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-build 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
This page explains how conceptual elements from the EHDSDischargeReport logical model are expressed in the corresponding FHIR CompositionEuHdr profile used by this Implementation Guide.
| EHDSDischargeReport (Logical Model) | Relationship | Composition (HDR) | ||||
|---|---|---|---|---|---|---|
| Element | Description | Relation | Resource | Element | Description | Notes |
| header | Document header elements. | related-to | Composition | . | Composition-level metadata. | CompositionEuHdr constrains header elements for HDR. |
| header.author[x] | The author of the report. | equivalent | Composition | author | Who authored the HDR. | Reference to Practitioner/PractitionerRole/Organization/Device per profile. |
| header.status | Status of the document. | equivalent | Composition | status | Workflow/clinical status of the HDR. | |
| header.documentType | Type of document (e.g. LOINC 34105-7). | equivalent | Composition | type | Document type code. | Fixed to LOINC 34105-7 in CompositionEuHdr. |
| header.documentTitle | Title of the document. | equivalent | Composition | title | Human-readable HDR title. | |
| header.period | Time of service being documented. | related-to | Composition | event.period | Period covered by the composition. | Map to the primary Composition.event entry. |
| header.intendedRecipient[x] | Intended recipient(s) of the information. | related-to | Composition | extension:information-recipient | Explicit communication intent. | Uses the information-recipient extension in CompositionEuHdr. |
| body.encounterInformation | Section: Encounter information. | related-to | Composition | encounter | Encounter referenced by the HDR. | Use EncounterEuHdr. |
| body.encounterInformation.generatedNarrative | Narrative of encounter information. | related-to | Encounter | text | ||
| body.encounterInformation.encounter | Encounter information. | equivalent | Composition | encounter | ||
| body.encounterInformation.note | Free text notes by the health professional. | related-to | Composition | extension:note | ||
| body.alerts | Section: Alerts. | equivalent | Composition | section:sectionAlert | Alerts section. | Use LOINC 104605-1. |
| body.alerts.generatedNarrative | Narrative content of the section. | equivalent | Composition | section:sectionAlert.text | Alerts narrative. | |
| body.alerts.medicalAlert | Description of medical alerts. | equivalent | Composition | section:sectionAlert | Alert entries. | Reference to Flag (EHDSAlert). |
| body.admissionEvaluation | Section: Admission evaluation. | equivalent | Composition | section:sectionAdmissionEvaluation | Admission evaluation section. | Reported only if relevant. |
| body.admissionEvaluation.generatedNarrative | Narrative content of the section. | equivalent | Composition | section:sectionAdmissionEvaluation.text | Admission evaluation narrative. | |
| body.admissionEvaluation.objectiveFindings | Objective findings. | related-to | Composition | section:sectionVitalSigns | Vital signs section. | Use Observation where appropriate. |
| body.admissionEvaluation.objectiveFindings | Objective findings. | related-to | Composition | section:sectionAnthropometry | Anthropometry section. | Use Observation where appropriate. |
| body.admissionEvaluation.objectiveFindings | Objective findings. | related-to | Composition | section:sectionPhysicalFindings | Physical findings section. | Use Observation where appropriate. |
| body.admissionEvaluation.functionalStatus[x] | Functional status assessment. | related-to | Composition | section:sectionFunctionalStatus | Functional status entries. | Condition/Observation/ClinicalImpression as allowed. |
| body.admissionEvaluation.note | Free text notes by the evaluation performer. | related-to | Composition | section:sectionAdmissionEvaluation.text | Admission evaluation narrative. | |
| body.patientHistory | Section: Patient health history. | equivalent | Composition | section:sectionPatientHx | Hx general Reported section. | |
| body.patientHistory.generatedNarrative | Narrative content of the section. | equivalent | Composition | section:sectionPatientHx.text | Hx general Reported narrative. | |
| body.patientHistory.note | Free text notes by the health professional. | related-to | Composition | section:sectionPatientHx.extension:note | Hx general Reported notes. | |
| body.courseOfEncounter | Course of encounter. | equivalent | Composition | section:sectionHospitalCourse | Hospital course section. | |
| body.courseOfEncounter.generatedNarrative | Narrative content of the section. | equivalent | Composition | section:sectionHospitalCourse.text | Hospital course narrative. | |
| body.courseOfEncounter.diagnosticSummary | Problems treated or affecting care. | equivalent | Composition | section:sectionDiagnosticSummary | Diagnostic summary section. | Reference to ConditionEuCore. |
| body.courseOfEncounter.procedures | Procedures performed during encounter. | equivalent | Composition | section:sectionSignificantProcedures | Significant procedures section. | Reference to ProcedureEuCore. |
| body.courseOfEncounter.medicalDevicesAndImplants | Medical devices and implants. | equivalent | Composition | section:sectionMedicalDevices | Medical devices section. | Reference to DeviceUseStatementEuHdr. |
| body.courseOfEncounter.pharmacotherapy | Medication treatments during encounter. | equivalent | Composition | section:sectionPharmacotherapy | Pharmacotherapy section. | MedicationStatement/Request/Dispense/Administration. |
| body.courseOfEncounter.objectiveFindings | Objective findings during encounter. | related-to | Composition | section:sectionVitalSigns | Vital signs section. | Use Observation where appropriate. |
| body.courseOfEncounter.objectiveFindings | Objective findings during encounter. | related-to | Composition | section:sectionAnthropometry | Anthropometry section. | Use Observation where appropriate. |
| body.courseOfEncounter.objectiveFindings | Objective findings during encounter. | related-to | Composition | section:sectionPhysicalFindings | Physical findings section. | Use Observation where appropriate. |
| body.courseOfEncounter.testResults | Significant medical test results. | equivalent | Composition | section:sectionSignificantResults | Significant results section. | Observation/DiagnosticReport/DocumentReference. |
| body.courseOfEncounter.note | Free text notes. | related-to | Composition | section:sectionHospitalCourse.text | Hospital course narrative. | |
| body.dischargeDetails | Discharge details. | equivalent | Composition | section:sectionDischargeDetails | Discharge details section. | |
| body.dischargeDetails.generatedNarrative | Narrative content of the section. | equivalent | Composition | section:sectionDischargeDetails.text | Discharge details narrative. | |
| body.dischargeDetails.objectiveFindings | Objective findings at discharge. | related-to | Composition | section:sectionPhysicalFindings / section:sectionVitalSigns | Discharge findings. | Use Observation where appropriate. |
| body.dischargeDetails.functionalStatus[x] | Functional status at discharge. | related-to | Composition | section:sectionFunctionalStatus | Functional status entries. | |
| body.dischargeDetails.note | Free text notes. | related-to | Composition | section:sectionDischargeDetails.text | Discharge details narrative. | |
| body.medicationSummary | Medication summary after discharge. | related-to | Composition | section:sectionDischargeMedications | Discharge medications section. | Post-discharge medications summary. |
| body.medicationSummary.generatedNarrative | Narrative content of the section. | equivalent | Composition | section:sectionDischargeMedications.text | Discharge medications narrative. | |
| body.medicationSummary.medicationUse | Details about medication and dosage. | equivalent | Composition | section:sectionDischargeMedications | Discharge medications section. | MedicationRequest/MedicationDispense/MedicationStatement. |
| body.medicationSummary.note | Free text notes. | related-to | Composition | section:sectionDischargeMedications.text | Discharge medications narrative. | |
| body.carePlan | Care plan and recommendations after discharge. | equivalent | Composition | section:sectionPlanOfCare | Plan of care section. | |
| body.carePlan.generatedNarrative | Narrative content of the section. | equivalent | Composition | section:sectionPlanOfCare.text | Plan of care narrative. | |
| body.carePlan.carePlan | Structured care plan after discharge. | equivalent | Composition | section:sectionPlanOfCare | Plan of care section. | Reference to CarePlanEuHdr. |
| body.carePlan.otherRecommendations | Other recommendations after discharge. | related-to | Composition | section:sectionPlanOfCare.text | Plan of care narrative. | May also be represented in Discharge Instructions narrative. |
| body.synthesis | Clinical synthesis. | equivalent | Composition | section:sectionSynthesis.text | Synthesis narrative. | |
| attachments | Report attachments. | equivalent | Composition | section:sectionAttachments | Attachments section. | DocumentReference/Binary in CompositionEuHdr. |
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