Generated Narrative: StructureDefinition EHDSDischargeReport Language: en Name Flags Card. Type Description & Constraints EHDSDischargeReport 0..* EHDSDocument Discharge Report model Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Instances of this logical model can be the target of a Reference #xD; header #xD; intendedRecipient[x] 0..* Intended recipient #xD; intendedRecipientEHDSPatient EHDSPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientEHDSHealthProfessional EHDSHealthProfessional #xD; intendedRecipientEHDSOrganisation EHDSOrganisation #xD; intendedRecipientEHDSDevice EHDSDevice #xD; healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information #xD; knowledgeResources 0..0 Related documents and information sources #xD; body 0..1 Base Structured body of the discharge report document #xD; advanceDirectives 0..1 Base Section: Advance Directives. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions #xD; alerts 0..1 Base Section: Alerts. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat. #xD; allergyAndIntolerance 0..* EHDSAllergyIntolerance Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter). #xD; encounterInformation 1..1 Base Section: Encounter information. #xD; narrative 1..1 string Narrative, potentially formatted, content of the section #xD; encounter 0..1 EHDSEncounter Encounter information #xD; admissionEvaluation 0..1 Base Section: Admission evaluation #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided. #xD; objectiveFindings 0..1 Base Objective findings #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided. #xD; time 0..1 dateTime Date and time of the admission evaluation examination #xD; performer 0..* EHDSHealthProfessional Health professional(s) responsible for the admission evaluation examination. #xD; anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness. #xD; vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.physicalExamination" title="Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.">physicalExamination 0..* EHDSObservation Physical examination #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.admissionEvaluation.functionalStatus" title="Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/">functionalStatus 0..1 Base Section: Functional status #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being #xD; patientHistory 0..1 Base Section: Patient health history (anamnesis). #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; medicalHistory 1..1 Base Medical history subsection. #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.patientHistory.medicalHistory.pastProblems" title="A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report. ">pastProblems 1..* EHDSCondition Past problems #xD; devicesAndImplants 1..* EHDSDeviceUse Devices and Implants #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.patientHistory.medicalHistory.historyOfProcedures" title="Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.">historyOfProcedures 0..* EHDSProcedure History of procedures #xD; vaccination 0..* EHDSImmunisation Vaccination history of the patient. #xD; epidemiologicalHistory 0..1 Base Epidemiological history #xD; infectiousContacts 0..* EHDSInfectiousContact Infectious contacts of the patient #xD; travelHistory 0..* EHDSTravelHistory Travel history reported by the patient. Multiple records could be provided. #xD; pregnancyHistory 0..1 Base Section: Pregnancy history #xD; currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status #xD; previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies #xD; previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies #xD; familyHistorySection 0..1 Base Family history section #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; familyHistory 0..* EHDSFamilyMemberHistory Family history #xD; socialDeterminantsOfHealth 0..1 Base Social determinants of health #xD; narrative 0..1 string Sub-section narrative #xD; participationInSociety 0..1 Base Participation in society #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation" title="Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.">workSituation 0..1 string Work situation #xD; hobby 0..1 string An activity the patient enjoys doing in their free time. #xD; socialNetwork 0..1 string Social network #xD; educationSection 0..1 Base Education section #xD; educationLevel 0..1 CodeableConcept Education level Binding Description: (preferred): hl7:v3.EducationLevel #xD; comment 0..1 string If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school). #xD; livingSituation 0..1 Base Living situation - household type and other related living situation information. #xD; houseType 0..1 CodeableConcept Type of home the patient lives in. Binding Description: (preferred): SNOMED CT #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption" title="Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.">homeAdaption 0..* CodeableConcept Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description: (preferred): SNOMED CT #xD; livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home. Binding Description: (preferred): SNOMED CT #xD; familySituation 0..1 Base Family situation #xD; comment 0..1 string Comment on the family situation. #xD; familyComposition 0..1 CodeableConcept Family composition Binding Description: (preferred): SNOMED CT #xD; maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code. Binding Description: (preferred): hl7:marital-status #xD; numberOfChildren 0..1 Quantity Number of children #xD; numberOfChildrenAtHome 0..1 Quantity Number of children living at home with the patient. #xD; childDetails 0..* Base Child details (age, co-living status and comment). #xD; livingAtHome 0..1 boolean Living at home. An indication stating whether the child lives at home. #xD; dateOfBirth 0..1 date Child’s date of birth. #xD; comment 0..1 string A comment on the child's family situation. #xD; careResponsibility 0..* CodeableConcept Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description: (preferred): SNOMED CT #xD; useOfSubstances 0..1 Base Use of substances #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; alcoholUse 0..* EHDSSubstanceUse Alcohol consumption by the patient. Multiple records on alcohol use could be provided. #xD; tobaccoUse 0..* EHDSSubstanceUse Tobacco use #xD; drugConsumption 0..* EHDSSubstanceUse Consumption of drugs and other substances (in terms of abuse). #xD; courseOfEncounter 1..1 Base Course of inpatient or outpatient encounter. #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary" title="The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.">diagnosticSummary 1..1 Base Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. #xD; narrative 0..1 string Problem specification in narrative form. #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails" title="Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the 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).">problemDetails 0..* Base Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the 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). #xD; presentOnAdmission 1..1 CodeableConcept Whether the condition was present on admission or acquired during encounter #xD; treatmentClass 1..1 CodeableConcept Class of the problem (treated, other) in relation to the encounter. #xD; problem 1..1 EHDSCondition Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem. #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.courseOfEncounter.significantProcedures" title="Significant surgical and non-surgical procedures performed during encounter 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.">significantProcedures 0..1 Base Significant procedures section #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; procedureEntry 0..* EHDSProcedure Structured procedure entry. #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants" title="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 encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system">medicalDevicesAndImplants 1..1 Base Medical devices and implants section #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; medicalDevicesAndImplants 1..* EHDSDeviceUse Medical devices and implants #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy" title="Selected drug treatment during encounter. Medicinal products that were administered during encounter 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 encounter, but is also recommended after discharge, will be listed in the summary table in the recommendation section.">pharmacotherapy 0..1 Base Pharmacotherapy section #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; pharmacotherapy 0..