XpanDH Hospital Discharge Report
0.1.0 - ci-build 150

XpanDH Hospital Discharge Report, published by XpanDH Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/xpandh-hdr/ and changes regularly. See the Directory of published versions

## Logical Model: HdrEHNHospitalStay - Detailed Descriptions

Draft as of 2025-10-10

Definitions for the HDRHospitalStay logical model.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. HDRHospitalStay
Definition | Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft
Short | A.2.7 - Hospital stay (eHN)
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. HDRHospitalStay.diagnosticSummary
Definition | 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.
Short | A.2.7.1 - Diagnostic summary
Control | 1..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
4. HDRHospitalStay.diagnosticSummary.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
6. HDRHospitalStay.diagnosticSummary.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `HDRHospitalStay.diagnosticSummary.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
8. HDRHospitalStay.diagnosticSummary.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. HDRHospitalStay.diagnosticSummary.problemDescription
Definition | Problem specification in narrative form
Short | A.2.7.1.1 - Problem description
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. HDRHospitalStay.diagnosticSummary.problemDetails
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | A.2.7.1.2 - Problem details
Comments | ICD-10* SNOMED CT ICD-O-3 Orphacode if rare disease is diagnosed IPS Absent and Unknown Data
Control | 0..*
Type | BackboneElement
14. HDRHospitalStay.diagnosticSummary.onsetDate
Definition | Onset date of a problem/condition
Short | A.2.7.1.3 - Onset date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. HDRHospitalStay.diagnosticSummary.endDate
Definition | The date or estimated date that the condition resolved or went into remission.
Short | A.2.7.1.4 - End date
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
18. HDRHospitalStay.diagnosticSummary.category
Definition | Category of the problem allows flagging for conditions acquired during hospital stay.
Short | A.2.7.1.5 - Category
Comments | Present on admission [POA]) Hospital acquired condition [HAC] Not applicable or unknown
Control | 1..1
Type | CodeableConcept
20. HDRHospitalStay.diagnosticSummary.treatmentClass
Definition | 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).
Short | A.2.7.1.6 - Treatment class
Comments | Treated, Other
Control | 1..1
Type | CodeableConcept
22. HDRHospitalStay.diagnosticSummary.clinicalStatus
Definition | Status of the condition/problem (active, resolved, inactive, ...)
Short | A.2.7.1.7 - Clinical status
Comments | hl7:condition-clinical
Control | 0..1
Type | CodeableConcept
24. HDRHospitalStay.diagnosticSummary.resolution
Definition | 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).
Short | A.2.7.1.8 - Resolution circumstances
Control | 0..1
Type | BackboneElement
26. HDRHospitalStay.diagnosticSummary.severity
Definition | A subjective assessment of the severity of the condition as evaluated by the clinician.
Short | A.2.7.1.9 - Severity
Comments | hl7:condition-severity
Control | 0..1
Type | CodeableConcept
28. HDRHospitalStay.diagnosticSummary.stage
Definition | Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.
Short | A.2.7.1.10 - Stage
Comments | e.g. TNM ICD-O-3
Control | 0..*
Type | CodeableConcept
30. HDRHospitalStay.significantProcedures
Definition | 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.
Short | A.2.7.2 - Significant procedures
Control | 1..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. HDRHospitalStay.significantProcedures.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
34. HDRHospitalStay.significantProcedures.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `HDRHospitalStay.significantProcedures.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
36. HDRHospitalStay.significantProcedures.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
38. HDRHospitalStay.significantProcedures.procedureCode
Definition | Procedure code
Short | A.2.7.2.1 - Procedure code
Comments | SNOMED CT IPS Absent and Unknown Data
Control | 0..*
Type | CodeableConcept
40. HDRHospitalStay.significantProcedures.description
Definition | Narrative description of the procedure
Short | A.2.7.2.2 - Procedure description
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
42. HDRHospitalStay.significantProcedures.bodySite
Definition | Procedure target body site and laterality
Short | A.2.7.2.3 - Body site
Comments | SNOMED CT
Control | 0..1
Type | CodeableConcept
44. HDRHospitalStay.significantProcedures.date
Definition | Date and time when procedure was performed
Short | A.2.7.2.4 - Procedure date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
46. HDRHospitalStay.significantProcedures.reason
Definition | The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.
