| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
Composition
|
ClinicalDocument | Hospital Discharge Report composition | ||
basedOn-order-or-requisition
|
0..* | Identifier, Reference ( ServiceRequest ) |
Document Based On Order
URL: http://hl7.eu/fhir/laboratory/StructureDefinition/composition-basedOn-order-or-requisition |
|
Slices for value[x]
|
Slice: Unordered, Open by type:$this | |||
value[x]:valueReference
|
0..1 | Reference (ServiceRequest: Encounter Request) | ||
|
information-recipient
|
0 .. * | Reference ( Practitioner (CZ) | Device | Patient (CZ) | RelatedPerson | Practitioner Role (CZ) | Organization (CZ) ) |
Sliced per type of recipient
URL: http://hl7.eu/fhir/StructureDefinition/information-recipient Slice: Unordered, Open by type:valueReference.resolve() |
|
|
extension:information-recipient/practictionerRole
|
0..* | |||
value[x]
|
Reference (PractitionerRole) | |||
identifier
|
HDR business identifier | |||
|
status
|
HDR status | |||
type
|
CodeableConcept |
Kind of composition ("Hospital Discharge Report") Required Pattern: At least the following |
||
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 34105-7 |
|
|
subject
|
1.. | Reference (Patient: HDR) | ||
|
encounter
|
Reference (Encounter) | |||
|
date
|
HDR date | |||
|
Slices for author
|
Sliced per type of author
Slice: Unordered, Open by type:valueReference.resolve() |
|||
|
author:practictionerRole
|
0..* | Reference (PractitionerRole) | ||
|
title
|
Hospital Discharge Report | |||
|
attester
|
||||
|
mode
|
The type of attestation | |||
|
Slices for section
|
2 .. |
Sections composing the Hospital Discharge Report
Slice: Unordered, Open by pattern:code |
||
section:patientHxSection
|
0..1 | Patient History Section | ||
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11329-0 |
|
|
text
|
1.. | |||
|
emptyReason
|
.. 0 | |||
|
section:admissionDiagnosisSection
|
0..1 | Admission Diagnosis | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 46241-6 |
|
|
text
|
1.. | |||
|
Slices for entry
|
Reference ( Condition ) |
Admission Diagnosis
Slice: Unordered, Open by type:resolve() |
||
|
entry:admissionDiagnosis
|
S | 0..* | Reference ( Condition ) | |
|
emptyReason
|
.. 0 | |||
|
section:sectionAdmissionMedications
|
0..1 | Admission Medications | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 42346-7 |
|
|
text
|
1.. | |||
|
Slices for entry
|
Reference ( MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference ) |
Admission Medication
Slice: Unordered, Open by type:resolve() |
||
|
entry:medicationStatement
|
S | 0..* | Reference (Medication Statement (IPS)) |
Admission Medication Statement |
|
entry:medicationRequest
|
S | 0..* | Reference (Medication Request (IPS)) |
Admission Medication Request |
|
emptyReason
|
.. 0 | |||
|
section:CCandReasonforVisitSection
|
0..1 | Chief Complaint and Reason for Visit | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 46239-0 |
|
|
text
|
1.. | |||
|
emptyReason
|
.. 0 | |||
|
section:sectionProblems
|
0..1 | HDR Problems Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11450-4 |
|
|
text
|
1.. | |||
|
Slices for entry
|
1 .. | Reference ( Condition | DocumentReference ) |
Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by type:resolve() |
|
|
entry:problemIps
|
S | 0..* | Reference (Condition (IPS)) |
Problem |
|
emptyReason
|
.. 0 | |||
|
section:sectionAllergies
|
1..1 | HDR Allergies and Intolerances Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 48765-2 |
|
|
text
|
1.. | |||
|
Slices for entry
|
1 .. | Reference ( AllergyIntolerance | DocumentReference ) |
Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open by type:resolve() |
|
|
entry:allergyIntolerance
|
S | 0..* | Reference (Allergy Intolerance (IPS)) |
HDR Allergy entry |
|
emptyReason
|
.. 0 | |||
|
section:alertSection
|
S | 0..1 | Health Concern Section | |
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 75310-3 |
|
|
text
|
1.. | |||
|
Slices for entry
|
Alerts
Slice: Unordered, Open by type:resolve() |
|||
|
entry:flag
|
S | 0..* | Reference (Flag) |
Flags |
|
entry:detectedIssue
|
S | 0..* | Reference ( DetectedIssue ) |
Detected Issue |
|
entry:riskAssessment
|
S | 0..* | Reference ( RiskAssessment ) |
Risk Assessment |
|
emptyReason
|
.. 0 | |||
|
section:sectionProceduresHx
|
0..1 | HDR History of Procedures Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 47519-4 |
|
|
text
|
1.. | |||
|
Slices for entry
|
1 .. | Reference ( Procedure | DocumentReference ) |
Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open by type:resolve() |
|
|
entry:procedure
|
S | 0..* | Reference (Procedure (IPS)) |
Past Procedure entry |
|
emptyReason
|
.. 0 | |||
|
section:sectionImmunizations
|
0..1 | HDR Immunizations Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11369-6 |
|
|
text
|
1.. | |||
|
Slices for entry
|
1 .. | Reference ( Immunization | DocumentReference ) |
Patient's immunization status and pertinent history.
Slice: Unordered, Open by type:resolve() |
|
|
entry:immunization
|
S | 0..* | Reference (Immunization (IPS)) |
Immunization entry |
|
emptyReason
|
.. 0 | |||
|
section:familyHistorySection
|
0..1 | Family History Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 10157-6 |
|
|
text
|
1.. | |||
|
entry
|
Reference ( FamilyMemberHistory ) | Family History | ||
|
emptyReason
|
.. 0 | |||
|
section:sectionMedicalDevices
|
0..1 | HDR Medical Devices Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 46264-8 |
|
|
text
|
1.. | |||
|
Slices for entry
|
1 .. | Reference ( DeviceUseStatement | DocumentReference ) |
Patient history of medical device use.
