This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

ShortA.2.7.7 - Synthesis
Control1..1
TypeBackboneElement
92. HospitalStay.synthesis.description
Definition

Summary description of the reason and course of hospitalisation for a specific problem.

ShortA.2.7.7.1 - Problem synthesis
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
94. HospitalStay.synthesis.reasoning
Definition

The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.

ShortA.2.7.7.2 - Clinical reasoning
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be found here

0. HospitalStay
Definition

Hospital Discharge Report - Hospital stay - A.2.6 eHN

ShortA.2.6 - Hospital stay (eHN)
Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. HospitalStay.diagnosticSummary
Definition

All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. 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.

ShortA.2.7.1 - Diagnostic summary
Control1..*
TypeBackboneElement
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. HospitalStay.diagnosticSummary.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. HospitalStay.diagnosticSummary.problemDescription
Definition

Problem specification in narrative form

ShortA.2.7.1.1 - Problem description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
8. HospitalStay.diagnosticSummary.problemDetails
Definition

Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.

ShortA.2.7.1.2 - Problem details
Control0..*
TypeBackboneElement
10. HospitalStay.diagnosticSummary.onsetDate
Definition

Onset date of a problem/condition

ShortA.2.7.1.3 - Onset date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
12. HospitalStay.diagnosticSummary.endDate
Definition

The date or estimated date that the condition resolved or went into remission.

ShortA.2.7.1.4 - End date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
14. HospitalStay.diagnosticSummary.category
Definition

Category of the problem allows flagging for conditions acquired during hospital stay.

ShortA.2.7.1.5 - Category
Control1..1
TypeCodeableConcept
16. HospitalStay.diagnosticSummary.treatmentClass
Definition

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital 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).

ShortA.2.7.1.6 - Treatment class
Control1..1
TypeCodeableConcept
18. HospitalStay.diagnosticSummary.clinicalStatus
Definition

Status of the condition/problem (active, resolved, inactive, ...)

ShortA.2.7.1.7 - Clinical status
Control0..1
TypeCodeableConcept
20. HospitalStay.diagnosticSummary.resolution
Definition

Describes the reason for which the status of the problem changed from current to inactive (e.g. surgical procedure, medical treatment, etc.). This field includes 'free text' if the resolution circumstances are not already included in other fields such as surgical procedure, medical device, etc., e.g. hepatic cystectomy (this will be the resolution circumstances for the problem 'hepatic cyst' and will be included in surgical procedures).

ShortA.2.7.1.8 - Resolution circumstances
Control0..1
TypeBackboneElement
22. HospitalStay.diagnosticSummary.severity
Definition

A subjective assessment of the severity of the condition as evaluated by the clinician.

ShortA.2.7.1.9 - Severity
Control0..1
TypeCodeableConcept
24. HospitalStay.diagnosticSummary.stage
Definition

Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.

ShortA.2.7.1.10 - Stage
Control0..*
TypeCodeableConcept
26. HospitalStay.significantProcedures
Definition

Significant surgical and non-surgical procedures performed during hospitalisation 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.

ShortA.2.7.2 - Significant procedures
Control1..*
TypeBackboneElement
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. HospitalStay.significantProcedures.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
30. HospitalStay.significantProcedures.procedureCode
Definition

Procedure code

ShortA.2.7.2.1 - Procedure code
Control0..*
TypeCodeableConcept
32. HospitalStay.significantProcedures.description
Definition

Narrative description of the procedure

ShortA.2.7.2.2 - Procedure description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
34. HospitalStay.significantProcedures.bodySite
Definition

Procedure target body site and laterality

ShortA.2.7.2.3 - Body site
Control0..1
TypeCodeableConcept
36. HospitalStay.significantProcedures.date
Definition

Date and time when procedure was performed

ShortA.2.7.2.4 - Procedure date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
38. HospitalStay.significantProcedures.reason
Definition

The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.

ShortA.2.7.2.5 - Procedure reason
Control0..*
TypeCodeableConcept
40. HospitalStay.significantProcedures.outcome
Definition

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

ShortA.2.7.2.6 - Outcome
Control0..1
TypeCodeableConcept
42. HospitalStay.significantProcedures.complication
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the procedure description, which will typically describe the procedure itself rather than any 'post procedure' issues.

