FHIR IG analytics| Package | xtehr.eu.ehds.models |
| Resource Type | StructureDefinition |
| Id | StructureDefinition-EHDSDischargeReport.json |
| FHIR Version | R5 |
| Source | https://build.fhir.org/ig/Xt-EHR/xt-ehr-common/StructureDefinition-EHDSDischargeReport.html |
| URL | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDischargeReport |
| Version | 0.2.1 |
| Status | draft |
| Date | 2026-02-04T19:00:50+00:00 |
| Name | EHDSDischargeReport |
| Title | Discharge Report model |
| Description | A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs. |
| Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDischargeReport |
| Kind | logical |
No resources found
| StructureDefinition | |
| EHDSAlert | Alert model |
| EHDSAttachment | Attachment model |
| EHDSCarePlan | Care plan model |
| EHDSCondition | Condition model |
| EHDSDeviceUse | Device use model |
| EHDSDocument | Document model |
| EHDSEncounter | Encounter model |
| EHDSFunctionalStatus | Functional status |
| EHDSHealthProfessional | Health professional model |
| EHDSLaboratoryObservation | Laboratory observation model |
| EHDSMedia | Media model |
| EHDSMedicationStatement | Medication statement model |
| EHDSObservation | Observation model |
| EHDSOrganisation | Organisation model |
| EHDSPatient | Patient model |
| EHDSProcedure | Procedure model |
| EHDSRelatedPerson | Related person model |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition EHDSDischargeReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  EHDSDischargeReport | 0..* | EHDSDocument | Discharge Report model Elements defined in Ancestors:header, header, presentedForm Instances of this logical model can be the target of a Reference | |
 header | ||||
 author[x] | 1..* | EHDSHealthProfessional, EHDSOrganisation, EHDSDevice | The author of the report. | |
| status | 1..1 | CodeableConcept | Status of the document | |
| period | 0..1 | Period | Time of service that is being documented (typically the same as the time of encounter) | |
  intendedRecipient[x] | 0..* | Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility. | ||
  intendedRecipientEHDSPatient | EHDSPatient | |||
| intendedRecipientEHDSRelatedPerson | EHDSRelatedPerson | |||
| intendedRecipientEHDSHealthProfessional | EHDSHealthProfessional | |||
| intendedRecipientEHDSOrganisation | EHDSOrganisation | |||
| body | 0..1 | Base | Structured body of the discharge report document | |
| alerts | 0..1 | Base | Section: Alerts. | |
 generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. | |
 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. | |
| encounterInformation | 1..1 | Base | Section: Encounter information. | |
| generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. | |
| encounter | 0..1 | EHDSEncounter | Encounter information | |
| note | 0..1 | string | Free text notes by the health professional | |
| admissionEvaluation | 0..1 | Base | Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care. | |
| generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. | |
| objectiveFindings | 0..* | EHDSObservation | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination | |
| functionalStatus | 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 | |
| note | 0..1 | string | Free text notes by the evaluation performer | |
| patientHistory | 0..1 | Base | Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available. | |
| generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative. | |
| note | 0..1 | string | Free text notes by the health professional | |
| courseOfEncounter | 0..1 | Base | Course of inpatient or outpatient encounter. | |
| generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. | |
| diagnosticSummary | 0..* | EHDSCondition | Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge). | |
| procedures | 0..* | EHDSProcedure | 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. Diagnostic procedures are typically captured as observation results and not repeated here. | |
| medicalDevicesAndImplants | 0..* | EHDSDeviceUse | Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter. | |
| pharmacotherapy | 0..* | EHDSMedicationStatement | Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications. | |
| testResults[x] | 0..* | Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived. | ||
| testResultsEHDSObservation | EHDSObservation | |||
| testResultsEHDSLaboratoryObservation | EHDSLaboratoryObservation | |||
| note | 0..1 | string | Free text notes by the health professional | |
| dischargeDetails | 0..1 | Base | Discharge details | |
| generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. | |
| objectiveFindings | 0..* | EHDSObservation | Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination | |
| functionalStatus | 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 | |
| note | 0..1 | string | Free text notes by the health professional | |
| medicationSummary | 0..1 | Base | 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. | |
| generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. | |
| medicationUse | 1..1 | EHDSMedicationStatement | Details about medication and dosaging | |
| note | 0..1 | string | Free text notes by the health professional | |
| carePlan | 0..1 | Base | Care plan and other recommendations after discharge. | |
| generatedNarrative | 0..1 | string | Narrative, potentially formatted, content of the whole section. | |
| carePlan | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided. | |
| 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. | |
| synthesis | 0..1 | string | 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. | |