Short | A.2.7.2.5 - Procedure reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
48. HDRHospitalStay.significantProcedures.outcome
Definition | The outcome of the procedure - did it resolve the reasons for the procedure being performed?
Short | A.2.7.2.6 - Outcome
Comments | SNOMED CT
Control | 0..1
Type | CodeableConcept
50. HDRHospitalStay.significantProcedures.complication
Definition | 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.
Short | A.2.7.2.7 - Complication
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
52. HDRHospitalStay.significantProcedures.focalDevice
Definition | 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.
Short | A.2.7.2.8 - Focal device
Control | 0..*
Type | ​CodeableReference
54. HDRHospitalStay.medicalDevices
Definition | 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
Short | A.2.7.3 - Medical devices and implants
Control | 1..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. HDRHospitalStay.medicalDevices.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
58. HDRHospitalStay.medicalDevices.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `HDRHospitalStay.medicalDevices.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
60. HDRHospitalStay.medicalDevices.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
62. HDRHospitalStay.medicalDevices.description
Definition | 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.
Short | A.2.7.3.1 - Device and implant description
Comments | SNOMED CT EMDN IPS Absent and Unknown Data
Control | 1..1
Type | CodeableConcept
64. HDRHospitalStay.medicalDevices.identifier
Definition | Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745
Short | A.2.7.3.2 - Device ID
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
66. HDRHospitalStay.medicalDevices.implantDate
Definition | The date and time the device was implanted or when its use began.
Short | A.2.7.3.3 - Implant date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
68. HDRHospitalStay.medicalDevices.endDate
Definition | 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
Short | A.2.7.3.4 - End date
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. HDRHospitalStay.medicalDevices.reason
Definition | The medical reason for use of the medical device.
Short | A.2.7.3.5 - Reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
72. HDRHospitalStay.pharmacotherapy
Definition | 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.
Short | A.2.7.5 - Pharmacotherapy
Control | 0..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
74. HDRHospitalStay.pharmacotherapy.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
76. HDRHospitalStay.pharmacotherapy.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `HDRHospitalStay.pharmacotherapy.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
78. HDRHospitalStay.pharmacotherapy.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. HDRHospitalStay.pharmacotherapy.reason
Definition | 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.
Short | A.2.7.5.1 - Medication reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..1
Type | CodeableConcept
82. HDRHospitalStay.pharmacotherapy.productCode
Definition | Product code
Short | A.2.7.5.2 - Code
Comments | IDMP
Control | 1..1
Type | CodeableConcept
84. HDRHospitalStay.pharmacotherapy.intendedUse
Definition | Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.
Short | A.2.7.5.3 - Intended use
Control | 0..*
Type | CodeableConcept
86. HDRHospitalStay.pharmacotherapy.productName
Definition | Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)
Short | A.2.7.5.4 - Brand name
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
88. HDRHospitalStay.pharmacotherapy.activeIngredient
Definition | Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: "paracetamol"
Short | A.2.7.5.5 - Active ingredient list
Comments | ATC (IDMP / EMA SPOR SMS)
Control | 0..*
Type | CodeableConcept
90. HDRHospitalStay.pharmacotherapy.strength
Definition | 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
Short | A.2.7.5.6 - Strength
Comments | UCUM EDQM Standard terms
Control | 0..*
Type | Ratio
92. HDRHospitalStay.pharmacotherapy.doseForm
Definition | The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)
Short | A.2.7.5.7 - Pharmaceutical dose form
Comments | EDQM Standard Terms
Control | 0..1
Type | CodeableConcept
94. HDRHospitalStay.pharmacotherapy.dosageRegimen
Definition | Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days
Short | A.2.7.5.8 - Dosage Regimen
Control | 0..*
Type | BackboneElement
96. HDRHospitalStay.pharmacotherapy.route
Definition | Path by which the pharmaceutical product is taken into or makes contact with the body.
Short | A.2.7.5.9 - Route of administration
Comments | EDQM Standard Terms
Control | 0..1
Type | CodeableConcept
98. HDRHospitalStay.pharmacotherapy.period
Definition | The time interval when the patient was, or was not, given the medication.
Short | A.2.7.5.10 - Period of treatment
Control | 0..1
Type | Period
100. HDRHospitalStay.significantResults
Definition | 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.
