Hospital Discharge Report Overview

Hospital Discharge Report

The Hospital Discharge Report (HDR) has main components:

• the header and
• the body.

The header contains essential administrative and identification data about the patient, healthcare providers, and other key participants in the patient's care.

The body consists of the core clinical details regarding the patient's stay, treatment, and discharge plan.

Header

The Hospital Discharge Report Header component provides a documentation for the:

• Identification of the patient/subject: This includes critical identification information like the patient's given name, family name, date of birth, and national healthcare patient ID. It also covers nationality, gender, and the patient’s country of affiliation.
• Patient/subject related contact information: This involves the patient’s address and telecommunication contact details (e.g., phone numbers and email addresses). It may also include details of a preferred healthcare professional (name, identifier, role, organization).
• Health insurance and payment information: Key data related to health insurance, including the insurance code, name of the health insurance provider, and the patient's health insurance number.
• Information recipient: Refers to the intended recipient of the hospital discharge report. This includes recipient's name, organization, address, and telecom details.
• Author: Documents the author of the report, including their identifier (e.g., license number), name, and organizational information. The author is responsible for signing off on the content of the report.
• Attester: The healthcare professional who verifies the content of the report. This includes the attester’s identifier, name, organization, and the date and time of attestation.
• Legal authenticator: The person taking legal responsibility for the report. Includes the identifier, name, organization, and date of authentication.
• Document metadata: Contains the document's unique identifier, type, and metadata such as the date and time of creation or modification, ensuring proper tracking of the report.

Body

The Hospital Discharge Report Body component includes:

• Presented form: the Hospital Discharge Report in its narrative form; that is in a printable representation.
• Advance directives: Legal documents like living wills or DNR orders guiding treatment decisions.
• Alerts: Important medical alerts like allergies or other critical patient conditions.
• Encounter: Details of the hospital encounter, including admission date, reason, and type (inpatient/outpatient).
• Admission evaluation: Key findings and diagnostic results from the admission process.
• Patient history: A comprehensive record of the patient’s medical history prior to the hospital stay.
• Course of hospitalisation: Progress of the patient during the hospital stay, including treatments and interventions.
• Discharge details: Information about the discharge date, destination, and post-discharge care instructions.
• Care plan and other recommendations after discharge: Detailed follow-up care plan, including medications and therapy recommendations.