| attachments[x] | 0..* | Report attachments data elements | ||
| attachmentsEHDSAttachment | EHDSAttachment | |||
| attachmentsEHDSMedia | EHDSMedia | |||
| Documentation for this format | ||||
FHIR
FHIRsmith{
"resourceType": "StructureDefinition",
"id": "EHDSDischargeReport",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-type-characteristics",
"valueCode": "can-be-target"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-type-characteristics",
"valueCode": "can-be-target"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-type-characteristics",
"valueCode": "can-be-target"
}
],
"url": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDischargeReport",
"version": "0.2.1",
"name": "EHDSDischargeReport",
"title": "Discharge Report model",
"status": "draft",
"date": "2026-02-04T19:00:50+00:00",
"publisher": "Xt-EHR",
"contact": [
{
"name": "Xt-EHR",
"telecom": [
{
"system": "url",
"value": "http://www.xt-ehr.eu/"
}
]
}
],
"description": "A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs.",
"fhirVersion": "5.0.0",
"mapping": [
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "logical",
"abstract": false,
"type": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDischargeReport",
"baseDefinition": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDocument",
"derivation": "specialization",
"snapshot": {
"extension": [
{
"url": "http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version",
"valueString": "0.2.1"
}
],
"element": [
{
"id": "EHDSDischargeReport",
"path": "EHDSDischargeReport",
"short": "Discharge Report model",
"definition": "A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs.",
"min": 0,
"max": "*",
"base": {
"path": "Base",
"min": 0,
"max": "*"
},
"isModifier": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EHDSDischargeReport.header",
"path": "EHDSDischargeReport.header",
"short": "Document header",
"definition": "Basic metadata for this information",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDataSet.header",
"min": 1,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.header.subject",
"path": "EHDSDischargeReport.header.subject",
"short": "Patient/subject information",
"definition": "Patient/subject information",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDataSet.header.subject",
"min": 1,
"max": "1"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient"
}
]
},
{
"id": "EHDSDischargeReport.header.identifier",
"path": "EHDSDischargeReport.header.identifier",
"short": "Unique identifier of the document",
"definition": "Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).",
"min": 1,
"max": "*",
"base": {
"path": "EHDSDataSet.header.identifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "EHDSDischargeReport.header.author[x]",
"path": "EHDSDischargeReport.header.author[x]",
"short": "The author of the report.",
"definition": "The author of the report.",
"min": 1,
"max": "*",
"base": {
"path": "EHDSDataSet.header.author[x]",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice"
}
]
},
{
"id": "EHDSDischargeReport.header.date",
"path": "EHDSDischargeReport.header.date",
"short": "Date of finalising/issuing the document",
"definition": "Date and optionally time of authoring/issuing",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDataSet.header.date",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "EHDSDischargeReport.header.status",
"path": "EHDSDischargeReport.header.status",
"short": "Status of the document",
"definition": "Status of the document",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDataSet.header.status",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
]
},
{
"id": "EHDSDischargeReport.header.source",
"path": "EHDSDischargeReport.header.source",
"short": "Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.",
"definition": "Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDataSet.header.source",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
]
},
{
"id": "EHDSDischargeReport.header.language",
"path": "EHDSDischargeReport.header.language",
"short": "Language in which the resource is written. Language is expressed by the IETF language tag.",
"definition": "Language in which the resource is written. Language is expressed by the IETF language tag.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDataSet.header.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "preferred",
"description": "BCP 47"
}
},
{
"id": "EHDSDischargeReport.header.documentType",
"path": "EHDSDischargeReport.header.documentType",
"short": "Type of document at hand, e.g. 60591-5 Patient summary document.",
"definition": "Type of document at hand, e.g. 60591-5 Patient summary document.",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDocument.header.documentType",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "preferred",
"description": "LOINC"
}
},
{
"id": "EHDSDischargeReport.header.documentTitle",
"path": "EHDSDischargeReport.header.documentTitle",
"short": "Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'",
"definition": "Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDocument.header.documentTitle",
"min": 1,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.header.period",
"path": "EHDSDischargeReport.header.period",
"short": "Time of service that is being documented (typically the same as the time of encounter)",
"definition": "Time of service that is being documented",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDocument.header.period",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Period"
}
]
},
{
"id": "EHDSDischargeReport.header.version",
"path": "EHDSDischargeReport.header.version",