ShortA.2.7.2.7 - Complication
Control0..*
TypeCodeableConcept
44. HospitalStay.significantProcedures.focalDevice
Definition

A reference to the device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

ShortA.2.7.2.8 - Focal device
Control0..*
TypeBackboneElement
46. HospitalStay.medicalDevices
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 hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system

ShortA.2.7.3 - Medical devices and implants
Control1..*
TypeBackboneElement
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. HospitalStay.medicalDevices.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
50. HospitalStay.medicalDevices.description
Definition

Describes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

ShortA.2.7.3.1 - Device and implant description
Control1..1
TypeCodeableConcept
52. HospitalStay.medicalDevices.identifier
Definition

Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745

ShortA.2.7.3.2 - Device ID
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
54. HospitalStay.medicalDevices.implantDate
Definition

The date and time the device was implanted or when its use began.

ShortA.2.7.3.3 - Implant date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
56. HospitalStay.medicalDevices.endDate
Definition

Date and time when the device was explanted from the patient or the external device was no longer in use; likewise when the device is planned to be explanted

ShortA.2.7.3.4 - End date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
58. HospitalStay.medicalDevices.reason
Definition

The medical reason for use of the medical device.

ShortA.2.7.3.5 - Reason
Control0..*
TypeCodeableConcept
60. HospitalStay.pharmacotherapy
Definition

Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation 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 hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.

ShortA.2.7.5 - Pharmacotherapy
Control0..*
TypeBackboneElement
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. HospitalStay.pharmacotherapy.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
64. HospitalStay.pharmacotherapy.reason
Definition

The reason why the medication is or was prescribed or used. It provides a link to the Past or current health conditions or problems that the patient has had or has.

ShortA.2.7.5.1 - Medication reason
Control0..1
TypeCodeableConcept
66. HospitalStay.pharmacotherapy.productCode
Definition

Product code

ShortA.2.7.5.2 - Code
Control1..1
TypeCodeableConcept
68. HospitalStay.pharmacotherapy.intendedUse
Definition

Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.

ShortA.2.7.5.3 - Intended use
Control0..*
TypeCodeableConcept
70. HospitalStay.pharmacotherapy.productName
Definition

Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)

ShortA.2.7.5.4 - Brand name
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
72. HospitalStay.pharmacotherapy.activeIngredient
Definition

Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: 'paracetamol'

ShortA.2.7.5.5 - Active ingredient list
Control0..*
TypeCodeableConcept
74. HospitalStay.pharmacotherapy.strength
Definition

The content of the active ingredient expressed quantifiably per dosage unit, per unit of volume or per unit of weight, according to the pharmaceutical dose form. Example: 500 mg per tablet

ShortA.2.7.5.6 - Strength
Control0..*
TypeRatio
76. HospitalStay.pharmacotherapy.doseForm
Definition

The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)

ShortA.2.7.5.7 - Pharmaceutical dose form
Control0..1
TypeCodeableConcept
78. HospitalStay.pharmacotherapy.dosageRegimen
Definition

Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days

ShortA.2.7.5.8 - Dosage Regimen
Control0..*
TypeBackboneElement
80. HospitalStay.pharmacotherapy.route
Definition

Path by which the pharmaceutical product is taken into or makes contact with the body.

ShortA.2.7.5.9 - Route of administration
Control0..1
TypeCodeableConcept
82. HospitalStay.pharmacotherapy.period
Definition

The time interval when the patient was, or was not, given the medication.

ShortA.2.7.5.10 - Period of treatment
Control0..1
TypePeriod
84. HospitalStay.significantResults
Definition

Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.

ShortA.2.7.6 - Significant Observation Results
Control0..*
TypeBackboneElement
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. HospitalStay.significantResults.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
88. HospitalStay.significantResults.date
Definition

Date and time of the observation

ShortA.2.7.6.1 - Date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
90. HospitalStay.significantResults.status
Definition

Status of the observation (e.g. registered, preliminary, final)

ShortA.2.7.6.2 - Observation status
Control1..1
TypeCodeableConcept
92. HospitalStay.significantResults.description
Definition

Narrative representation of the observation result and findings.

ShortA.2.7.6.3 - Result description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
94. HospitalStay.significantResults.details
Definition

Observation details include code that identifies observation, specification of the observed body structure or specimen, date and time of the specimen collection, observation method or protocol used and other aspects of the observation.

