HDRHospitalStay
type: StructureDefinition
node role: treeRoot
id:
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text:
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  div: Generated Narrative: StructureDefinition HDRHospitalStay Name Flags Card. Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> HDRHospitalStay 0..* Base A.2.7 - Hospital stay (eHN) #xD; <a href="StructureDefinition-HDRHospitalStay-definitions.html#HDRHospitalStay.diagnosticSummary" title="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.">diagnosticSummary 1..* BackboneElement A.2.7.1 - Diagnostic summary #xD; problemDescription 1..1 string A.2.7.1.1 - Problem description #xD; problemDetails 0..* BackboneElement A.2.7.1.2 - Problem details #xD; onsetDate 1..1 dateTime A.2.7.1.3 - Onset date #xD; endDate 0..1 dateTime A.2.7.1.4 - End date #xD; category 1..1 CodeableConcept A.2.7.1.5 - Category #xD; <a href="StructureDefinition-HDRHospitalStay-definitions.html#HDRHospitalStay.diagnosticSummary.treatmentClass" title="Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated…
url:
  v: http://hl7.eu/fhir/ig/xpandh/hdr/StructureDefinition/HDRHospitalStay
version:
  v: 0.1.0
name:
  v: HdrEHNHospitalStay
title:
  v: A.2.7 - Hospital stay (eHN)
status:
  v: draft
date:
  v: 2025-10-10T16:32:47+00:00
publisher:
  v: XpanDH Project
contact:
  name:
    v: XpanDH Project
  telecom:
    system:
      v: url
    value:
      v: https://xpandh-project.iscte-iul.pt
description:
  v: Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft
jurisdiction:
  coding:
    system:
      v: http://unstats.un.org/unsd/methods/m49/m49.htm
    code:
      v: 150
    display:
      v: Europe
copyright:
  v: Used by permission of the XpanDH project, all rights reserved Creative Commons License
fhir version:
  v: 4.0.1
kind:
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abstract:
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type:
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      v: Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft
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      v: HDRHospitalStay.diagnosticSummary
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      v: A.2.7.1 - Diagnostic summary
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      v: 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.
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id:
  v: HDRHospitalStay.diagnosticSummary.problemDescription
path:
  v: HDRHospitalStay.diagnosticSummary.problemDescription
short:
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definition:
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id:
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short:
  v: A.2.7.1.2 - Problem details
definition:
  v: Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
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  v: ICD-10* SNOMED CT ICD-O-3 Orphacode if rare disease is diagnosed IPS Absent and Unknown Data
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id:
  v: HDRHospitalStay.diagnosticSummary.onsetDate
path:
  v: HDRHospitalStay.diagnosticSummary.onsetDate
short:
  v: A.2.7.1.3 - Onset date
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id:
  v: HDRHospitalStay.diagnosticSummary.endDate
path:
  v: HDRHospitalStay.diagnosticSummary.endDate
short:
  v: A.2.7.1.4 - End date
definition:
  v: The date or estimated date that the condition resolved or went into remission.
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id:
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path:
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short:
  v: A.2.7.1.5 - Category
definition:
  v: Category of the problem allows flagging for conditions acquired during hospital stay.
comment:
  v: - Present on admission [POA]) - Hospital acquired condition [HAC] - Not applicable or unknown
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short:
  v: A.2.7.1.6 - Treatment class
definition:
  v: 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).
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id:
  v: HDRHospitalStay.diagnosticSummary.clinicalStatus
path:
  v: HDRHospitalStay.diagnosticSummary.clinicalStatus
short:
  v: A.2.7.1.7 - Clinical status
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  v: Status of the condition/problem (active, resolved, inactive, ...)
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id:
  v: HDRHospitalStay.diagnosticSummary.resolution
path:
  v: HDRHospitalStay.diagnosticSummary.resolution
short:
  v: A.2.7.1.8 - Resolution circumstances
definition:
  v: 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).
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id:
  v: HDRHospitalStay.diagnosticSummary.severity
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short:
  v: A.2.7.1.9 - Severity
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  v: A subjective assessment of the severity of the condition as evaluated by the clinician.
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id:
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short:
  v: A.2.7.1.10 - Stage
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  v: Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.
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  v: e.g. TNM ICD-O-3
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id:
  v: HDRHospitalStay.significantProcedures
path:
  v: HDRHospitalStay.significantProcedures
short:
  v: A.2.7.2 - Significant procedures
definition:
  v: 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.
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  v: 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.
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id:
  v: HDRHospitalStay.significantProcedures.procedureCode
path:
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short:
  v: A.2.7.2.1 - Procedure code
definition:
  v: Procedure code
comment:
  v: SNOMED CT IPS Absent and Unknown Data
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  v: Narrative description of the procedure
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id:
  v: HDRHospitalStay.significantProcedures.bodySite
path:
  v: HDRHospitalStay.significantProcedures.bodySite
short:
  v: A.2.7.2.3 - Body site
definition:
  v: Procedure target body site and laterality
comment:
  v: SNOMED CT
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id:
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path:
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short:
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definition:
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id:
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path:
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short:
  v: A.2.7.2.5 - Procedure reason
definition:
  v: The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.
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  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
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id:
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path:
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short:
  v: A.2.7.2.6 - Outcome
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id:
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short:
  v: A.2.7.2.7 - Complication
definition:
  v: 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.
comment:
  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
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id:
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short:
  v: A.2.7.2.8 - Focal device
definition:
  v: 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.
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id:
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path:
  v: HDRHospitalStay.medicalDevices
short:
  v: A.2.7.3 - Medical devices and implants
definition:
  v: 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
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    link: http://hl7.org/fhir/StructureDefinition/Element

