Generated Narrative: StructureDefinition HDRPatientHistory Name Flags Card. Type Description & Constraints HDRPatientHistory 0..* Base A.2.6 - Patient history (eHN) #xD; medicalHistory 1..1 BackboneElement A.2.6.1 - Medical history #xD; <a href="StructureDefinition-HDRPatientHistory-definitions.html#HDRPatientHistory.medicalHistory.historyOfConditions" title="A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report. ">historyOfConditions 1..* BackboneElement A.2.6.1.1 - History of problems #xD; conditionSpecification 1..1 string A.2.6.1.1.1 - Problem description #xD; conditionDetails 0..* BackboneElement A.2.6.1.1.2 - Problem details #xD; onsetDate 1..1 dateTime A.2.6.1.1.3 - Onset date #xD; endDate 0..1 dateTime A.2.6.1.1.4 - End date #xD; clinicalStatus 0..1 CodeableConcept A.2.6.1.1.5 - Clinical status #xD; <a href="StructureDefinition-HDRPatientHistory-definitions.html#HDRPatientHistory.medicalHistory.historyOfConditions.resolution" title="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).">resolution 0..1 BackboneElement A.2.6.1.1.6 - Resolution circumstances #xD; severity 0..1 CodeableConcept A.2.6.1.1.7 - Severity #xD; stage 0..* CodeableConcept A.2.6.1.1.8 - Stage #xD; medicalDevices 1..* BackboneElement A.2.6.1.2 - Devices and Implants #xD; description 1..1 CodeableConcept A.2.6.1.2.1 - Device and implant description #xD; identifier 0..1 Identifier A.2.6.1.2.2 - Device ID #xD; implantDate 1..1 dateTime A.2.6.1.2.3 - Implant date #xD; endDate 0..1 dateTime A.2.6.1.2.4 - End date #xD; reason 0..* CodeableConcept A.2.6.1.2.5 - Reason #xD; historyOfProcedures 0..* BackboneElement A.2.6.1.3 - History of procedures #xD; procedureCode 0..1 CodeableConcept A.2.6.1.3.1 - Procedure code #xD; description 1..1 string A.2.6.1.3.2 - Procedure description #xD; bodySite 0..1 CodeableConcept A.2.6.1.3.3 - Body site #xD; date 0..1 dateTime A.2.6.1.3.4 - Procedure date #xD; reason 0..1 CodeableConcept A.2.6.1.3.5 - Procedure reason #xD; outcome 0..1 CodeableConcept A.2.6.1.3.6 - Outcome #xD; focalDevice 0..* CodeableReference() A.2.6.1.3.7 - Focal device #xD; vaccination 0..* BackboneElement A.2.6.1.4 - Vaccination #xD; diseaseOrAgent 0..* CodeableConcept A.2.6.1.4.1 - Disease or agent targeted #xD; vaccine 1..1 CodeableConcept A.2.6.1.4.2 - Vaccine/prophylaxis #xD; productName 0..1 string A.2.6.1.4.4 - Vaccine medicinal product #xD; manufacturerOrMAH 0..1 BackboneElement A.2.6.1.4.5 - Marketing Authorisation Holder #xD; orderNumber 0..1 integer A.2.6.1.4.6 - Number in a series of vaccinations / doses #xD; vaccinationDate 1..1 dateTime A.2.6.1.4.7 - Date of vaccination #xD; nextVaccinationDate 0..1 dateTime A.2.6.1.4.8 - Next vaccination date #xD; epidemiologicalHistory 0..1 BackboneElement A.2.6.1.5 - Epidemiological history #xD; infectiousContacts 0..* BackboneElement A.2.6.1.5.1 - Infectious contacts #xD; period 0..1 Period A.2.6.1.5.1.1 - Time period #xD; infectiousAgent 0..* CodeableConcept A.2.6.1.5.1.2 - Infectious agent #xD; proximity 0..1 CodeableConcept A.2.6.1.5.1.3 - Proximity #xD; country 0..1 CodeableConcept A.2.6.1.5.1.4 - Country #xD; note 0..1 string A.2.6.1.5.1.5 - Additional information #xD; travelHistory 0..* BackboneElement A.2.6.1.5.2 - Travel history #xD; period 0..1 Period A.2.6.1.5.2.1 - Time period #xD; country 1..1 CodeableConcept A.2.6.1.5.2.2 - Country visited #xD; comment 0..1 string A.2.6.1.5.2.3 - Comment #xD; familyHistory 0..* BackboneElement A.2.6.2 - Family history #xD; relationship 0..1 CodeableConcept A.2.6.2.1 - Patient relationship #xD; birthDate 0..1 dateTime A.2.6.2.2 - Date of birth #xD; deathDateOrAge 0..1 BackboneElement A.2.6.2.3 - Age or date of death #xD; conditions 0..* BackboneElement A.2.6.2.5 - Condition #xD; causeOfDeath 0..1 CodeableConcept A.2.6.2.6 - Cause of death #xD; socialDeterminants 0..1 BackboneElement A.2.6.3 - Social determinants of health #xD; participationInSociety 0..1 BackboneElement A.2.6.3.1 - Participation in society #xD; <a href="StructureDefinition-HDRPatientHistory-definitions.html#HDRPatientHistory.socialDeterminants.participationInSociety.workSituation" title="Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.">workSituation 0..1 string A.2.6.3.1.1 - Work situation #xD; hobby 0..1 string A.2.6.3.1.2 - Hobby #xD; socailNetwork 0..1 string A.2.6.3.1.3 - Social network #xD; education 0..1 BackboneElement A.2.6.3.2 - Education #xD; level 0..1 CodeableConcept A.2.6.3.2.1 - Education level #xD; comment 0..1 string A.2.6.3.2.2 - Comment #xD; livingSituation 0..1 BackboneElement A.2.6.3.3 - Living situation #xD; houseType 0..1 CodeableConcept A.2.6.3.3.1 - House type #xD; homeAdaption 0..* CodeableConcept A.2.6.3.3.2 - Home adaption #xD; livingConditions 0..* CodeableConcept A.2.6.3.3.3 - Living conditions #xD; familySituation 0..1 BackboneElement A.2.6.3.4 - Family situation #xD; comment 0..1 string A.2.6.3.4.1 - Comment #xD; familyComposition 0..1 CodeableConcept A.2.6.3.4.2 - Family composition #xD; maritalStatus 0..1 CodeableConcept A.2.6.3.4.3 - Marital status #xD; numberOfChildren 0..1 integer A.2.6.3.4.4 - Number of children #xD; numberOfChildrenAtHome 0..1 integer A.2.6.3.4.5 - Number of children at home #xD; childDetails 0..* BackboneElement A.2.6.3.4.6 - Child details #xD; careResponsibility 0..* BackboneElement A.2.6.3.4.7 - Care responsibility #xD; useOfSubstances 0..1 BackboneElement A.2.6.4 - Use of substances #xD; alcohol 0..