ShortA.2.7.6.4 - Observation details
Control1..1
TypeBackboneElement
96. HospitalStay.significantResults.result
Definition

Result of the observation including numeric and coded results of the measurement, details about how the tests were done to get the result values, information about reference ranges and result interpretation. Content of the observation result will vary according to the type of the observation.

ShortA.2.7.6.5 - Observation result
Control0..1
TypeBackboneElement
98. HospitalStay.significantResults.reporter
Definition

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

ShortA.2.7.6.7 - Reporter
Control0..*
TypeBackboneElement
100. HospitalStay.synthesis
Definition

This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

ShortA.2.7.7 - Synthesis
Control1..1
TypeBackboneElement
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
102. HospitalStay.synthesis.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
104. HospitalStay.synthesis.description
Definition

Summary description of the reason and course of hospitalisation for a specific problem.

ShortA.2.7.7.1 - Problem synthesis
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
106. HospitalStay.synthesis.reasoning
Definition

The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.

ShortA.2.7.7.2 - Clinical reasoning
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be found here

0. HospitalStay
Definition

Hospital Discharge Report - Hospital stay - A.2.6 eHN

ShortA.2.6 - Hospital stay (eHN)
Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. HospitalStay.diagnosticSummary
Definition

All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. 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.

ShortA.2.7.1 - Diagnostic summary
Control1..*
TypeBackboneElement
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. HospitalStay.diagnosticSummary.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
6. HospitalStay.diagnosticSummary.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on HospitalStay.diagnosticSummary.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 8. HospitalStay.diagnosticSummary.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored even if unrecognized
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    10. HospitalStay.diagnosticSummary.problemDescription
    Definition

    Problem specification in narrative form

    ShortA.2.7.1.1 - Problem description
    Control1..1
    Typestring
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    12. HospitalStay.diagnosticSummary.problemDetails
    Definition

    Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.

    ShortA.2.7.1.2 - Problem details
    Control0..*
    TypeBackboneElement
    14. HospitalStay.diagnosticSummary.onsetDate
    Definition

    Onset date of a problem/condition

    ShortA.2.7.1.3 - Onset date
    Control1..1
    TypedateTime
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    16. HospitalStay.diagnosticSummary.endDate
    Definition

    The date or estimated date that the condition resolved or went into remission.

    ShortA.2.7.1.4 - End date
    Control0..1
    TypedateTime
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    18. HospitalStay.diagnosticSummary.category
    Definition

    Category of the problem allows flagging for conditions acquired during hospital stay.

    ShortA.2.7.1.5 - Category
    Control1..1
    TypeCodeableConcept
    20. HospitalStay.diagnosticSummary.treatmentClass
    Definition

    Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital 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).

    ShortA.2.7.1.6 - Treatment class
    Control1..1
    TypeCodeableConcept
    22. HospitalStay.diagnosticSummary.clinicalStatus
    Definition

    Status of the condition/problem (active, resolved, inactive, ...)

    ShortA.2.7.1.7 - Clinical status
    Control0..1
    TypeCodeableConcept
    24. HospitalStay.diagnosticSummary.resolution
    Definition

    Describes the reason for which the status of the problem changed from current to inactive (e.g. surgical procedure, medical treatment, etc.). This field includes 'free text' if the resolution circumstances are not already included in other fields such as surgical procedure, medical device, etc., e.g. hepatic cystectomy (this will be the resolution circumstances for the problem 'hepatic cyst' and will be included in surgical procedures).

    ShortA.2.7.1.8 - Resolution circumstances
    Control0..1
    TypeBackboneElement
    26. HospitalStay.diagnosticSummary.severity
    Definition

    A subjective assessment of the severity of the condition as evaluated by the clinician.

    ShortA.2.7.1.9 - Severity
    Control0..1
    TypeCodeableConcept
    28. HospitalStay.diagnosticSummary.stage
    Definition

    Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.

    ShortA.2.7.1.10 - Stage
    Control0..*
    TypeCodeableConcept
    30. HospitalStay.significantProcedures
    Definition

    Significant surgical and non-surgical procedures performed during hospitalisation 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.