"short": "Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.",
"definition": "Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDocument.header.version",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.header.attestation",
"path": "EHDSDischargeReport.header.attestation",
"short": "Document attestation details",
"definition": "Document attestation details",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDocument.header.attestation",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.header.attestation.attester[x]",
"path": "EHDSDischargeReport.header.attestation.attester[x]",
"short": "Attester who validated the document. Multiple attesters could be provided.",
"definition": "Attester who validated the document. Multiple attesters could be provided.",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDocument.header.attestation.attester[x]",
"min": 1,
"max": "1"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice"
}
]
},
{
"id": "EHDSDischargeReport.header.attestation.datetime",
"path": "EHDSDischargeReport.header.attestation.datetime",
"short": "Date and time of the approval of the document by Attester.",
"definition": "Date and time of the approval of the document by Attester.",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDocument.header.attestation.datetime",
"min": 1,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "EHDSDischargeReport.header.legalAuthentication",
"path": "EHDSDischargeReport.header.legalAuthentication",
"short": "Document legal authentication details",
"definition": "Document legal authentication details",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDocument.header.legalAuthentication",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.header.legalAuthentication.legalAuthenticator[x]",
"path": "EHDSDischargeReport.header.legalAuthentication.legalAuthenticator[x]",
"short": "The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)",
"definition": "The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDocument.header.legalAuthentication.legalAuthenticator[x]",
"min": 1,
"max": "1"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation"
}
]
},
{
"id": "EHDSDischargeReport.header.legalAuthentication.datetime",
"path": "EHDSDischargeReport.header.legalAuthentication.datetime",
"short": "Date and time when the document was authorised.",
"definition": "Date and time when the document was authorised.",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDocument.header.legalAuthentication.datetime",
"min": 1,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "EHDSDischargeReport.header.eventType",
"path": "EHDSDischargeReport.header.eventType",
"short": "Categorisation 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 between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.",
"definition": "Categorisation 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 between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDocument.header.eventType",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "preferred",
"description": "LOINC, SNOMED CT, dicom-cid-33-Modality"
}
},
{
"id": "EHDSDischargeReport.header.serviceSpecialty",
"path": "EHDSDischargeReport.header.serviceSpecialty",
"short": "Additional details about where the content was created (e.g. clinical specialty)",
"definition": "Additional details about where the content was created (e.g. clinical specialty)",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDocument.header.serviceSpecialty",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "preferred",
"description": "SNOMED CT"
}
},
{
"id": "EHDSDischargeReport.header.custodian",
"path": "EHDSDischargeReport.header.custodian",
"short": "Organisation that is in charge of maintaining the document/report.",
"definition": "Organisation that is in charge of maintaining the document/report.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDocument.header.custodian",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation"
}
]
},
{
"id": "EHDSDischargeReport.presentedForm",
"path": "EHDSDischargeReport.presentedForm",
"short": "A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document",
"definition": "A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDocument.presentedForm",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment"
}
]
},
{
"id": "EHDSDischargeReport.header.intendedRecipient[x]",
"path": "EHDSDischargeReport.header.intendedRecipient[x]",
"short": "Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.",
"definition": "Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.header.intendedRecipient[x]",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation"
}
]
},
{
"id": "EHDSDischargeReport.body",
"path": "EHDSDischargeReport.body",
"short": "Structured body of the discharge report document",
"definition": "Structured body of the discharge report document",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.alerts",
"path": "EHDSDischargeReport.body.alerts",
"short": "Section: Alerts.",
"definition": "Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.",
"requirements": "eHN Guideline HDR (v1.1): A.2.2",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.alerts",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.alerts.generatedNarrative",
"path": "EHDSDischargeReport.body.alerts.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.alerts.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.alerts.medicalAlert",
"path": "EHDSDischargeReport.body.alerts.medicalAlert",
"short": "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.",
"definition": "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.",