id:
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  v: HDRHospitalStay.medicalDevices.id
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definition:
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id:
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    path:
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  rules:
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short:
  v: Additional content defined by implementations
definition:
  v: 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.
comment:
  v: 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.
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alias:
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    v: http://hl7.org/fhir/StructureDefinition/Element
    link: http://hl7.org/fhir/StructureDefinition/Element
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id:
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short:
  v: Extensions that cannot be ignored even if unrecognized
definition:
  v: 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).
comment:
  v: 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.
requirements:
  v: 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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
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  source:
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    link: http://hl7.org/fhir/StructureDefinition/Element
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    v: ext-1
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    v: Must have either extensions or value[x], not both
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    link: http://hl7.org/fhir/StructureDefinition/Extension
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  v: Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
is summary:
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  identity:
    v: rim
  map:
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id:
  v: HDRHospitalStay.medicalDevices.description
path:
  v: HDRHospitalStay.medicalDevices.description
short:
  v: A.2.7.3.1 - Device and implant description
definition:
  v: 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.
comment:
  v: SNOMED CT EMDN IPS Absent and Unknown Data
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id:
  v: HDRHospitalStay.medicalDevices.identifier
path:
  v: HDRHospitalStay.medicalDevices.identifier
short:
  v: A.2.7.3.2 - Device ID
definition:
  v: Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745
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type:
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    v: Identifier

id:
  v: HDRHospitalStay.medicalDevices.implantDate
path:
  v: HDRHospitalStay.medicalDevices.implantDate
short:
  v: A.2.7.3.3 - Implant date
definition:
  v: The date and time the device was implanted or when its use began.
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  v: 1
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  v: 1
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type:
  code:
    v: dateTime

id:
  v: HDRHospitalStay.medicalDevices.endDate
path:
  v: HDRHospitalStay.medicalDevices.endDate
short:
  v: A.2.7.3.4 - End date
definition:
  v: 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
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id:
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path:
  v: HDRHospitalStay.medicalDevices.reason
short:
  v: A.2.7.3.5 - Reason
definition:
  v: The medical reason for use of the medical device.
comment:
  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
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id:
  v: HDRHospitalStay.pharmacotherapy
path:
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short:
  v: A.2.7.5 - Pharmacotherapy
definition:
  v: 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.
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    v: All FHIR elements must have a @value or children
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    link: http://hl7.org/fhir/StructureDefinition/Element