Short | A.2.7.6 - Significant Observation Results
Control | 0..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
102. HDRHospitalStay.significantResults.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
104. HDRHospitalStay.significantResults.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `HDRHospitalStay.significantResults.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
106. HDRHospitalStay.significantResults.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
108. HDRHospitalStay.significantResults.date
Definition | Date and time of the observation
Short | A.2.7.6.1 - Date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. HDRHospitalStay.significantResults.status
Definition | Status of the observation (e.g. registered, preliminary, final)
Short | A.2.7.6.2 - Observation status
Comments | hl7:observation-status
Control | 1..1
Type | CodeableConcept
112. HDRHospitalStay.significantResults.description
Definition | Narrative representation of the observation result and findings.
Short | A.2.7.6.3 - Result description
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. HDRHospitalStay.significantResults.details
Definition | 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.
Short | A.2.7.6.4 - Observation details
Comments | LOINC NPU SNOMED CT
Control | 1..1
Type | BackboneElement
116. HDRHospitalStay.significantResults.result
Definition | 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.
Short | A.2.7.6.5 - Observation result
Comments | SNOMED CT UCUM (measurement units)
Control | 0..1
Type | BackboneElement
118. HDRHospitalStay.significantResults.reporter
Definition | With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.
Short | A.2.7.6.7 - Reporter
Control | 0..*
Type | BackboneElement
120. HDRHospitalStay.synthesis
Definition | 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.
Short | A.2.7.7 - Synthesis
Control | 1..1
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
122. HDRHospitalStay.synthesis.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
124. HDRHospitalStay.synthesis.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `HDRHospitalStay.synthesis.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
126. HDRHospitalStay.synthesis.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
128. HDRHospitalStay.synthesis.description
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | A.2.7.7.1 - Problem synthesis
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
130. HDRHospitalStay.synthesis.reasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | A.2.7.7.2 - Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. HDRHospitalStay
Definition | Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft
Short | A.2.7 - Hospital stay (eHN)
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. HDRHospitalStay.diagnosticSummary
Definition | 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.
Short | A.2.7.1 - Diagnostic summary
Control | 1..*
Type | BackboneElement
4. HDRHospitalStay.diagnosticSummary.problemDescription
Definition | Problem specification in narrative form
Short | A.2.7.1.1 - Problem description
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
6. HDRHospitalStay.diagnosticSummary.problemDetails
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | A.2.7.1.2 - Problem details
Comments | ICD-10* SNOMED CT ICD-O-3 Orphacode if rare disease is diagnosed IPS Absent and Unknown Data
Control | 0..*
Type | BackboneElement
8. HDRHospitalStay.diagnosticSummary.onsetDate
Definition | Onset date of a problem/condition
Short | A.2.7.1.3 - Onset date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
10. HDRHospitalStay.diagnosticSummary.endDate
Definition | The date or estimated date that the condition resolved or went into remission.
Short | A.2.7.1.4 - End date
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. HDRHospitalStay.diagnosticSummary.category
Definition | Category of the problem allows flagging for conditions acquired during hospital stay.
Short | A.2.7.1.5 - Category
Comments | Present on admission [POA]) Hospital acquired condition [HAC] Not applicable or unknown
Control | 1..1
Type | CodeableConcept
14. HDRHospitalStay.diagnosticSummary.treatmentClass
Definition | 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).
Short | A.2.7.1.6 - Treatment class
Comments | Treated, Other
Control | 1..1
Type | CodeableConcept
16. HDRHospitalStay.diagnosticSummary.clinicalStatus
Definition | Status of the condition/problem (active, resolved, inactive, ...)
Short | A.2.7.1.7 - Clinical status
Comments | hl7:condition-clinical
Control | 0..1
Type | CodeableConcept
18. HDRHospitalStay.diagnosticSummary.resolution
Definition | 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).
Short | A.2.7.1.8 - Resolution circumstances
Control | 0..1
Type | BackboneElement
20. HDRHospitalStay.diagnosticSummary.severity
Definition | A subjective assessment of the severity of the condition as evaluated by the clinician.
Short | A.2.7.1.9 - Severity
Comments | hl7:condition-severity
Control | 0..1
Type | CodeableConcept
22. HDRHospitalStay.diagnosticSummary.stage
Definition | Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.