    ShortA.2.7.2 - Significant procedures
    Control1..*
    TypeBackboneElement
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. HospitalStay.significantProcedures.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    34. HospitalStay.significantProcedures.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on HospitalStay.significantProcedures.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 36. HospitalStay.significantProcedures.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored even if unrecognized
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
      Summarytrue
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content, modifiers
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      38. HospitalStay.significantProcedures.procedureCode
      Definition

      Procedure code

      ShortA.2.7.2.1 - Procedure code
      Control0..*
      TypeCodeableConcept
      40. HospitalStay.significantProcedures.description
      Definition

      Narrative description of the procedure

      ShortA.2.7.2.2 - Procedure description
      Control1..1
      Typestring
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      42. HospitalStay.significantProcedures.bodySite
      Definition

      Procedure target body site and laterality

      ShortA.2.7.2.3 - Body site
      Control0..1
      TypeCodeableConcept
      44. HospitalStay.significantProcedures.date
      Definition

      Date and time when procedure was performed

      ShortA.2.7.2.4 - Procedure date
      Control1..1
      TypedateTime
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      46. HospitalStay.significantProcedures.reason
      Definition

      The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.

      ShortA.2.7.2.5 - Procedure reason
      Control0..*
      TypeCodeableConcept
      48. HospitalStay.significantProcedures.outcome
      Definition

      The outcome of the procedure - did it resolve the reasons for the procedure being performed?

      ShortA.2.7.2.6 - Outcome
      Control0..1
      TypeCodeableConcept
      50. HospitalStay.significantProcedures.complication
      Definition

      Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the procedure description, which will typically describe the procedure itself rather than any 'post procedure' issues.

      ShortA.2.7.2.7 - Complication
      Control0..*
      TypeCodeableConcept
      52. HospitalStay.significantProcedures.focalDevice
      Definition

      A reference to the device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

      ShortA.2.7.2.8 - Focal device
      Control0..*
      TypeBackboneElement
      54. HospitalStay.medicalDevices
      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 hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system

      ShortA.2.7.3 - Medical devices and implants
      Control1..*
      TypeBackboneElement
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      56. HospitalStay.medicalDevices.id
      Definition

      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

      ShortUnique id for inter-element referencing
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      58. HospitalStay.medicalDevices.extension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

      ShortAdditional content defined by implementations
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on HospitalStay.medicalDevices.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 60. HospitalStay.medicalDevices.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        62. HospitalStay.medicalDevices.description
        Definition

        Describes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

        ShortA.2.7.3.1 - Device and implant description
        Control1..1
        TypeCodeableConcept
        64. HospitalStay.medicalDevices.identifier
        Definition

        Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745

        ShortA.2.7.3.2 - Device ID
        NoteThis is a business identifier, not a resource identifier (see discussion)
        Control0..1
        TypeIdentifier
        66. HospitalStay.medicalDevices.implantDate
        Definition

        The date and time the device was implanted or when its use began.

        ShortA.2.7.3.3 - Implant date
        Control1..1
        TypedateTime
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        68. HospitalStay.medicalDevices.endDate
        Definition

        Date and time when the device was explanted from the patient or the external device was no longer in use; likewise when the device is planned to be explanted

        ShortA.2.7.3.4 - End date
        Control0..1
        TypedateTime
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        70. HospitalStay.medicalDevices.reason
        Definition

        The medical reason for use of the medical device.

        ShortA.2.7.3.5 - Reason
        Control0..*
        TypeCodeableConcept
        72. HospitalStay.pharmacotherapy
        Definition

        Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation 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 hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.

        ShortA.2.7.5 - Pharmacotherapy
        Control0..*
        TypeBackboneElement
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        74. HospitalStay.pharmacotherapy.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        76. HospitalStay.pharmacotherapy.extension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

        ShortAdditional content defined by implementations
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Alternate Namesextensions, user content
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        SlicingThis element introduces a set of slices on HospitalStay.pharmacotherapy.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ url
        • 78. HospitalStay.pharmacotherapy.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          80. HospitalStay.pharmacotherapy.reason
          Definition

          The reason why the medication is or was prescribed or used. It provides a link to the Past or current health conditions or problems that the patient has had or has.

          ShortA.2.7.5.1 - Medication reason
          Control0..1
          TypeCodeableConcept
          82. HospitalStay.pharmacotherapy.productCode
          Definition

          Product code

          ShortA.2.7.5.2 - Code
          Control1..1
          TypeCodeableConcept
          84. HospitalStay.pharmacotherapy.intendedUse
          Definition

          Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.