"requirements": "eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.alerts.medicalAlert",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation",
"path": "EHDSDischargeReport.body.encounterInformation",
"short": "Section: Encounter information.",
"definition": "Section: Encounter information.",
"requirements": "eHN Guideline HDR (v1.1): A.2.2",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.encounterInformation",
"min": 1,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation.generatedNarrative",
"path": "EHDSDischargeReport.body.encounterInformation.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.encounterInformation.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation.encounter",
"path": "EHDSDischargeReport.body.encounterInformation.encounter",
"short": "Encounter information",
"definition": "Encounter information",
"requirements": "eHN Guideline HDR (v1.1): A.2.3",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.encounterInformation.encounter",
"min": 0,
"max": "1"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSEncounter"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation.note",
"path": "EHDSDischargeReport.body.encounterInformation.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.encounterInformation.note",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation",
"path": "EHDSDischargeReport.body.admissionEvaluation",
"short": "Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.",
"definition": "Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.",
"requirements": "eHN Guideline HDR (v1.1): A.2.4",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.admissionEvaluation",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.generatedNarrative",
"path": "EHDSDischargeReport.body.admissionEvaluation.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.admissionEvaluation.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.objectiveFindings",
"path": "EHDSDischargeReport.body.admissionEvaluation.objectiveFindings",
"short": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"definition": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"requirements": "eHN Guideline HDR (v1.1): A.2.4.1",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.admissionEvaluation.objectiveFindings",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.functionalStatus",
"path": "EHDSDischargeReport.body.admissionEvaluation.functionalStatus",
"short": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"definition": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"requirements": "eHN Guideline HDR (v1.1): A.2.4.2",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.admissionEvaluation.functionalStatus",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.note",
"path": "EHDSDischargeReport.body.admissionEvaluation.note",
"short": "Free text notes by the evaluation performer",
"definition": "Free text notes by the evaluation performer",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.admissionEvaluation.note",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.patientHistory",
"path": "EHDSDischargeReport.body.patientHistory",
"short": "Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.",
"definition": "Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.",
"requirements": "eHN Guideline HDR (v1.1): A.2.5",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.patientHistory",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.patientHistory.generatedNarrative",
"path": "EHDSDischargeReport.body.patientHistory.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.",
"definition": "Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.patientHistory.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.patientHistory.note",
"path": "EHDSDischargeReport.body.patientHistory.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.patientHistory.note",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter",
"path": "EHDSDischargeReport.body.courseOfEncounter",
"short": "Course of inpatient or outpatient encounter.",
"definition": "Course of inpatient or outpatient encounter.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.generatedNarrative",
"path": "EHDSDischargeReport.body.courseOfEncounter.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary",
"path": "EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary",
"short": "Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).",
"definition": "Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.1",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.procedures",
"path": "EHDSDischargeReport.body.courseOfEncounter.procedures",
"short": "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. Diagnostic procedures are typically captured as observation results and not repeated here.",
"definition": "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. Diagnostic procedures are typically captured as observation results and not repeated here.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.2",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter.procedures",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants",
"path": "EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants",
"short": "Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.",
"definition": "Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.3",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy",
"path": "EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy",
"short": "Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.",
"definition": "Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.5",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.testResults[x]",