Slice: Unordered, Open by type:resolve() |
|
|
entry:deviceUse
|
S | 0..* | Reference (Device Use Statement (IPS)) |
Medical Device entry |
|
emptyReason
|
.. 0 | |||
|
section:sectionPastIllnessHx
|
0..1 | HDR History of Past Illness Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11348-0 |
|
|
text
|
1.. | |||
|
entry
|
1.. | Reference (Condition (IPS)) | Conditions the patient suffered in the past. | |
|
emptyReason
|
.. 0 | |||
|
section:sectionFunctionalStatus
|
0..1 | IPS Functional Status | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 47420-5 |
|
|
text
|
1.. | |||
|
entry
|
Reference ( Condition | Condition (IPS) | ClinicalImpression | DocumentReference ) | Optional entry used to represent disabilities and functional assessments | ||
|
emptyReason
|
.. 0 | |||
|
section:CareTeamSection
|
S | 0..1 | Care Team Section | |
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 85847-2 |
|
|
text
|
1.. | |||
|
Slices for entry
|
Care Teams
Slice: Unordered, Open by type:resolve() |
|||
|
entry:cteam
|
S | 0..* | Reference (CareTeam) |
Care Team |
|
emptyReason
|
.. 0 | |||
|
section
|
.. 0 | |||
|
section:sectionPregnancyHx
|
0..1 | IPS History of Pregnancy Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 10162-6 |
|
|
text
|
1.. | |||
|
entry
|
Reference (Observation - Pregnancy: outcome | Observation - Pregnancy: status | Observation | DocumentReference ) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. | ||
|
emptyReason
|
.. 0 | |||
|
section:sectionSocialHistory
|
0..1 | HDR Social History Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 29762-2 |
|
|
text
|
1.. | |||
|
entry
|
Reference ( Observation | DocumentReference | Observation - SH: alcohol use | Observation - SH: tobacco use) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) | ||
|
emptyReason
|
.. 0 | |||
|
section:sectionHospitalCourse
|
0..1 | Hospital course | ||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 8648-8 |
|
|
text
|
1.. | |||
|
section:sectionMedications
|
1..1 | Hospital Discharge Report Medication Summary Section | ||
|
title
|
1.. | Medication Summary section | ||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 10160-0 |
|
|
text
|
1.. | |||
|
entry
|
1.. | Reference (Medication Statement (IPS) | Medication Request (IPS) | MedicationAdministration | MedicationDispense ) | Medications relevant for the scope of the patient summary | |
|
emptyReason
|
.. 0 | |||
|
section:sectionMedicationsAdministered
|
0..1 | Admission Medications | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 29549-3 |
|
|
text
|
1.. | |||
|
entry
|
Reference (Medication Statement (IPS) | Medication Request (IPS) | MedicationAdministration | MedicationDispense ) | |||
|
emptyReason
|
.. 0 | |||
|
section:sectionResults
|
0..1 | IPS Results Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 30954-2 |
|
|
text
|
1.. | |||
|
entry
|
Reference ( Observation | DiagnosticReport | DocumentReference | Observation Results (IPS) | DiagnosticReport (IPS)) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. | ||
|
emptyReason
|
.. 0 | |||
|
section:sectionProcedure
|
0..1 | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 29554-3 |
|
|
text
|
1.. | |||
|
entry
|
Reference (Procedure (IPS)) | |||
|
emptyReason
|
.. 0 | |||
|
section:sectionVitalSigns
|
0..1 | IPS Vital Signs Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 8716-3 |
|
|
text
|
1.. | |||
|
entry
|
Reference ( Observation | DocumentReference | Vital Signs Profile ) | Notable vital signs or physical findings. | ||
|
emptyReason
|
.. 0 | |||
|
section:dischargeDiagnosisSection
|
0..1 | Discharge Diagnosis Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11535-2 |
|
|
text
|
1.. | |||
|
entry
|
Discharge Diagnosis | |||
|
emptyReason
|
.. 0 | |||
|
section:sectionDischargeMedications
|
0..1 | Admission Medications | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 42346-7 |
|
|
text
|
1.. | |||
|
entry
|
Reference (Medication Statement (IPS) | Medication Request (IPS) | MedicationAdministration | MedicationDispense ) | |||
|
emptyReason
|
.. 0 | |||
|
section:sectionPlanOfCare
|
0..1 | IPS Plan of Care Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 18776-5 |
|
|
text
|
1.. | |||
|
entry
|
Reference ( CarePlan | DocumentReference ) | |||
|
emptyReason
|
.. 0 | |||
|
section:hospitalDischargeStudiesSection
|
0..1 | Hospital Discharge Studies Summary Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11493-4 |
|
|
text
|
1.. | |||
|
entry
|
Study Summary | |||
|
emptyReason
|
.. 0 | |||
|
section:sectionAdvanceDirectives
|
0..1 | IPS Advance Directives Section | ||
|
title
|
1.. | |||
|
code
|
1.. | CodeableConcept | Fixed Value: As shown | |
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 42348-3 |
|
|
text
|
1.. | |||
|
entry
|
Reference ( Consent | DocumentReference ) | |||
|
emptyReason
|
.. 0 | |||
|
section:sectionEncounters
|
0..1 | Encounters sections | ||
|
title
|
1.. | |||
|
code
|
1.. | Fixed Value: As shown | ||
|
coding
|
1..1 | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 46240-8 |
|
|
text
|
1.. | |||
|
emptyReason
|
.. 0 | |||
|
Documentation for this format
|
||||