* BackboneElement A.2.6.4.1 - Alcohol use #xD; currentStatus 0..1 CodeableConcept A.2.6.4.1.1 - Status #xD; periodAndQuantity 0..* CodeableConcept A.2.6.4.1.2 - Period and quantity #xD; comment 0..1 string A.2.6.4.1.3 - Comment #xD; tobacco 0..* BackboneElement A.2.6.4.2 - Tobacco use #xD; currentStatus 0..1 CodeableConcept A.2.6.4.2.1 - Status #xD; periodAndQuantity 0..* BackboneElement A.2.6.4.2.2 - Period and quantity #xD; comment 0..1 string A.2.6.4.2.3 - Comment #xD; drugConsumption 0..* BackboneElement A.2.6.4.3 - Drug consumption #xD; currentStatus 0..1 CodeableConcept A.2.6.4.3.1 - Status #xD; periodAndQuantity 0..1 BackboneElement A.2.6.4.3.2 - Period and quantity #xD; drugType 0..1 CodeableConcept A.2.6.4.3.3 - Drug or medication type #xD; route 0..* CodeableConcept A.2.6.4.3.4 - Route of administration #xD; comment 0..1 string A.2.6.4.3.5 - Comment #xD; Documentation for this format
Hospital Discharge Report - Patient history - A.2.6 eHN Maturity Level: 0 Draft
Used by permission of the XpanDH project, all rights reserved Creative Commons License
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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Extensions are always sliced by (at least) url
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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.
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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).
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A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
ICD-10* SNOMED CT Orphacode if rare disease is diagnosed IPS Absent and Unknown Data ICD-O-3
The date or estimated date that the condition resolved or went into remission.
Status of the condition/problem (active, resolved, inactive, ...)
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.
Stage/grade, usually assessed formally using a specific staging/grading system.
A.2.6.1.2.1 - Device and implant description
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
Historical procedures performed on or for a patient, relevant for the current encounter.
ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
SNOMED CT LOINC, NPU (for laboratory procedures) IPS Absent and Unknown Data
Procedure target body site and laterality
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.
The outcome of the procedure - did it resolve the reasons for the procedure being performed? Applicable mainly on surgical procedures.
A reference to the device or devices that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.
Disease or agent that the vaccination provides protection against
Generic description of the vaccine/prophylaxis or its component(s)
A.2.6.1.4.5 - Marketing Authorisation Holder
Marketing Authorisation Holder or manufacturer (Identifier and name)
EMA's Organisations Management Service (EMA SPOR OMS)
A.2.6.1.4.6 - Number in a series of vaccinations / doses
The date and time when the vaccination was administered
The date when the vaccination is planned to be given/repeated (e.g. next dose)
A date and duration or date time interval of contact. Partial dates are allowed.
Information about a suspected infectious agent or agents the person was exposed to.
Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
Country in which the person was potentially exposed to an infectious agent.
A textual note with additional information about infectious contact.
Travel history reported by the patient. Multiple records could be provided.
Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
The family relation between the related person and the patient.
Age or date of the death of the family member.
Medical problems this person suffers or suffered.
Information about disease or condition that was the main cause of death.
Information about social determinants of health.
Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
An activity the patient enjoys doing in their free time.
A description of the patient’s social network, such as family, neighbours and friends.
Indication of the highest level of education achieved.
If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Household type and other related living situation information.
Adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Conditions that affect the accessibility of the home or the stay in the home. Multiple data elements could be provided.
The family composition describes the patient’s home situation and the form of cohabitation.
A person’s marital status according to the terms and definition in the national civil code.
The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
A.2.6.3.4.5 - Number of children at home
The number of children living at home with the patient.
Child age, co-living status and comment. Multiple child details could be provided.
The activities the patient carries out to care for a dependent family member.
Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
The status of the patient’s alcohol use.
Period of use and amount (The extent of the patient’s alcohol use in units of alcohol per time period.)
Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
The status of the patient’s tobacco use.
Period of use and amount (The extent of the patient’s tobacco use in units of alcohol per time period.)
Consumption of drugs and other substances (in terms of abuse).