"path": "EHDSDischargeReport.body.courseOfEncounter.testResults[x]",
"short": "Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.",
"definition": "Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter.testResults[x]",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.note",
"path": "EHDSDischargeReport.body.courseOfEncounter.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.courseOfEncounter.note",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails",
"path": "EHDSDischargeReport.body.dischargeDetails",
"short": "Discharge details",
"definition": "Structured information should be provided, however if not available, at least a section narrative should be present.",
"requirements": "eHN Guideline HDR (v1.1): A.2.7",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.dischargeDetails",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.generatedNarrative",
"path": "EHDSDischargeReport.body.dischargeDetails.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.dischargeDetails.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.objectiveFindings",
"path": "EHDSDischargeReport.body.dischargeDetails.objectiveFindings",
"short": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"definition": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"requirements": "eHN Guideline HDR (v1.1): A.2.7.1",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.dischargeDetails.objectiveFindings",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.functionalStatus",
"path": "EHDSDischargeReport.body.dischargeDetails.functionalStatus",
"short": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"definition": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"requirements": "eHN Guideline HDR (v1.1): A.2.7.2",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.dischargeDetails.functionalStatus",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.note",
"path": "EHDSDischargeReport.body.dischargeDetails.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.dischargeDetails.note",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary",
"path": "EHDSDischargeReport.body.medicationSummary",
"short": "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.",
"definition": "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.",
"requirements": "eHN Guideline HDR (v1.1): A.2.8.1",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.medicationSummary",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary.generatedNarrative",
"path": "EHDSDischargeReport.body.medicationSummary.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.medicationSummary.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary.medicationUse",
"path": "EHDSDischargeReport.body.medicationSummary.medicationUse",
"short": "Details about medication and dosaging",
"definition": "Details about medication and dosaging",
"min": 1,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.medicationSummary.medicationUse",
"min": 1,
"max": "1"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary.note",
"path": "EHDSDischargeReport.body.medicationSummary.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.medicationSummary.note",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan",
"path": "EHDSDischargeReport.body.carePlan",
"short": "Care plan and other recommendations after discharge.",
"definition": "Care plan and other recommendations after discharge.",
"requirements": "eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.carePlan",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan.generatedNarrative",
"path": "EHDSDischargeReport.body.carePlan.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.carePlan.generatedNarrative",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan.carePlan",
"path": "EHDSDischargeReport.body.carePlan.carePlan",
"short": "Structured care plan after discharge. Multiple care plans could be provided.",
"definition": "Structured care plan after discharge. Multiple care plans could be provided.",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.body.carePlan.carePlan",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan.otherRecommendations",
"path": "EHDSDischargeReport.body.carePlan.otherRecommendations",
"short": "Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.",
"definition": "Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.",
"requirements": "eHN Guideline HDR (v1.1): A.2.8.3",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.carePlan.otherRecommendations",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.synthesis",
"path": "EHDSDischargeReport.body.synthesis",
"short": "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.",
"definition": "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.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.7",
"min": 0,
"max": "1",
"base": {
"path": "EHDSDischargeReport.body.synthesis",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.attachments[x]",
"path": "EHDSDischargeReport.attachments[x]",
"short": "Report attachments data elements",
"definition": "Report attachments data elements",
"min": 0,
"max": "*",
"base": {
"path": "EHDSDischargeReport.attachments[x]",
"min": 0,
"max": "*"
},
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedia"
}
]
}
]
},
"differential": {
"element": [
{
"id": "EHDSDischargeReport",
"path": "EHDSDischargeReport",
"short": "Discharge Report model",
"definition": "A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs."
},
{
"id": "EHDSDischargeReport.header.author[x]",
"path": "EHDSDischargeReport.header.author[x]",
"short": "The author of the report.",
"definition": "The author of the report."