          ShortA.2.7.5.3 - Intended use
          Control0..*
          TypeCodeableConcept
          86. HospitalStay.pharmacotherapy.productName
          Definition

          Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)

          ShortA.2.7.5.4 - Brand name
          Control1..1
          Typestring
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          88. HospitalStay.pharmacotherapy.activeIngredient
          Definition

          Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: 'paracetamol'

          ShortA.2.7.5.5 - Active ingredient list
          Control0..*
          TypeCodeableConcept
          90. HospitalStay.pharmacotherapy.strength
          Definition

          The content of the active ingredient expressed quantifiably per dosage unit, per unit of volume or per unit of weight, according to the pharmaceutical dose form. Example: 500 mg per tablet

          ShortA.2.7.5.6 - Strength
          Control0..*
          TypeRatio
          92. HospitalStay.pharmacotherapy.doseForm
          Definition

          The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)

          ShortA.2.7.5.7 - Pharmaceutical dose form
          Control0..1
          TypeCodeableConcept
          94. HospitalStay.pharmacotherapy.dosageRegimen
          Definition

          Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days

          ShortA.2.7.5.8 - Dosage Regimen
          Control0..*
          TypeBackboneElement
          96. HospitalStay.pharmacotherapy.route
          Definition

          Path by which the pharmaceutical product is taken into or makes contact with the body.

          ShortA.2.7.5.9 - Route of administration
          Control0..1
          TypeCodeableConcept
          98. HospitalStay.pharmacotherapy.period
          Definition

          The time interval when the patient was, or was not, given the medication.

          ShortA.2.7.5.10 - Period of treatment
          Control0..1
          TypePeriod
          100. HospitalStay.significantResults
          Definition

          Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.

          ShortA.2.7.6 - Significant Observation Results
          Control0..*
          TypeBackboneElement
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          102. HospitalStay.significantResults.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          104. HospitalStay.significantResults.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          SlicingThis element introduces a set of slices on HospitalStay.significantResults.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 106. HospitalStay.significantResults.modifierExtension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

            ShortExtensions that cannot be ignored even if unrecognized
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
            Summarytrue
            Requirements

            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

            Alternate Namesextensions, user content, modifiers
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            108. HospitalStay.significantResults.date
            Definition

            Date and time of the observation

            ShortA.2.7.6.1 - Date
            Control1..1
            TypedateTime
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            110. HospitalStay.significantResults.status
            Definition

            Status of the observation (e.g. registered, preliminary, final)

            ShortA.2.7.6.2 - Observation status
            Control1..1
            TypeCodeableConcept
            112. HospitalStay.significantResults.description
            Definition

            Narrative representation of the observation result and findings.

            ShortA.2.7.6.3 - Result description
            Control0..1
            Typestring
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            114. HospitalStay.significantResults.details
            Definition

            Observation details include code that identifies observation, specification of the observed body structure or specimen, date and time of the specimen collection, observation method or protocol used and other aspects of the observation.

            ShortA.2.7.6.4 - Observation details
            Control1..1
            TypeBackboneElement
            116. HospitalStay.significantResults.result
            Definition

            Result of the observation including numeric and coded results of the measurement, details about how the tests were done to get the result values, information about reference ranges and result interpretation. Content of the observation result will vary according to the type of the observation.

            ShortA.2.7.6.5 - Observation result
            Control0..1
            TypeBackboneElement
            118. HospitalStay.significantResults.reporter
            Definition

            With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

            ShortA.2.7.6.7 - Reporter
            Control0..*
            TypeBackboneElement
            120. HospitalStay.synthesis
            Definition

            This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

            ShortA.2.7.7 - Synthesis
            Control1..1
            TypeBackboneElement
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            122. HospitalStay.synthesis.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            124. HospitalStay.synthesis.extension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            ShortAdditional content defined by implementations
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            SlicingThis element introduces a set of slices on HospitalStay.synthesis.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ url
            • 126. HospitalStay.synthesis.modifierExtension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

              ShortExtensions that cannot be ignored even if unrecognized
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
              Summarytrue
              Requirements

              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

              Alternate Namesextensions, user content, modifiers
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              128. HospitalStay.synthesis.description
              Definition

              Summary description of the reason and course of hospitalisation for a specific problem.

              ShortA.2.7.7.1 - Problem synthesis
              Control1..*
              Typestring
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              130. HospitalStay.synthesis.reasoning
              Definition

              The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.

              ShortA.2.7.7.2 - Clinical reasoning
              Control0..1
              Typestring
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension