FHIR IG analytics| Package | hl7.fhir.eu.hdr |
| Resource Type | Composition |
| Id | Composition-b9dc409d-ec81-4556-9fac-4dc3f731c199.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: Composition b9dc409d-ec81-4556-9fac-4dc3f731c199
Profile: Composition (HDR)
status: Final
type: Hospital Discharge summary
date: 2025-04-29 13:30:00+0100
author: PractitionerRole
title: Hospital Discharge Report
custodian: Organization Casa di cura Villa S. Giuliana
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "b9dc409d-ec81-4556-9fac-4dc3f731c199",
"meta": {
"profile": [
"http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr"
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "34105-7",
"display": "Hospital Discharge summary"
}
]
},
"subject": {
"reference": "urn:uuid:b01a2623-e219-41d2-8e78-1fa1439751d0"
},
"encounter": {
"reference": "urn:uuid:7c9a2bf1-507f-4d43-b06e-d78e9670379d"
},
"date": "2025-04-29T13:30:00+01:00",
"author": [
{
"reference": "urn:uuid:74403dd8-bb1b-45f9-bb69-e843dfaf45e9"
}
],
"title": "Hospital Discharge Report",
"custodian": {
"reference": "urn:uuid:a61a91f8-b8f2-4947-9a64-5165ea380a38"
},
"section": [
{
"title": "Admission evaluation",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "67851-6"
},
{
"system": "http://loinc.org",
"code": "67852-4",
"display": "Hospital Admission evaluation note"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi De Luca, a 57-year-old male, was admitted on 1st April following a pre-diabetic episode characterized by episodes of fatigue, polyuria, and increased thirst. Recent routine blood tests showed elevated fasting blood glucose and HbA1c levels that required further investigation.<p/>When Mr De Luca arrived in the morning we recorded a fasting blood glucose level at 180 mg/dL. His HbA1c level was 7.8%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.</div>"
}
},
{
"title": "Family History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10157-6",
"display": "History of family member diseases Narrative"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).</div>"
},
"entry": [
{
"reference": "urn:uuid:635c22e7-d7f1-45ad-9b4d-d4fe35239085"
},
{
"reference": "urn:uuid:3fbdfbe1-9d70-47ec-ac05-3e30b063365a"
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]
},
{
"title": "Vital signs",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital signs"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Vital signs</th><th>1st April</th><th>10th April</th></tr></thead><tbody><tr><td>Body weight</td><td>109 kg</td><td>108 kg</td></tr><tr><td>Body height</td><td>177 cm</td><td/></tr><tr><td>Blood Pressure</td><td>155 / 95 mmHg</td><td>150 / 90 mmHg</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:f0113857-b9b7-429b-8893-b645a38ae20a"
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{
"reference": "urn:uuid:065c918f-730a-47f8-938a-7ad54618037b"
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{
"reference": "urn:uuid:81783ae4-c36d-424f-8cea-fe7d3407a36b"
},
{
"reference": "urn:uuid:a19e48e1-2271-4cdb-9c76-b0626c7a5363"
},
{
"reference": "urn:uuid:fd7f7580-5788-45dd-88ec-dca615d69c7d"
}
]
},
{
"title": "Tobacco use",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11367-0",
"display": "History of Tobacco use"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">The patient smokes "a few" cigarettes per day.</div>"
},
"entry": [
{
"reference": "urn:uuid:67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6"
}
]
},
{
"title": "Hospital Course",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8648-8",
"display": "Hospital Course"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment.<p/>Throughout his hospital stay, Mr. De Luca was monitored closely. His blood sugar levels improved modestly with the introduction of Metformin, and no acute complications were observed.</div>"
}
},
{
"title": "Significant Observation Results",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data Narrative"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Blood Glucose Monitoring Regular monitoring of fasting blood glucose levels and random blood glucose levels. Fasting glucose levels consistently ranged between 140-180 mg/dL.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Fasting glucose [Moles/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>2 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>3 April 2025</td><td>150 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>5 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table>HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Hemoglobin A1c [Mass/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>7.2%</td><td>< 5.7%</td></tr></tbody></table>Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Glucose [Mass/volume] in Serum or Plasma --1 hour post dose glucose</th><th>Range</th></tr></thead><tbody><tr><td>2 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table></div>"
}
},
{
"title": "Significant procedures",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10185-7",
"display": "Hospital discharge procedures Narrative"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Lifestyle Consultation: Mr. De Luca met with a dietitian to discuss necessary changes in his diet, focusing on a low glycemic index diet and the need to monitor carbohydrate intake. He was also advised to engage in regular physical activity.<p/>Diabetes Education: Mr. De Luca attended educational sessions on diabetes management, including the importance of regular blood sugar monitoring, recognizing hypoglycemia and hyperglycemia symptoms, and foot care.<p/>Starting Pharmacotherapy with Metformin.</div>"
},
"entry": [
{
"reference": "urn:uuid:92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0"
},
{
"reference": "urn:uuid:a74a3dca-92fa-4b71-8e70-89a07ac74bc3"
},
{
"reference": "urn:uuid:53a8c3c3-5d1b-4950-87bc-fddae2ebc079"
}
]
},
{
"title": "Medications",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "87232-5",
"display": "Medication administration.brief"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels.<table class=\"hl7__hdr\"><thead><tr><th>Medication administrations</th><th>Dose/Frequency</th><th>SNOMED</th></tr></thead><tbody><tr><td>Metformin, oral tbl</td><td>500 mg, twice / day</td><td>765507008</td></tr><tr><td>Multivitamines</td><td>daily</td><td/></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:bda0b497-c9f2-47ca-8339-da1d379cb2f4"
}
]
},
{
"title": "Follow-up",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Plan of care note"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Follow-up</th><th>Activity</th><th>SNOMED</th></tr></thead><tbody><tr><td>Endocrinology Clinic</td><td>Follow-up appointment in 2 weeks to assess response to treatment</td><td>306118006 Referral to endocrinology service (procedure)</td></tr><tr><td>Dietitian Consultation</td><td>Appointment in 1 month for further dietary planning</td><td>103699006 Referral to dietitian (procedure)</td></tr><tr><td>Routine Blood tests</td><td>Repeat HbA1c in 3 months</td><td>43396009 Hemoglobin A1c measurement (procedure)</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:b84038f8-9541-4c5b-93b0-a7f1b8e55bd3"
}
]
},
{
"title": "Diagnosis at Discharge",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11535-2",
"display": "Hospital discharge Dx Narrative"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Discharge Diagnoses</th><th>Codes</th></tr></thead><tbody><tr><td>Type 2 Diabetes Mellitus – Newly diagnosed.</td><td><ul><li>Type 2 diabetes mellitus E11 (ICD-10)</li><li>Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)</li></ul></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:a5bf69e4-24db-48a8-9eda-71516dcaf1d9"
}
]
},
{
"title": "Hospital Discharge Instructions",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8653-8",
"display": "Hospital Discharge Instructions"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Instructions at Discharge to Mr. De Luca<ul><li>Continue home glucose monitoring and to maintain a log for review at follow-up appointments.</li><li>Continue with the prescribed medication and lifestyle changes.</li><li>Monitor blood sugar levels at home regularly.</li><li>Adhere to the diabetic diet plan.</li><li>Stay physically active, with at least 30 minutes of moderate exercise most days of the week.</li><li>Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).</li></ul></div>"
}
}
]
}