Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft

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.

Problem specification in narrative form

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

ICD-10* SNOMED CT ICD-O-3 Orphacode if rare disease is diagnosed IPS Absent and Unknown Data

Onset date of a problem/condition

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

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

• Present on admission [POA])
• Hospital acquired condition [HAC]
• Not applicable or unknown

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).

Treated, Other

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

hl7:condition-clinical

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).

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

hl7:condition-severity

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

e.g. TNM ICD-O-3

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.

Procedure code

SNOMED CT IPS Absent and Unknown Data

Narrative description of the procedure

Procedure target body site and laterality

SNOMED CT

Date and time when procedure was performed

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

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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

SNOMED CT

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.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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.

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

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.

SNOMED CT EMDN IPS Absent and Unknown Data

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

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

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

The medical reason for use of the medical device.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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.

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.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

Product code

IDMP

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

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

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

ATC (IDMP / EMA SPOR SMS)

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

UCUM EDQM Standard terms

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

EDQM Standard Terms

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

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

EDQM Standard Terms

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

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.

Date and time of the observation

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

hl7:observation-status

Narrative representation of the observation result and findings.

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.

LOINC NPU SNOMED CT

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.

SNOMED CT UCUM (measurement units)

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

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.

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

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

Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft

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.

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

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.

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.

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).

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.

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.

Problem specification in narrative form

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

ICD-10* SNOMED CT ICD-O-3 Orphacode if rare disease is diagnosed IPS Absent and Unknown Data

Onset date of a problem/condition

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

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

• Present on admission [POA])
• Hospital acquired condition [HAC]
• Not applicable or unknown

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).

Treated, Other

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

hl7:condition-clinical

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).

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

hl7:condition-severity

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

e.g. TNM ICD-O-3

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.

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

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.

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.

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).

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.

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.

Procedure code

SNOMED CT IPS Absent and Unknown Data

Narrative description of the procedure

Procedure target body site and laterality

SNOMED CT

Date and time when procedure was performed

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

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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

SNOMED CT

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.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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.

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

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

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.

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.

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).

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.

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.

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.

SNOMED CT EMDN IPS Absent and Unknown Data

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

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

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

The medical reason for use of the medical device.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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.

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

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.

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.

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).

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.

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.

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.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

Product code

IDMP

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

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

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

ATC (IDMP / EMA SPOR SMS)

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

UCUM EDQM Standard terms

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

EDQM Standard Terms

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

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

EDQM Standard Terms

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

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.

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

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.

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.

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).

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.

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.

Date and time of the observation

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

hl7:observation-status

Narrative representation of the observation result and findings.

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.

LOINC NPU SNOMED CT

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.

SNOMED CT UCUM (measurement units)

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

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.

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

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.

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.

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).

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.

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.

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

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

Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft

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.

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

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.

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.

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).

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.

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.

Problem specification in narrative form

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

ICD-10* SNOMED CT ICD-O-3 Orphacode if rare disease is diagnosed IPS Absent and Unknown Data

Onset date of a problem/condition

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

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

• Present on admission [POA])
• Hospital acquired condition [HAC]
• Not applicable or unknown

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).

Treated, Other

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

hl7:condition-clinical

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).

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

hl7:condition-severity

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

e.g. TNM ICD-O-3

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.

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

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.

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.

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).

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.

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.

Procedure code

SNOMED CT IPS Absent and Unknown Data

Narrative description of the procedure

Procedure target body site and laterality

SNOMED CT

Date and time when procedure was performed

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

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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

SNOMED CT

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.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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.

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

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

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.

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.

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).

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.

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.

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.

SNOMED CT EMDN IPS Absent and Unknown Data

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

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

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

The medical reason for use of the medical device.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

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.

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

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.

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.

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).

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.

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.

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.

ICD-10* SNOMED CT Orphacode if rare disease is diagnosed

Product code

IDMP

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

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

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

ATC (IDMP / EMA SPOR SMS)

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

UCUM EDQM Standard terms

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

EDQM Standard Terms

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

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

EDQM Standard Terms

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

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.

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

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.

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.

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).

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.

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.

Date and time of the observation

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

hl7:observation-status

Narrative representation of the observation result and findings.

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.

LOINC NPU SNOMED CT

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.

SNOMED CT UCUM (measurement units)

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

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.

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

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.

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.

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).

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.

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.

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

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