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

Artifacts Summary

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

Hospital Discharge Report

Hospital Discharge Report entry profiles.

Bundle: obligations

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

Composition: obligations

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

Obligations (Informative)

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

Allergy Intolerance: obligations

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

Care Plan: obligations

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

Condition: obligations

This profile defines obligations for the Condition in the scope of this guide. It supports the Diagnostic summary part of the eHN data model adding two additional categories: first category distinguishes conditions present at admission and acquired during hospital stay, while second category is used to indicate impact of the condition to the treatment during hospital stay (treated, untreated).

Device: obligations

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

DeviceUseStatement: obligations

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

Encounter: obligations

This profile defines obligations for Inpatient Encounter in HL7 FHIR for the scope of this guide.

Flag: obligations

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

Human Name: obligations

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

Immunization: obligations

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

Laboratory Observation: obligations

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

Medication: obligations

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

MedicationAdministration: obligations

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

MedicationDispense: obligations

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

MedicationRequest: obligations

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

MedicationStatement: obligations

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

Observation: obligations

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

Organization: obligations

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

Patient: obligations

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

Practitioner: obligations

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

PractitionerRole: obligations

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

Procedure: obligations

This profile defines obligations for the Procedure resource by this guide.

RelatedPerson: obligations

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

Specimen: obligations

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

Structures: Resource Profiles

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

Bundle (HDR)

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

Care Plan (HDR)

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

Composition (HDR)

Clinical document used to represent a Hospital Discharge Report (HDR) for the scope of this guide.

Device (HDR)

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

DeviceUseStatement (HDR)

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

Encounter (HDR)

This profile defines how to represent Inpatient Encounter in HL7 FHIR for the scope of this guide.

Goal (HDR)

Goal profile aligned with the Care Plan logical model.

MedicationAdministration (HDR)

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

MedicationDispense (HDR)

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

Terminology: Value Sets

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

Admission Urgency Value Set

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

Condition Value Set

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

Document Category Value Set

Hospital Discharge Report Document Category value set includes concepts from the LOINC code system that are used to classify the document as a discharge summary note.

Encounter Class Value Set

Hospital Discharge Report Encounter Class value set includes codes from the HL7 v3-ActCode code system that are used to classify the general type of inpatient encounter.

Encounter Status Value Set

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

Encounter Type Value Set

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

Example: Example Instances

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

AllergyIntolerance - Strawberry for patient Novak

Patient experiences itching and tongue swelling in response to strawberries.

AllergyIntolerance: Critical Allergy to Penicillin

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

Ambulance interního lékařství, MUDr. Jiří Zdvořilý

Example of ambulatory physician

BodyStructure: Left Hip Joint

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

Bundle: HL7 Europe Hospital Discharge Report (1)

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

Bundle: HL7 Europe Hospital Discharge Report (2)

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

Bundle: HL7 Europe Hospital Discharge Report (3)

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

Bundle: HL7 Europe Hospital Discharge Report (4)

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

Bundle: HL7 Europe Hospital Discharge Report (4)

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

CRP - Novák Petr

HDR - example of CRP observation for Novák Petr

CZ-Condition-HDR Example

Czech HDR - example of a condition (Heart Failure)

CZ-Procedure-HDR Example - Pacemaker 2

Czech HDR - example of a Procedure - Pacemaker

CarePlan-Novak-Petr

Czech HDR - example of a care plan

CarePlan: Diabetes Management Plan

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

Composition: HDR (1)

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

Composition: HDR (Petr Novák)

HL7 EU HDR Composition with sub-sections for patient Novák Petr

Condition-HDR Example E8.90 for patient Novak

HDR - example of a condition (Postoperative Hypothyroidism)

Condition-HDR Example K40.9

Example of a condition K40.9 with details on admission

Condition-HDR Iron Deficiency Anemia

Example of a condition Iron deficiency anaemia secondary to blood loss (chronic)

Condition: Osteoarthritis of the Left Hip

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

Condition: Type 2 Diabetes Mellitus

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

Device-Pacemaker

Heart pacemaker Medtronic W1DR01

Device: Implantable Pacemaker

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

Device: Total Hip Replacement Prosthesis

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

DeviceUseStatement: Implanted Pacemaker

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

DeviceUseStatement: Total Hip Replacement Prosthesis

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

Dispense – Euthyrox

Euthyrox v tabletách

Dispense – Euthyrox for patient Novak

Výdej léčivého přípravku Euthyrox pacientovi Novákovi

Dispense – Ibalgin 400

Výdej léčivého přípravku Ibalgin 400 mg pacientovi Novákovi

Dispense – Paracetamol

Výdej léčivého přípravku Paracetamol pacientovi Novákovi

Dosažený stupeň vzdělání

Pacient má vysokoškolské vzdělání v oboru informatiky.