id:
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path:
  v: HDRHospitalStay.pharmacotherapy.id
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  v: Unique id for inter-element referencing
definition:
  v: Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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id:
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  v: Additional content defined by implementations
definition:
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comment:
  v: 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.
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    v: error
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    link: http://hl7.org/fhir/StructureDefinition/Element
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id:
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path:
  v: HDRHospitalStay.pharmacotherapy.modifierExtension
short:
  v: Extensions that cannot be ignored even if unrecognized
definition:
  v: 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).
comment:
  v: 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.
requirements:
  v: 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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
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    link: http://hl7.org/fhir/StructureDefinition/Element
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id:
  v: HDRHospitalStay.pharmacotherapy.reason
path:
  v: HDRHospitalStay.pharmacotherapy.reason
short:
  v: A.2.7.5.1 - Medication reason
definition:
  v: 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.
comment:
  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
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type:
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id:
  v: HDRHospitalStay.pharmacotherapy.productCode
path:
  v: HDRHospitalStay.pharmacotherapy.productCode
short:
  v: A.2.7.5.2 - Code
definition:
  v: Product code
comment:
  v: IDMP
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type:
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id:
  v: HDRHospitalStay.pharmacotherapy.intendedUse
path:
  v: HDRHospitalStay.pharmacotherapy.intendedUse
short:
  v: A.2.7.5.3 - Intended use
definition:
  v: Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.
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id:
  v: HDRHospitalStay.pharmacotherapy.productName
path:
  v: HDRHospitalStay.pharmacotherapy.productName
short:
  v: A.2.7.5.4 - Brand name
definition:
  v: Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)
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type:
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id:
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path:
  v: HDRHospitalStay.pharmacotherapy.activeIngredient
short:
  v: A.2.7.5.5 - Active ingredient list
definition:
  v: Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: \"paracetamol\"
comment:
  v: ATC (IDMP / EMA SPOR SMS)
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id:
  v: HDRHospitalStay.pharmacotherapy.strength
path:
  v: HDRHospitalStay.pharmacotherapy.strength
short:
  v: A.2.7.5.6 - Strength
definition:
  v: 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
comment:
  v: UCUM EDQM Standard terms
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id:
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path:
  v: HDRHospitalStay.pharmacotherapy.doseForm
short:
  v: A.2.7.5.7 - Pharmaceutical dose form
definition:
  v: The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)
comment:
  v: EDQM Standard Terms
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id:
  v: HDRHospitalStay.pharmacotherapy.dosageRegimen
path:
  v: HDRHospitalStay.pharmacotherapy.dosageRegimen
short:
  v: A.2.7.5.8 - Dosage Regimen
definition:
  v: Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days
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id:
  v: HDRHospitalStay.pharmacotherapy.route
path:
  v: HDRHospitalStay.pharmacotherapy.route
short:
  v: A.2.7.5.9 - Route of administration
definition:
  v: Path by which the pharmaceutical product is taken into or makes contact with the body.
comment:
  v: EDQM Standard Terms
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id:
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path:
  v: HDRHospitalStay.pharmacotherapy.period
short:
  v: A.2.7.5.10 - Period of treatment
definition:
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comment:
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id:
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id:
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id:
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id:
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  v: 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.
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id:
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id:
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element:
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    v: 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.
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    v: A.2.7.1.6 - Treatment class
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    v: Treated, Other
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    v: A.2.7.1.7 - Clinical status
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    v: 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).
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    v: A subjective assessment of the severity of the condition as evaluated by the clinician.
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    v: hl7:condition-severity
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    v: A.2.7.1.10 - Stage
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    v: Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.
  comment:
    v: e.g. TNM ICD-O-3
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element:
  id:
    v: HDRHospitalStay.significantProcedures
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v: A.2.7.2 - Significant procedures

v: 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.