* EHDSMedicationStatement Pharmacotherapy structured entry. #xD; significantObservationResults 0..1 Base Significant Observation Results #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided. #xD; significantObservationResult[x] 0..* Significant Observation Result #xD; significantObservationResultEHDSObservation EHDSObservation #xD; significantObservationResultEHDSLaboratoryObservation EHDSLaboratoryObservation #xD; synthesis 1..1 Base Synthesis #xD; problemSynthesis 1..* string Summary description of the reason and course of hospitalisation for a specific problem. #xD; clinicalReasoning 0..1 string Clinical reasoning #xD; dischargeDetails 1..1 Base Discharge details #xD; narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided. #xD; objectiveFindings 0..1 Base Objective findings #xD; narrative 0..1 string Narrative content of the section. #xD; anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness. #xD; vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.dischargeDetails.objectiveFindings.physicalExamination" title="Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.">physicalExamination 0..* EHDSObservation Physical examination #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.dischargeDetails.functionalStatus" title="Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/">functionalStatus 0..1 Base Section: Functional status #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being #xD; <a href="StructureDefinition-EHDSDischargeReport-definitions.html#EHDSDischargeReport.body.dischargeDetails.medicationSummary" title="Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.">medicationSummary 0..1 Base Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued. #xD; narrative 0..1 string Narrative content of the section. #xD; entry 0..* Base Structured medication entry #xD; medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging #xD; daysSupplied 0..1 Quantity Number of days for which the patient was provided with the drug at the time of discharge #xD; carePlan 0..* Base Care plan and other recommendations after discharge. #xD; narrative 0..1 string Narrative content of the section. #xD; carePlan 0..* EHDSCarePlan Structured care plan after discharge. Multiple care plans could be provided. #xD; otherRecommendations 0..1 string Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc. #xD; attachments[x] 0..* Report attachments data elements #xD; attachmentsEHDSAttachment EHDSAttachment #xD; attachmentsEHDSMedia EHDSMedia #xD; Documentation for this format
EHDS refined base model for Discharge Report
Copyright HL7 Europe. Licensed under Creative Commons public domain (CC0 1.0).
Common header for all patient-related data
Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Date and time of the issuing the document/resource by its author.
Date and time of the last update to the resource
Date and time of the last update to the document/information
Reason for the current status of the resource.
Language in which the resource is written. Language is expressed by the IETF language tag.
A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Identifies the type of document at hand, e.g. Discharge report.
Document title, such as Discharge Report, Laboratory Result Report, etc.
The status of the Discharge report. E.g., preliminary, final.
Time of service that is being documented
Attester who validated the document. Mulitple attesters could be provided.
Date and time of the approval of the document by Attester.
The person taking responsibility for the medical content of the document
Date and time when the document was authorized.
Categorization of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.
Additional details about where the content was created (e.g. clinical specialty)
Organisation that is in charge of maintaining the document/report.
An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
Level of confidentiality of the document. Implicit value is normal.
Related documents and information sources
Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
Health insurance and payment information
Structured body of the discharge report document
Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Narrative, potentially formatted, content of the section
Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Information about substantial alerts or warnings that health professionals should be aware of.
Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Date and time of the admission evaluation examination
Health professional(s) responsible for the admission evaluation examination.
Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Section: Patient health history (anamnesis).
Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
Travel history reported by the patient. Multiple records could be provided.
To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown
Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Information about social determinants of health.
Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
An activity the patient enjoys doing in their free time.
A description of the patient’s social network, such as family, neighbours and friends.
Information about patient education level.
Indication of the highest level of education achieved.
If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Living situation - household type and other related living situation information.
Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Living conditions that affect the accessibility of the home or the stay in the home.
The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Person’s marital status according to the terms and definition in the national civil code.
The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Number of children living at home with the patient.
Child details (age, co-living status and comment).
Living at home. An indication stating whether the child lives at home.
A comment on the child's family situation.
Care responsibility. The activities the patient carries out to care for a dependent family member.
Information about use and/or abuse of specific substances.
Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Consumption of drugs and other substances (in terms of abuse).
Course of inpatient or outpatient encounter.
Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Problem specification in narrative form.
Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the 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).
Whether the condition was present on admission or acquired during encounter
Category of the problem allows flagging for conditions acquired during encounter.
Value set can include Present on admission [POA], Hospital acquired condition [HAC], Not applicable or Unknown
Class of the problem (treated, other) in relation to the encounter.
Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Significant surgical and non-surgical procedures performed during encounter 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.
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 encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Selected drug treatment during encounter. Medicinal products that were administered during encounter 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 encounter, but is also recommended after discharge, will be listed in the summary table in the recommendation section.
Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during encounter. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
Structured significant observation entry.
This section provides clinical synthesis (e.g. description of reasons and course of encounter) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.
Summary description of the reason and course of hospitalisation for a specific problem.
The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Structured information should be provided, however if not available, at least a section narrative should be present.
Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
Number of days for which the patient was provided with the drug at the time of discharge
Supply is intended to either hand over the medicine or write out a prescription. A 0 value indicates that the patient has not been provided with the drug (e.g. if the patient has a sufficient supply of the drug)
Care plan and other recommendations after discharge.
Care plan and other recommendations after discharge section.
Structured care plan after discharge. Multiple care plans could be provided.
Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.