Encounter-HDR Example of encounter with emergency priority

Czech HDR - example of encounter with emergency priority

Encounter: Hospital Admission and Discharge

A sample Encounter resource for a hospital admission and discharge.

ExampleAbdominalCircumference

Example instance for abdominal circumference observation using the CZ_ObservationAbdominalCircumferenceHdr profile.

ExampleBMI

Example instance for BMI observation using the CZ_ObservationBMIHdr profile.

ExampleBloodPressure

Example instance for blood pressure observation (systolic and diastolic).

ExampleChestCircumference

Example instance for chest circumference observation using the CZ_ObservationChestCircumferenceHdr profile.

ExampleHeadCircumference

Example instance for head circumference observation using the CZ_ObservationHeadCircumferenceHdr profile.

ExampleHeight

Example instance for height observation using the CZ_ObservationHeightHdr profile.

ExampleSdohAlcohol

Example of Social History Observation - Alcohol Use

ExampleSdohSmoking

Example of Social History Observation - Smoking

ExampleWeight

Example instance for weight observation using the CZ_ObservationWeightHdr profile.

FamilyMemberHistory: Type 2 Diabetes Mellitus - Mother

Mother has a history of type 2 diabetes mellitus.

Flag: Critical Allergy to Penicillin

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

Flag: Do Not Use Left Arm

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

Immunization example of Covid

Immunization of Covid

Immunization: COVID-19

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

Medication – Ibalgin 400

Lek Ibalgin 400 v tabletách

Medication – Paracetamol

Lek Paracetamol v tabletách

Medication: 01A-Cefuroxime1500GenericExplicit

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

Medication: 01C-Cefuroxime1500Branded

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

MedicationAdministration: Paracetamol

A sample MedicationAdministration resource for Paracetamol.

MedicationDispense: 400D-dispense-1

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

MedicationRequest: 400C-prescription-cefuroxime-singleline

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

MedicationStatement-HDR Example: Euthyrox

HDR - example: Euthyrox

MedicationStatement-HDR Example: Ibalgin

HDR - example of Ibalgin 400

MedicationStatement-HDR Example: Paracetamol

Czech HDR - example: Paracetamol

MedicationStatement: Enalapril

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

Observation - Travel History

Travel history observation

Observation: ABO group

ABO blood group type in blood.

Observation: Body weight

Vital signs observation representing the body weight of the patient.

Organization-1

An example of the organization of a provider

Organization-L1

A minimalist example of the organization of a healthcare provider for the purposes of the HDR document.

Organization-L1-HOSP

A minimalist example of a subordinate department within a hospital hierarchy for the purposes of the HDR document.

Organization-L1-Odd

A minimalist example of a subordinate department within a hospital hierarchy for the purposes of the HDR document.

Organization: Erasmus MC

Organization representing the Erasmus MC, Sophia kinderziekenhuis.

Patient-Novak-Petr

Example of patient Petr Novak with identification by czech national identifiers (RID, RCIS) and contact information

Patient: Dutch Patient

Patient resource representing Fiona Swart, a Dutch patient.

Použití kardiostimulátoru

Záznam o implantaci kardiostimulátoru z důvodu bradykardie

Practitioner-2

Practitioner id(KRZP)=987654321

Practitioner-Admitter

Participant Admitter HDR

Practitioner-Author

Participant HDR

Practitioner-Author-detail

Practitioner role MUDr. Ivan Anděl

Practitioner-Referrer

Participant Referrer HDR

Practitioner-Referrer-detail

practitioner's detail

Practitioner-UZV

Participant UZV HDR

Procedure-HDR Example - Inguinal hernia

HDR - example of a Procedure - Repair of inguinal hernia

Procedure: Cesarean Section

A planned cesarean section procedure.

Procedure: Total Replacement of the Left Hip

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

Sample Czech Location Chrudim Chir1

Example instance of a location conforming to the CZ_LocationCore profile.

Sample Czech Location Chrudim JIP

Example instance of a location conforming to the CZ_LocationCore profile.

Sociální síť

Pacient má aktivní sociální síť a pravidelně se setkává s přáteli.

Společenské uplatnění

Pacient je aktivní v komunitních aktivitách a dobrovolnictví.

Střední podvýživa

Střední podvýživa – doporučení nutriční terapie u pacienta.

Vzdělání

Pacient má vysokoškolské vzdělání v oboru informatiky.