v: 1

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  v: Procedure code
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  v: SNOMED CT IPS Absent and Unknown Data
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type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.significantProcedures.description
path:
  v: HDRHospitalStay.significantProcedures.description
short:
  v: A.2.7.2.2 - Procedure description
definition:
  v: Narrative description of the procedure
min:
  v: 1
max:
  v: 1
type:
  code:
    v: string

id:
  v: HDRHospitalStay.significantProcedures.bodySite
path:
  v: HDRHospitalStay.significantProcedures.bodySite
short:
  v: A.2.7.2.3 - Body site
definition:
  v: Procedure target body site and laterality
comment:
  v: SNOMED CT
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.significantProcedures.date
path:
  v: HDRHospitalStay.significantProcedures.date
short:
  v: A.2.7.2.4 - Procedure date
definition:
  v: Date and time when procedure was performed
min:
  v: 1
max:
  v: 1
type:
  code:
    v: dateTime

id:
  v: HDRHospitalStay.significantProcedures.reason
path:
  v: HDRHospitalStay.significantProcedures.reason
short:
  v: A.2.7.2.5 - Procedure reason
definition:
  v: The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.
comment:
  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.significantProcedures.outcome
path:
  v: HDRHospitalStay.significantProcedures.outcome
short:
  v: A.2.7.2.6 - Outcome
definition:
  v: The outcome of the procedure - did it resolve the reasons for the procedure being performed?
comment:
  v: SNOMED CT
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.significantProcedures.complication
path:
  v: HDRHospitalStay.significantProcedures.complication
short:
  v: A.2.7.2.7 - Complication
definition:
  v: 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.
comment:
  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.significantProcedures.focalDevice
path:
  v: HDRHospitalStay.significantProcedures.focalDevice
short:
  v: A.2.7.2.8 - Focal device
definition:
  v: 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.
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableReference

id:
  v: HDRHospitalStay.medicalDevices
path:
  v: HDRHospitalStay.medicalDevices
short:
  v: A.2.7.3 - Medical devices and implants
definition:
  v: 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
min:
  v: 1
max:
  v: *
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.medicalDevices.description
path:
  v: HDRHospitalStay.medicalDevices.description
short:
  v: A.2.7.3.1 - Device and implant description
definition:
  v: 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.
comment:
  v: SNOMED CT EMDN IPS Absent and Unknown Data
min:
  v: 1
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.medicalDevices.identifier
path:
  v: HDRHospitalStay.medicalDevices.identifier
short:
  v: A.2.7.3.2 - Device ID
definition:
  v: Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Identifier

id:
  v: HDRHospitalStay.medicalDevices.implantDate
path:
  v: HDRHospitalStay.medicalDevices.implantDate
short:
  v: A.2.7.3.3 - Implant date
definition:
  v: The date and time the device was implanted or when its use began.
min:
  v: 1
max:
  v: 1
type:
  code:
    v: dateTime

id:
  v: HDRHospitalStay.medicalDevices.endDate
path:
  v: HDRHospitalStay.medicalDevices.endDate
short:
  v: A.2.7.3.4 - End date
definition:
  v: 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
min:
  v: 0
max:
  v: 1
type:
  code:
    v: dateTime

id:
  v: HDRHospitalStay.medicalDevices.reason
path:
  v: HDRHospitalStay.medicalDevices.reason
short:
  v: A.2.7.3.5 - Reason
definition:
  v: The medical reason for use of the medical device.
comment:
  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.pharmacotherapy
path:
  v: HDRHospitalStay.pharmacotherapy
short:
  v: A.2.7.5 - Pharmacotherapy
definition:
  v: 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.
min:
  v: 0
max:
  v: *
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.pharmacotherapy.reason
path:
  v: HDRHospitalStay.pharmacotherapy.reason
short:
  v: A.2.7.5.1 - Medication reason
definition:
  v: 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.
comment:
  v: ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.pharmacotherapy.productCode
path:
  v: HDRHospitalStay.pharmacotherapy.productCode
short:
  v: A.2.7.5.2 - Code
definition:
  v: Product code
comment:
  v: IDMP
min:
  v: 1
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.pharmacotherapy.intendedUse
path:
  v: HDRHospitalStay.pharmacotherapy.intendedUse
short:
  v: A.2.7.5.3 - Intended use
definition:
  v: Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.pharmacotherapy.productName
path:
  v: HDRHospitalStay.pharmacotherapy.productName
short:
  v: A.2.7.5.4 - Brand name
definition:
  v: Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)
min:
  v: 1
max:
  v: 1
type:
  code:
    v: string