Short | A.2.7.1.10 - Stage
Comments | e.g. TNM ICD-O-3
Control | 0..*
Type | CodeableConcept
24. HDRHospitalStay.significantProcedures
Definition | 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.
Short | A.2.7.2 - Significant procedures
Control | 1..*
Type | BackboneElement
26. HDRHospitalStay.significantProcedures.procedureCode
Definition | Procedure code
Short | A.2.7.2.1 - Procedure code
Comments | SNOMED CT IPS Absent and Unknown Data
Control | 0..*
Type | CodeableConcept
28. HDRHospitalStay.significantProcedures.description
Definition | Narrative description of the procedure
Short | A.2.7.2.2 - Procedure description
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
30. HDRHospitalStay.significantProcedures.bodySite
Definition | Procedure target body site and laterality
Short | A.2.7.2.3 - Body site
Comments | SNOMED CT
Control | 0..1
Type | CodeableConcept
32. HDRHospitalStay.significantProcedures.date
Definition | Date and time when procedure was performed
Short | A.2.7.2.4 - Procedure date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
34. HDRHospitalStay.significantProcedures.reason
Definition | The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.
Short | A.2.7.2.5 - Procedure reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
36. HDRHospitalStay.significantProcedures.outcome
Definition | The outcome of the procedure - did it resolve the reasons for the procedure being performed?
Short | A.2.7.2.6 - Outcome
Comments | SNOMED CT
Control | 0..1
Type | CodeableConcept
38. HDRHospitalStay.significantProcedures.complication
Definition | 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.
Short | A.2.7.2.7 - Complication
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
40. HDRHospitalStay.significantProcedures.focalDevice
Definition | 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.
Short | A.2.7.2.8 - Focal device
Control | 0..*
Type | ​CodeableReference
42. HDRHospitalStay.medicalDevices
Definition | 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
Short | A.2.7.3 - Medical devices and implants
Control | 1..*
Type | BackboneElement
44. HDRHospitalStay.medicalDevices.description
Definition | 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.
Short | A.2.7.3.1 - Device and implant description
Comments | SNOMED CT EMDN IPS Absent and Unknown Data
Control | 1..1
Type | CodeableConcept
46. HDRHospitalStay.medicalDevices.identifier
Definition | Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745
Short | A.2.7.3.2 - Device ID
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
48. HDRHospitalStay.medicalDevices.implantDate
Definition | The date and time the device was implanted or when its use began.
Short | A.2.7.3.3 - Implant date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
50. HDRHospitalStay.medicalDevices.endDate
Definition | 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
Short | A.2.7.3.4 - End date
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
52. HDRHospitalStay.medicalDevices.reason
Definition | The medical reason for use of the medical device.
Short | A.2.7.3.5 - Reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
54. HDRHospitalStay.pharmacotherapy
Definition | 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.
Short | A.2.7.5 - Pharmacotherapy
Control | 0..*
Type | BackboneElement
56. HDRHospitalStay.pharmacotherapy.reason
Definition | 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.
Short | A.2.7.5.1 - Medication reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..1
Type | CodeableConcept
58. HDRHospitalStay.pharmacotherapy.productCode
Definition | Product code
Short | A.2.7.5.2 - Code
Comments | IDMP
Control | 1..1
Type | CodeableConcept
60. HDRHospitalStay.pharmacotherapy.intendedUse
Definition | Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.
Short | A.2.7.5.3 - Intended use
Control | 0..*
Type | CodeableConcept
62. HDRHospitalStay.pharmacotherapy.productName
Definition | Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)
Short | A.2.7.5.4 - Brand name
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
64. HDRHospitalStay.pharmacotherapy.activeIngredient
Definition | Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: "paracetamol"
Short | A.2.7.5.5 - Active ingredient list
Comments | ATC (IDMP / EMA SPOR SMS)
Control | 0..*
Type | CodeableConcept
66. HDRHospitalStay.pharmacotherapy.strength
Definition | 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
Short | A.2.7.5.6 - Strength
Comments | UCUM EDQM Standard terms
Control | 0..*
Type | Ratio
68. HDRHospitalStay.pharmacotherapy.doseForm
Definition | The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)
Short | A.2.7.5.7 - Pharmaceutical dose form
Comments | EDQM Standard Terms
Control | 0..1
Type | CodeableConcept
70. HDRHospitalStay.pharmacotherapy.dosageRegimen
Definition | Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days
Short | A.2.7.5.8 - Dosage Regimen
Control | 0..*
Type | BackboneElement
72. HDRHospitalStay.pharmacotherapy.route
Definition | Path by which the pharmaceutical product is taken into or makes contact with the body.