},
{
"id": "EHDSDischargeReport.header.status",
"path": "EHDSDischargeReport.header.status",
"definition": "Status of the document"
},
{
"id": "EHDSDischargeReport.header.period",
"path": "EHDSDischargeReport.header.period",
"short": "Time of service that is being documented (typically the same as the time of encounter)"
},
{
"id": "EHDSDischargeReport.header.intendedRecipient[x]",
"path": "EHDSDischargeReport.header.intendedRecipient[x]",
"short": "Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.",
"definition": "Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation"
}
]
},
{
"id": "EHDSDischargeReport.body",
"path": "EHDSDischargeReport.body",
"short": "Structured body of the discharge report document",
"definition": "Structured body of the discharge report document",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.alerts",
"path": "EHDSDischargeReport.body.alerts",
"short": "Section: Alerts.",
"definition": "Information about substantial alerts or warnings (including allergies) that health professionals should be aware of.",
"requirements": "eHN Guideline HDR (v1.1): A.2.2",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.alerts.generatedNarrative",
"path": "EHDSDischargeReport.body.alerts.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.alerts.medicalAlert",
"path": "EHDSDischargeReport.body.alerts.medicalAlert",
"short": "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.",
"definition": "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.",
"requirements": "eHN Guideline HDR (v1.1): A.2.2.2, A.2.2.1",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation",
"path": "EHDSDischargeReport.body.encounterInformation",
"short": "Section: Encounter information.",
"definition": "Section: Encounter information.",
"requirements": "eHN Guideline HDR (v1.1): A.2.2",
"min": 1,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation.generatedNarrative",
"path": "EHDSDischargeReport.body.encounterInformation.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation.encounter",
"path": "EHDSDischargeReport.body.encounterInformation.encounter",
"short": "Encounter information",
"definition": "Encounter information",
"requirements": "eHN Guideline HDR (v1.1): A.2.3",
"min": 0,
"max": "1",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSEncounter"
}
]
},
{
"id": "EHDSDischargeReport.body.encounterInformation.note",
"path": "EHDSDischargeReport.body.encounterInformation.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation",
"path": "EHDSDischargeReport.body.admissionEvaluation",
"short": "Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.",
"definition": "Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.",
"requirements": "eHN Guideline HDR (v1.1): A.2.4",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.generatedNarrative",
"path": "EHDSDischargeReport.body.admissionEvaluation.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.objectiveFindings",
"path": "EHDSDischargeReport.body.admissionEvaluation.objectiveFindings",
"short": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"definition": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"requirements": "eHN Guideline HDR (v1.1): A.2.4.1",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.functionalStatus",
"path": "EHDSDischargeReport.body.admissionEvaluation.functionalStatus",
"short": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"definition": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"requirements": "eHN Guideline HDR (v1.1): A.2.4.2",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus"
}
]
},
{
"id": "EHDSDischargeReport.body.admissionEvaluation.note",
"path": "EHDSDischargeReport.body.admissionEvaluation.note",
"short": "Free text notes by the evaluation performer",
"definition": "Free text notes by the evaluation performer",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.patientHistory",
"path": "EHDSDischargeReport.body.patientHistory",
"short": "Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.",
"definition": "Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.",
"requirements": "eHN Guideline HDR (v1.1): A.2.5",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.patientHistory.generatedNarrative",
"path": "EHDSDischargeReport.body.patientHistory.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.",
"definition": "Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.patientHistory.note",
"path": "EHDSDischargeReport.body.patientHistory.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter",
"path": "EHDSDischargeReport.body.courseOfEncounter",
"short": "Course of inpatient or outpatient encounter.",
"definition": "Course of inpatient or outpatient encounter.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.generatedNarrative",
"path": "EHDSDischargeReport.body.courseOfEncounter.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary",
"path": "EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary",
"short": "Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).",
"definition": "Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.1",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.procedures",
"path": "EHDSDischargeReport.body.courseOfEncounter.procedures",
"short": "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. Diagnostic procedures are typically captured as observation results and not repeated here.",