id:
  v: HDRHospitalStay.pharmacotherapy.activeIngredient
path:
  v: HDRHospitalStay.pharmacotherapy.activeIngredient
short:
  v: A.2.7.5.5 - Active ingredient list
definition:
  v: Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: \"paracetamol\"
comment:
  v: ATC (IDMP / EMA SPOR SMS)
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.pharmacotherapy.strength
path:
  v: HDRHospitalStay.pharmacotherapy.strength
short:
  v: A.2.7.5.6 - Strength
definition:
  v: 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
comment:
  v: UCUM EDQM Standard terms
min:
  v: 0
max:
  v: *
type:
  code:
    v: Ratio

id:
  v: HDRHospitalStay.pharmacotherapy.doseForm
path:
  v: HDRHospitalStay.pharmacotherapy.doseForm
short:
  v: A.2.7.5.7 - Pharmaceutical dose form
definition:
  v: The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)
comment:
  v: EDQM Standard Terms
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.pharmacotherapy.dosageRegimen
path:
  v: HDRHospitalStay.pharmacotherapy.dosageRegimen
short:
  v: A.2.7.5.8 - Dosage Regimen
definition:
  v: Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days
min:
  v: 0
max:
  v: *
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.pharmacotherapy.route
path:
  v: HDRHospitalStay.pharmacotherapy.route
short:
  v: A.2.7.5.9 - Route of administration
definition:
  v: Path by which the pharmaceutical product is taken into or makes contact with the body.
comment:
  v: EDQM Standard Terms
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.pharmacotherapy.period
path:
  v: HDRHospitalStay.pharmacotherapy.period
short:
  v: A.2.7.5.10 - Period of treatment
definition:
  v: The time interval when the patient was, or was not, given the medication.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Period

id:
  v: HDRHospitalStay.significantResults
path:
  v: HDRHospitalStay.significantResults
short:
  v: A.2.7.6 - Significant Observation Results
definition:
  v: 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.
min:
  v: 0
max:
  v: *
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.significantResults.date
path:
  v: HDRHospitalStay.significantResults.date
short:
  v: A.2.7.6.1 - Date
definition:
  v: Date and time of the observation
min:
  v: 1
max:
  v: 1
type:
  code:
    v: dateTime

id:
  v: HDRHospitalStay.significantResults.status
path:
  v: HDRHospitalStay.significantResults.status
short:
  v: A.2.7.6.2 - Observation status
definition:
  v: Status of the observation (e.g. registered, preliminary, final)
comment:
  v: hl7:observation-status
min:
  v: 1
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: HDRHospitalStay.significantResults.description
path:
  v: HDRHospitalStay.significantResults.description
short:
  v: A.2.7.6.3 - Result description
definition:
  v: Narrative representation of the observation result and findings.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: HDRHospitalStay.significantResults.details
path:
  v: HDRHospitalStay.significantResults.details
short:
  v: A.2.7.6.4 - Observation details
definition:
  v: 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.
comment:
  v: LOINC NPU SNOMED CT
min:
  v: 1
max:
  v: 1
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.significantResults.result
path:
  v: HDRHospitalStay.significantResults.result
short:
  v: A.2.7.6.5 - Observation result
definition:
  v: 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.
comment:
  v: SNOMED CT UCUM (measurement units)
min:
  v: 0
max:
  v: 1
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.significantResults.reporter
path:
  v: HDRHospitalStay.significantResults.reporter
short:
  v: A.2.7.6.7 - Reporter
definition:
  v: With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.
min:
  v: 0
max:
  v: *
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.synthesis
path:
  v: HDRHospitalStay.synthesis
short:
  v: A.2.7.7 - Synthesis
definition:
  v: 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.
min:
  v: 1
max:
  v: 1
type:
  code:
    v: BackboneElement

id:
  v: HDRHospitalStay.synthesis.description
path:
  v: HDRHospitalStay.synthesis.description
short:
  v: A.2.7.7.1 - Problem synthesis
definition:
  v: Summary description of the reason and course of hospitalisation for a specific problem.
min:
  v: 1
max:
  v: *
type:
  code:
    v: string

id:
  v: HDRHospitalStay.synthesis.reasoning
path:
  v: HDRHospitalStay.synthesis.reasoning
short:
  v: A.2.7.7.2 - Clinical reasoning
definition:
  v: The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string