Short | A.2.7.5.9 - Route of administration
Comments | EDQM Standard Terms
Control | 0..1
Type | CodeableConcept
74. HDRHospitalStay.pharmacotherapy.period
Definition | The time interval when the patient was, or was not, given the medication.
Short | A.2.7.5.10 - Period of treatment
Control | 0..1
Type | Period
76. HDRHospitalStay.significantResults
Definition | 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.
Short | A.2.7.6 - Significant Observation Results
Control | 0..*
Type | BackboneElement
78. HDRHospitalStay.significantResults.date
Definition | Date and time of the observation
Short | A.2.7.6.1 - Date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. HDRHospitalStay.significantResults.status
Definition | Status of the observation (e.g. registered, preliminary, final)
Short | A.2.7.6.2 - Observation status
Comments | hl7:observation-status
Control | 1..1
Type | CodeableConcept
82. HDRHospitalStay.significantResults.description
Definition | Narrative representation of the observation result and findings.
Short | A.2.7.6.3 - Result description
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
84. HDRHospitalStay.significantResults.details
Definition | 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.
Short | A.2.7.6.4 - Observation details
Comments | LOINC NPU SNOMED CT
Control | 1..1
Type | BackboneElement
86. HDRHospitalStay.significantResults.result
Definition | 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.
Short | A.2.7.6.5 - Observation result
Comments | SNOMED CT UCUM (measurement units)
Control | 0..1
Type | BackboneElement
88. HDRHospitalStay.significantResults.reporter
Definition | With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.
Short | A.2.7.6.7 - Reporter
Control | 0..*
Type | BackboneElement
90. HDRHospitalStay.synthesis
Definition | 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.
Short | A.2.7.7 - Synthesis
Control | 1..1
Type | BackboneElement
92. HDRHospitalStay.synthesis.description
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | A.2.7.7.1 - Problem synthesis
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
94. HDRHospitalStay.synthesis.reasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | A.2.7.7.2 - Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. HDRHospitalStay
Definition | Hospital Discharge Report - Hospital stay - A.2.7 eHN Maturity Level: 0 Draft
Short | A.2.7 - Hospital stay (eHN)
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. HDRHospitalStay.diagnosticSummary
Definition | 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.
Short | A.2.7.1 - Diagnostic summary
Control | 1..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
4. HDRHospitalStay.diagnosticSummary.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
6. HDRHospitalStay.diagnosticSummary.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `HDRHospitalStay.diagnosticSummary.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
8. HDRHospitalStay.diagnosticSummary.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
10. HDRHospitalStay.diagnosticSummary.problemDescription
Definition | Problem specification in narrative form
Short | A.2.7.1.1 - Problem description
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. HDRHospitalStay.diagnosticSummary.problemDetails
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | A.2.7.1.2 - Problem details
Comments | ICD-10* SNOMED CT ICD-O-3 Orphacode if rare disease is diagnosed IPS Absent and Unknown Data
Control | 0..*
Type | BackboneElement
14. HDRHospitalStay.diagnosticSummary.onsetDate
Definition | Onset date of a problem/condition
Short | A.2.7.1.3 - Onset date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. HDRHospitalStay.diagnosticSummary.endDate
Definition | The date or estimated date that the condition resolved or went into remission.
Short | A.2.7.1.4 - End date
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
18. HDRHospitalStay.diagnosticSummary.category
Definition | Category of the problem allows flagging for conditions acquired during hospital stay.
Short | A.2.7.1.5 - Category
Comments | Present on admission [POA]) Hospital acquired condition [HAC] Not applicable or unknown
Control | 1..1
Type | CodeableConcept
20. HDRHospitalStay.diagnosticSummary.treatmentClass
Definition | 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).
Short | A.2.7.1.6 - Treatment class
Comments | Treated, Other
Control | 1..1
Type | CodeableConcept
22. HDRHospitalStay.diagnosticSummary.clinicalStatus
Definition | Status of the condition/problem (active, resolved, inactive, ...)