"definition": "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. Diagnostic procedures are typically captured as observation results and not repeated here.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.2",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants",
"path": "EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants",
"short": "Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.",
"definition": "Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.3",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy",
"path": "EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy",
"short": "Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.",
"definition": "Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.5",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.testResults[x]",
"path": "EHDSDischargeReport.body.courseOfEncounter.testResults[x]",
"short": "Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.",
"definition": "Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation"
}
]
},
{
"id": "EHDSDischargeReport.body.courseOfEncounter.note",
"path": "EHDSDischargeReport.body.courseOfEncounter.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails",
"path": "EHDSDischargeReport.body.dischargeDetails",
"short": "Discharge details",
"definition": "Structured information should be provided, however if not available, at least a section narrative should be present.",
"requirements": "eHN Guideline HDR (v1.1): A.2.7",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.generatedNarrative",
"path": "EHDSDischargeReport.body.dischargeDetails.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.objectiveFindings",
"path": "EHDSDischargeReport.body.dischargeDetails.objectiveFindings",
"short": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"definition": "Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination",
"requirements": "eHN Guideline HDR (v1.1): A.2.7.1",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.functionalStatus",
"path": "EHDSDischargeReport.body.dischargeDetails.functionalStatus",
"short": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"definition": "An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being",
"requirements": "eHN Guideline HDR (v1.1): A.2.7.2",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSFunctionalStatus"
}
]
},
{
"id": "EHDSDischargeReport.body.dischargeDetails.note",
"path": "EHDSDischargeReport.body.dischargeDetails.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary",
"path": "EHDSDischargeReport.body.medicationSummary",
"short": "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.",
"definition": "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.",
"requirements": "eHN Guideline HDR (v1.1): A.2.8.1",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary.generatedNarrative",
"path": "EHDSDischargeReport.body.medicationSummary.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary.medicationUse",
"path": "EHDSDischargeReport.body.medicationSummary.medicationUse",
"short": "Details about medication and dosaging",
"definition": "Details about medication and dosaging",
"min": 1,
"max": "1",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationStatement"
}
]
},
{
"id": "EHDSDischargeReport.body.medicationSummary.note",
"path": "EHDSDischargeReport.body.medicationSummary.note",
"short": "Free text notes by the health professional",
"definition": "Free text notes by the health professional",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan",
"path": "EHDSDischargeReport.body.carePlan",
"short": "Care plan and other recommendations after discharge.",
"definition": "Care plan and other recommendations after discharge.",
"requirements": "eHN Guideline HDR (v1.1): A.2.8.2 (A.2.9.2)",
"min": 0,
"max": "1",
"type": [
{
"code": "Base"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan.generatedNarrative",
"path": "EHDSDischargeReport.body.carePlan.generatedNarrative",
"short": "Narrative, potentially formatted, content of the whole section.",
"definition": "Narrative, potentially formatted, content of the whole section.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan.carePlan",
"path": "EHDSDischargeReport.body.carePlan.carePlan",
"short": "Structured care plan after discharge. Multiple care plans could be provided.",
"definition": "Structured care plan after discharge. Multiple care plans could be provided.",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan"
}
]
},
{
"id": "EHDSDischargeReport.body.carePlan.otherRecommendations",
"path": "EHDSDischargeReport.body.carePlan.otherRecommendations",
"short": "Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.",
"definition": "Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.",
"requirements": "eHN Guideline HDR (v1.1): A.2.8.3",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.body.synthesis",
"path": "EHDSDischargeReport.body.synthesis",
"short": "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.",
"definition": "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.",
"requirements": "eHN Guideline HDR (v1.1): A.2.6.7",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EHDSDischargeReport.attachments[x]",
"path": "EHDSDischargeReport.attachments[x]",
"short": "Report attachments data elements",
"definition": "Report attachments data elements",
"min": 0,
"max": "*",
"type": [
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment"
},
{
"code": "http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedia"
}
]
}
]
}
}