FHIR IG analytics| Package | fhir.r4.ukcore.stu3.currentbuild |
| Resource Type | Composition |
| Id | UKCore-Composition-Discharge-Example.json |
| FHIR Version | R4 |
No resources found
No resources found
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FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "UKCore-Composition-Discharge-Example",
"text": {
"status": "additional",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType",
"valueCodeableConcept": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "310000008",
"display": "Accident and Emergency service"
}
]
}
}
],
"identifier": {
"system": "https://tools.ietf.org/html/rfc4122",
"value": "2d361270-039f-4a48-827b-ef255ff8b6c4"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "373942005",
"display": "Discharge summary"
}
]
},
"subject": {
"reference": "urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5"
},
"encounter": {
"reference": "urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9"
},
"date": "2021-02-12T19:00:00+00:00",
"author": [
{
"reference": "urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb"
}
],
"title": "Accident & Emergency Discharge summary",
"custodian": {
"reference": "urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc"
},
"section": [
{
"title": "Allergies and adverse reaction",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "allergies-and-adverse-reaction",
"display": "Allergies and adverse reaction"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Causative agent</th><td>Penicillin -class of antibiotic</td></tr><tr><th>Description of reaction</th><td>Eruption due to drug</td></tr><tr><th>Severity</th><td>Mild</td></tr><tr><th>Certainty</th><td>Certain</td></tr><tr><th>Comment</th><td>No swelling</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b"
}
]
},
{
"title": "Attendance details",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "attendance-details",
"display": "Attendance details"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Date and time of contact</th><td>12-Feb-2015 07:00</td></tr></tbody></table></div>"
}
},
{
"title": "Clinical narrative",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "clinical-narrative",
"display": "Clinical narrative"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Clinical narrative</th></tr><tr><td><p>60 year old man complaining of chest pain lasting around 2 hours.</p><p>Examination unremarkable.</p><p>Inferior ischaemic changes on ECG.</p></td></tr></tbody></table><table><tbody><tr><td><pre>Full Blood Count TestValueUnitsReference Range White Cell Count11.1x10*9/L3.5 - 10.0 Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0 Haematocrit0.230L/L0.400 - 0.500 Mean Cell Volume90fL84 - 98 Mean Cell Hb33.0pg27.5 - 32.0 Mean Cell Hb Con34.0pg31.0 - 35.0 RDW12.0%< 14.5 Platelet Count300x10*9/L150 - 400 Machine Differential TestValueUnitsReference Range Neutrophils7.0x10*9/L1.7 - 7.5 Lymphocytes3.5x10*9/L1.0 - 3.5 Monocytes0.3x10*9/L< 0.6 Eosinophils0.4x10*9/L< 0.4 Basophils0.1x10*9/L< 0.1 LUCs0.2x10*9/L< 0.4</pre></td></tr></tbody></table></div>"
}
},
{
"title": "Contact for further information",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "contact-for-further-information",
"display": "Contact for further information"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Contact for further information</th><td>Dr Paul Rastall Tel: 0113 6323200</td></tr></tbody></table></div>"
}
},
{
"title": "Diagnoses",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "diagnoses",
"display": "Diagnoses"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Acute ST segment elevation myocardial infarction</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f"
}
]
},
{
"title": "Discharge details",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "discharge-details",
"display": "Discharge details"
}
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Discharge status</th><td>Streamed from emergency department to urgent care service following initial assessment</td></tr><tr><th>Date/time of discharge</th><td>12-Feb-2015 08:00</td></tr><tr><th>Discharge destination</th><td>NHS other Hospital Provider - Ward for general Patients or the younger physically disabled</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9"
}
]
},
{
"title": "GP practice",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "general-practitioner-practice",
"display": "General practitioner practice"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>GP name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>GP practice details</th><td><p>Name: MGP Medical Centre</p><p>Address:</p><p>Address Line: 1 MGP House, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 7PA</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1"
}
]
},
{
"title": "Information and advice given",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "information-and-advice-given",
"display": "Information and advice given"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Information and advice given</th><td>Patient advised to be admitted to ward for further tests after ECG results showed inferior ischaemic changes.</td></tr></tbody></table></div>"
}
},
{
"title": "Medications and medical devices",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "medications-and-medical-devices",
"display": "Medications and medical devices"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Ramipril 2.5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>One 2.5mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Aspirin 75mg tablets (Sigma Pharmaceuticals Plc)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 75mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Simvastatin 40mg tablets (Brown & Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca"
}
]
},
{
"title": "Patient demographics",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "patient-demographics",
"display": "Patient demographics"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5"
}
]
},
{
"title": "Person completing record",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "person-completing-record",
"display": "Person completing record"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb"
}
]
},
{
"title": "Plan and requested actions",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "plan-and-requested-actions",
"display": "Plan and requested actions"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of his chest pain on 12 February 2015.</p><p>Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's University Hospital Accident and Emergency Department)</p><p>Status: Completed</p><p>Outcome: Patient expects to find out the more information about the reasons for his chest pain when tests are carried out after admission.</p></td></tr></tbody></table></div>"
}
},
{
"title": "Presenting complaints or issues",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "presenting-complaints-or-issues",
"display": "Presenting complaints or issues"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Presenting complaints or issue</th><td>Chest pain</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f"
}
]
},
{
"title": "Procedures",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "procedures",
"display": "Procedures"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Procedure name</th><td>Electrocardiographic monitoring</td></tr><tr><th>Comment</th><td>ECGs showed inferior ischaemic changes.</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1"
}
]
},
{
"title": "Referrer details",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "referrer-details",
"display": "Referrer details"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Referrer details</th><td>Self-referral to accident and emergency department</td></tr></tbody></table></div>"
}
},
{
"title": "Senior reviewing clinician",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "senior-reviewing-clinician",
"display": "Senior reviewing clinician"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Mr</p><p>Family Name: Abacus</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9"
}
]
}
]
}