Short | A.2.7.1.7 - Clinical status
Comments | hl7:condition-clinical
Control | 0..1
Type | CodeableConcept
24. HDRHospitalStay.diagnosticSummary.resolution
Definition | 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).
Short | A.2.7.1.8 - Resolution circumstances
Control | 0..1
Type | BackboneElement
26. HDRHospitalStay.diagnosticSummary.severity
Definition | A subjective assessment of the severity of the condition as evaluated by the clinician.
Short | A.2.7.1.9 - Severity
Comments | hl7:condition-severity
Control | 0..1
Type | CodeableConcept
28. HDRHospitalStay.diagnosticSummary.stage
Definition | Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.
Short | A.2.7.1.10 - Stage
Comments | e.g. TNM ICD-O-3
Control | 0..*
Type | CodeableConcept
30. HDRHospitalStay.significantProcedures
Definition | 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.
Short | A.2.7.2 - Significant procedures
Control | 1..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. HDRHospitalStay.significantProcedures.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
34. HDRHospitalStay.significantProcedures.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `HDRHospitalStay.significantProcedures.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
36. HDRHospitalStay.significantProcedures.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
38. HDRHospitalStay.significantProcedures.procedureCode
Definition | Procedure code
Short | A.2.7.2.1 - Procedure code
Comments | SNOMED CT IPS Absent and Unknown Data
Control | 0..*
Type | CodeableConcept
40. HDRHospitalStay.significantProcedures.description
Definition | Narrative description of the procedure
Short | A.2.7.2.2 - Procedure description
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
42. HDRHospitalStay.significantProcedures.bodySite
Definition | Procedure target body site and laterality
Short | A.2.7.2.3 - Body site
Comments | SNOMED CT
Control | 0..1
Type | CodeableConcept
44. HDRHospitalStay.significantProcedures.date
Definition | Date and time when procedure was performed
Short | A.2.7.2.4 - Procedure date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
46. HDRHospitalStay.significantProcedures.reason
Definition | The coded reason why the procedure was performed. This may be a coded entity or may simply be present as text.
Short | A.2.7.2.5 - Procedure reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
48. HDRHospitalStay.significantProcedures.outcome
Definition | The outcome of the procedure - did it resolve the reasons for the procedure being performed?
Short | A.2.7.2.6 - Outcome
Comments | SNOMED CT
Control | 0..1
Type | CodeableConcept
50. HDRHospitalStay.significantProcedures.complication
Definition | 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.
Short | A.2.7.2.7 - Complication
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
52. HDRHospitalStay.significantProcedures.focalDevice
Definition | 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.
Short | A.2.7.2.8 - Focal device
Control | 0..*
Type | ​CodeableReference
54. HDRHospitalStay.medicalDevices
Definition | 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
Short | A.2.7.3 - Medical devices and implants
Control | 1..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. HDRHospitalStay.medicalDevices.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
58. HDRHospitalStay.medicalDevices.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `HDRHospitalStay.medicalDevices.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
60. HDRHospitalStay.medicalDevices.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
62. HDRHospitalStay.medicalDevices.description
Definition | 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.
Short | A.2.7.3.1 - Device and implant description
Comments | SNOMED CT EMDN IPS Absent and Unknown Data
Control | 1..1
Type | CodeableConcept
64. HDRHospitalStay.medicalDevices.identifier
Definition | Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745
Short | A.2.7.3.2 - Device ID
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
66. HDRHospitalStay.medicalDevices.implantDate
Definition | The date and time the device was implanted or when its use began.
Short | A.2.7.3.3 - Implant date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
68. HDRHospitalStay.medicalDevices.endDate
Definition | 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
Short | A.2.7.3.4 - End date
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. HDRHospitalStay.medicalDevices.reason
Definition | The medical reason for use of the medical device.
Short | A.2.7.3.5 - Reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..*
Type | CodeableConcept
72. HDRHospitalStay.pharmacotherapy
Definition | 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.
Short | A.2.7.5 - Pharmacotherapy
Control | 0..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
74. HDRHospitalStay.pharmacotherapy.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
76. HDRHospitalStay.pharmacotherapy.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `HDRHospitalStay.pharmacotherapy.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
78. HDRHospitalStay.pharmacotherapy.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
80. HDRHospitalStay.pharmacotherapy.reason
Definition | 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.
Short | A.2.7.5.1 - Medication reason
Comments | ICD-10* SNOMED CT Orphacode if rare disease is diagnosed
Control | 0..1
Type | CodeableConcept
82. HDRHospitalStay.pharmacotherapy.productCode
Definition | Product code
Short | A.2.7.5.2 - Code
Comments | IDMP
Control | 1..1
Type | CodeableConcept
84. HDRHospitalStay.pharmacotherapy.intendedUse
Definition | Indication intended use as: prevention or treatment Example: prophylaxis, treatment, diagnostic, anaesthesia.
Short | A.2.7.5.3 - Intended use
Control | 0..*
Type | CodeableConcept
86. HDRHospitalStay.pharmacotherapy.productName
Definition | Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)
Short | A.2.7.5.4 - Brand name
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
88. HDRHospitalStay.pharmacotherapy.activeIngredient
Definition | Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product. Example: "paracetamol"
Short | A.2.7.5.5 - Active ingredient list
Comments | ATC (IDMP / EMA SPOR SMS)
Control | 0..*
Type | CodeableConcept
90. HDRHospitalStay.pharmacotherapy.strength
Definition | 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
Short | A.2.7.5.6 - Strength
Comments | UCUM EDQM Standard terms
Control | 0..*
Type | Ratio
92. HDRHospitalStay.pharmacotherapy.doseForm
Definition | The form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablet, syrup)
Short | A.2.7.5.7 - Pharmaceutical dose form
Comments | EDQM Standard Terms
Control | 0..1
Type | CodeableConcept
94. HDRHospitalStay.pharmacotherapy.dosageRegimen
Definition | Number of units per intake and frequency of intake over a specified duration of time. Example: 1 tablet every 24h, for 10 days
Short | A.2.7.5.8 - Dosage Regimen
Control | 0..*
Type | BackboneElement
96. HDRHospitalStay.pharmacotherapy.route
Definition | Path by which the pharmaceutical product is taken into or makes contact with the body.
Short | A.2.7.5.9 - Route of administration
Comments | EDQM Standard Terms
Control | 0..1
Type | CodeableConcept
98. HDRHospitalStay.pharmacotherapy.period
Definition | The time interval when the patient was, or was not, given the medication.
Short | A.2.7.5.10 - Period of treatment
Control | 0..1
Type | Period
100. HDRHospitalStay.significantResults
Definition | 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.
Short | A.2.7.6 - Significant Observation Results
Control | 0..*
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
102. HDRHospitalStay.significantResults.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
104. HDRHospitalStay.significantResults.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `HDRHospitalStay.significantResults.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
106. HDRHospitalStay.significantResults.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
108. HDRHospitalStay.significantResults.date
Definition | Date and time of the observation
Short | A.2.7.6.1 - Date
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. HDRHospitalStay.significantResults.status
Definition | Status of the observation (e.g. registered, preliminary, final)
Short | A.2.7.6.2 - Observation status
Comments | hl7:observation-status
Control | 1..1
Type | CodeableConcept
112. HDRHospitalStay.significantResults.description
Definition | Narrative representation of the observation result and findings.
Short | A.2.7.6.3 - Result description
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. HDRHospitalStay.significantResults.details
Definition | 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.
Short | A.2.7.6.4 - Observation details
Comments | LOINC NPU SNOMED CT
Control | 1..1
Type | BackboneElement
116. HDRHospitalStay.significantResults.result
Definition | 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.
Short | A.2.7.6.5 - Observation result
Comments | SNOMED CT UCUM (measurement units)
Control | 0..1
Type | BackboneElement
118. HDRHospitalStay.significantResults.reporter
Definition | With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.
Short | A.2.7.6.7 - Reporter
Control | 0..*
Type | BackboneElement
120. HDRHospitalStay.synthesis
Definition | 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.
Short | A.2.7.7 - Synthesis
Control | 1..1
Type | BackboneElement
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
122. HDRHospitalStay.synthesis.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
124. HDRHospitalStay.synthesis.extension
Definition | 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.
Short | Additional content defined by implementations
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `HDRHospitalStay.synthesis.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
126. HDRHospitalStay.synthesis.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored even if unrecognized
Comments | 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | 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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
128. HDRHospitalStay.synthesis.description
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | A.2.7.7.1 - Problem synthesis
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
130. HDRHospitalStay.synthesis.reasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | A.2.7.7.2 - Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension