EHDS Logical Information Models
0.1.0 - ci-build

EHDS Logical Information Models, published by Xt-EHR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Xt-EHR/xt-ehr-common/tree/main and changes regularly. See the Directory of published versions

Logical Model: Discharge Report model

Official URL: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDischargeReport Version: 0.1.0
Draft as of 2025-07-25 Computable Name: EHDSDischargeReport

EHDS refined base model for Discharge Report

Feedback is welcome on any aspect of the content.
However, the following topics have been identified as areas where input would be particularly valuable:
  • Pharmacotherapy section. Is the section's purpose clear and the section useful in its current definition? Are the current implementations using the same approach, or is the section's content conveyed in the Medication Summary section?
  • Diagnostic Summary section. Is the section together with EHDSCondition model sufficient for capturing details related to a hospital encounter diagnostics?
  • Medication Summary section. In some jurisdictions, any handover of a medication to the patient at the time of discharge is marked in the report. Is the model capturing the information expected for this use case, or would it be captured better using EHDSMedicationDispense model. </div>

    • Usages:

    • This Logical Model is not used by any profiles in this Implementation Guide

    You can also check for usages in the FHIR IG Statistics

    Formal Views of Profile Content

    Description of Profiles, Differentials, Snapshots and how the different presentations work.

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. EHDSDischargeReport 0..* EHDSDocument
    Elements defined in Ancestors:header, presentedForm, header, knowledgeResources
    Discharge Report model
    Instances of this logical model can be the target of a Reference
    ... header 1..1 Base Document header elements
    .... subject 1..1 EHDSPatient Subject
    .... identifier 1..* Identifier Document ID
    .... authorship 1..* Base Authorship
    ..... author[x] 1..1 Author
    ...... authorEHDSHealthProfessional EHDSHealthProfessional
    ...... authorEHDSOrganisation EHDSOrganisation
    ...... authorEHDSDevice EHDSDevice
    ..... datetime 1..1 dateTime Date and time of authoring/issuing
    .... lastUpdate 0..1 dateTime Date and time of the last update to the resource
    .... status 1..1 CodeableConcept Status of the resource
    .... statusReason[x] 0..1 Reason for the current status of the resource.
    ..... statusReasonCodeableConcept CodeableConcept
    ..... statusReasonString string
    .... language 0..1 CodeableConcept Language
    Binding Description: (preferred): BCP 47
    .... version 0..1 string Version
    .... documentType 1..1 CodeableConcept Document type
    Binding Description: (preferred): LOINC
    .... documentTitle 1..1 string Document title
    .... documentStatus 1..1 CodeableConcept Document status
    Binding Description: (preferred): hl7:CompositionStatus
    .... period 0..1 Period Period
    .... attestation 0..* Base Attestation
    ..... attester 1..1 EHDSHealthProfessional Attester
    ..... datetime 1..1 dateTime DateTime
    .... legalAuthentication 0..1 Base Legal authentication
    ..... legalAuthenticator 1..1 EHDSHealthProfessional Legal authenticator
    ..... datetime 1..1 dateTime DateTime
    .... eventType 0..* CodeableConcept Event type
    Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
    .... authorSpecialty 0..* CodeableConcept Specialty
    Binding Description: (preferred): SNOMED CT
    .... custodian 1..1 EHDSOrganisation Document custodian
    .... documentFormat 0..1 CodeableConcept Document format
    Binding Description: (preferred): HL7 Document Format Codes
    .... confidentiality 0..1 CodeableConcept Confidentiality
    Binding Description: (preferred): hl7:Confidentiality
    .... intendedRecipient[x] 0..* Intended recipient
    ..... intendedRecipientEHDSPatient EHDSPatient
    ..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
    ..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
    ..... intendedRecipientEHDSOrganisation EHDSOrganisation
    ..... intendedRecipientEHDSDevice EHDSDevice
    .... healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information
    ... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
    ... body 0..1 Base Structured body of the discharge report document
    .... advanceDirectives 0..1 Base Section: Advance Directives.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the section
    ..... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
    .... alerts 0..1 Base Section: Alerts.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the 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.
    ..... allergyAndIntolerance 0..* EHDSAllergyIntolerance Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
    .... encounterInformation 1..1 Base Section: Encounter information.
    ..... narrative 1..1 string Narrative, potentially formatted, content of the section
    ..... encounter 0..1 EHDSEncounter Encounter information
    .... admissionEvaluation 0..1 Base Section: Admission evaluation
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ...... time 0..1 dateTime Date and time of the admission evaluation examination
    ...... performer 0..* EHDSHealthProfessional Health professional(s) responsible for the admission evaluation examination.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    .... patientHistory 0..1 Base Section: Patient health history (anamnesis).
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ..... medicalHistory 1..1 Base Medical history subsection.
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pastProblems 1..* EHDSCondition Past problems
    ...... devicesAndImplants 1..* EHDSDeviceUse Devices and Implants
    ...... historyOfProcedures 0..* EHDSProcedure History of procedures
    ...... vaccination 0..* EHDSImmunisation Vaccination history of the patient.
    ...... epidemiologicalHistory 0..1 Base Epidemiological history
    ....... infectiousContacts 0..* EHDSInfectiousContact Infectious contacts of the patient
    ....... travelHistory 0..* EHDSTravelHistory Travel history reported by the patient. Multiple records could be provided.
    ...... pregnancyHistory 0..1 Base Section: Pregnancy history
    ....... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
    ....... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
    ....... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
    ..... familyHistorySection 0..1 Base Family history section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... familyHistory 0..* EHDSFamilyMemberHistory Family history
    ..... socialDeterminantsOfHealth 0..1 Base Social determinants of health
    ...... narrative 0..1 string Sub-section narrative
    ...... participationInSociety 0..1 Base Participation in society
    ....... workSituation 0..1 string Work situation
    ....... hobby 0..1 string An activity the patient enjoys doing in their free time.
    ....... socialNetwork 0..1 string Social network
    ...... educationSection 0..1 Base Education section
    ....... educationLevel 0..1 CodeableConcept Education level
    Binding Description: (preferred): hl7:v3.EducationLevel
    ....... comment 0..1 string If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
    ...... livingSituation 0..1 Base Living situation - household type and other related living situation information.
    ....... houseType 0..1 CodeableConcept Type of home the patient lives in.
    Binding Description: (preferred): SNOMED CT
    ....... homeAdaption 0..* CodeableConcept Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
    Binding Description: (preferred): SNOMED CT
    ....... livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home.
    Binding Description: (preferred): SNOMED CT
    ...... familySituation 0..1 Base Family situation
    ....... comment 0..1 string Comment on the family situation.
    ....... familyComposition 0..1 CodeableConcept Family composition
    Binding Description: (preferred): SNOMED CT
    ....... maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code.
    Binding Description: (preferred): hl7:marital-status
    ....... numberOfChildren 0..1 Quantity Number of children
    ....... numberOfChildrenAtHome 0..1 Quantity Number of children living at home with the patient.
    ....... childDetails 0..* Base Child details (age, co-living status and comment).
    ........ livingAtHome 0..1 boolean Living at home. An indication stating whether the child lives at home.
    ........ dateOfBirth 0..1 date Child’s date of birth.
    ........ comment 0..1 string A comment on the child's family situation.
    ....... careResponsibility 0..* CodeableConcept Care responsibility. The activities the patient carries out to care for a dependent family member.
    Binding Description: (preferred): SNOMED CT
    ...... useOfSubstances 0..1 Base Use of substances
    ....... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ....... alcoholUse 0..* EHDSSubstanceUse Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
    ....... tobaccoUse 0..* EHDSSubstanceUse Tobacco use
    ....... drugConsumption 0..* EHDSSubstanceUse Consumption of drugs and other substances (in terms of abuse).
    .... courseOfEncounter 1..1 Base Course of inpatient or outpatient encounter.
    ..... diagnosticSummary 1..1 Base Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
    ...... narrative 0..1 string Problem specification in narrative form.
    ...... problemDetails 0..* Base Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
    ....... presentOnAdmission 1..1 CodeableConcept Whether the condition was present on admission or acquired during encounter
    ....... treatmentClass 1..1 CodeableConcept Class of the problem (treated, other) in relation to the encounter.
    ....... problem 1..1 EHDSCondition Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
    ..... significantProcedures 0..1 Base Significant procedures section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... procedureEntry 0..* EHDSProcedure Structured procedure entry.
    ..... medicalDevicesAndImplants 1..1 Base Medical devices and implants section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... medicalDevicesAndImplants 1..* EHDSDeviceUse Medical devices and implants
    ..... pharmacotherapy 0..1 Base Pharmacotherapy section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pharmacotherapy 0..* EHDSMedicationStatement Pharmacotherapy structured entry.
    ..... significantObservationResults 0..1 Base Significant Observation Results
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... significantObservationResult[x] 0..* Significant Observation Result
    ....... significantObservationResultEHDSObservation EHDSObservation
    ....... significantObservationResultEHDSLaboratoryObservation EHDSLaboratoryObservation
    ..... synthesis 1..1 Base Synthesis
    ...... problemSynthesis 1..* string Summary description of the reason and course of hospitalisation for a specific problem.
    ...... clinicalReasoning 0..1 string Clinical reasoning
    .... dischargeDetails 1..1 Base Discharge details
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    ..... medicationSummary 0..1 Base Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
    ...... narrative 0..1 string Narrative content of the section.
    ...... entry 0..* Base Structured medication entry
    ....... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
    ....... daysSupplied 0..1 Quantity Number of days for which the patient was provided with the drug at the time of discharge
    ..... carePlan 0..* Base Care plan and other recommendations after discharge.
    ...... narrative 0..1 string Narrative content of the 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.
    .... attachmentsEHDSAttachment EHDSAttachment
    .... attachmentsEHDSMedia EHDSMedia

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    EHDSDischargeReport.header.languagepreferred
    EHDSDischargeReport.header.documentTypepreferred
    EHDSDischargeReport.header.documentStatuspreferred
    EHDSDischargeReport.header.eventTypepreferred
    EHDSDischargeReport.header.authorSpecialtypreferred
    EHDSDischargeReport.header.documentFormatpreferred
    EHDSDischargeReport.header.confidentialitypreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevelpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseTypepreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaptionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditionspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyCompositionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatuspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibilitypreferred

    This structure is derived from EHDSDocument

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. EHDSDischargeReport 0..* EHDSDocument
    Elements defined in Ancestors:header, presentedForm, header, knowledgeResources
    Discharge Report model
    Instances of this logical model can be the target of a Reference
    ... header
    .... intendedRecipient[x] 0..* Intended recipient
    ..... intendedRecipientEHDSPatient EHDSPatient
    ..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
    ..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
    ..... intendedRecipientEHDSOrganisation EHDSOrganisation
    ..... intendedRecipientEHDSDevice EHDSDevice
    .... healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information
    ... knowledgeResources 0..0
    ... body 0..1 Base Structured body of the discharge report document
    .... advanceDirectives 0..1 Base Section: Advance Directives.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the section
    ..... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
    .... alerts 0..1 Base Section: Alerts.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the 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.
    ..... allergyAndIntolerance 0..* EHDSAllergyIntolerance Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
    .... encounterInformation 1..1 Base Section: Encounter information.
    ..... narrative 1..1 string Narrative, potentially formatted, content of the section
    ..... encounter 0..1 EHDSEncounter Encounter information
    .... admissionEvaluation 0..1 Base Section: Admission evaluation
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ...... time 0..1 dateTime Date and time of the admission evaluation examination
    ...... performer 0..* EHDSHealthProfessional Health professional(s) responsible for the admission evaluation examination.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    .... patientHistory 0..1 Base Section: Patient health history (anamnesis).
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ..... medicalHistory 1..1 Base Medical history subsection.
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pastProblems 1..* EHDSCondition Past problems
    ...... devicesAndImplants 1..* EHDSDeviceUse Devices and Implants
    ...... historyOfProcedures 0..* EHDSProcedure History of procedures
    ...... vaccination 0..* EHDSImmunisation Vaccination history of the patient.
    ...... epidemiologicalHistory 0..1 Base Epidemiological history
    ....... infectiousContacts 0..* EHDSInfectiousContact Infectious contacts of the patient
    ....... travelHistory 0..* EHDSTravelHistory Travel history reported by the patient. Multiple records could be provided.
    ...... pregnancyHistory 0..1 Base Section: Pregnancy history
    ....... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
    ....... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
    ....... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
    ..... familyHistorySection 0..1 Base Family history section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... familyHistory 0..* EHDSFamilyMemberHistory Family history
    ..... socialDeterminantsOfHealth 0..1 Base Social determinants of health
    ...... narrative 0..1 string Sub-section narrative
    ...... participationInSociety 0..1 Base Participation in society
    ....... workSituation 0..1 string Work situation
    ....... hobby 0..1 string An activity the patient enjoys doing in their free time.
    ....... socialNetwork 0..1 string Social network
    ...... educationSection 0..1 Base Education section
    ....... educationLevel 0..1 CodeableConcept Education level
    Binding Description: (preferred): hl7:v3.EducationLevel
    ....... comment 0..1 string If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
    ...... livingSituation 0..1 Base Living situation - household type and other related living situation information.
    ....... houseType 0..1 CodeableConcept Type of home the patient lives in.
    Binding Description: (preferred): SNOMED CT
    ....... homeAdaption 0..* CodeableConcept Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
    Binding Description: (preferred): SNOMED CT
    ....... livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home.
    Binding Description: (preferred): SNOMED CT
    ...... familySituation 0..1 Base Family situation
    ....... comment 0..1 string Comment on the family situation.
    ....... familyComposition 0..1 CodeableConcept Family composition
    Binding Description: (preferred): SNOMED CT
    ....... maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code.
    Binding Description: (preferred): hl7:marital-status
    ....... numberOfChildren 0..1 Quantity Number of children
    ....... numberOfChildrenAtHome 0..1 Quantity Number of children living at home with the patient.
    ....... childDetails 0..* Base Child details (age, co-living status and comment).
    ........ livingAtHome 0..1 boolean Living at home. An indication stating whether the child lives at home.
    ........ dateOfBirth 0..1 date Child’s date of birth.
    ........ comment 0..1 string A comment on the child's family situation.
    ....... careResponsibility 0..* CodeableConcept Care responsibility. The activities the patient carries out to care for a dependent family member.
    Binding Description: (preferred): SNOMED CT
    ...... useOfSubstances 0..1 Base Use of substances
    ....... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ....... alcoholUse 0..* EHDSSubstanceUse Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
    ....... tobaccoUse 0..* EHDSSubstanceUse Tobacco use
    ....... drugConsumption 0..* EHDSSubstanceUse Consumption of drugs and other substances (in terms of abuse).
    .... courseOfEncounter 1..1 Base Course of inpatient or outpatient encounter.
    ..... diagnosticSummary 1..1 Base Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
    ...... narrative 0..1 string Problem specification in narrative form.
    ...... problemDetails 0..* Base Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
    ....... presentOnAdmission 1..1 CodeableConcept Whether the condition was present on admission or acquired during encounter
    ....... treatmentClass 1..1 CodeableConcept Class of the problem (treated, other) in relation to the encounter.
    ....... problem 1..1 EHDSCondition Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
    ..... significantProcedures 0..1 Base Significant procedures section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... procedureEntry 0..* EHDSProcedure Structured procedure entry.
    ..... medicalDevicesAndImplants 1..1 Base Medical devices and implants section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... medicalDevicesAndImplants 1..* EHDSDeviceUse Medical devices and implants
    ..... pharmacotherapy 0..1 Base Pharmacotherapy section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pharmacotherapy 0..* EHDSMedicationStatement Pharmacotherapy structured entry.
    ..... significantObservationResults 0..1 Base Significant Observation Results
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... significantObservationResult[x] 0..* Significant Observation Result
    ....... significantObservationResultEHDSObservation EHDSObservation
    ....... significantObservationResultEHDSLaboratoryObservation EHDSLaboratoryObservation
    ..... synthesis 1..1 Base Synthesis
    ...... problemSynthesis 1..* string Summary description of the reason and course of hospitalisation for a specific problem.
    ...... clinicalReasoning 0..1 string Clinical reasoning
    .... dischargeDetails 1..1 Base Discharge details
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    ..... medicationSummary 0..1 Base Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
    ...... narrative 0..1 string Narrative content of the section.
    ...... entry 0..* Base Structured medication entry
    ....... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
    ....... daysSupplied 0..1 Quantity Number of days for which the patient was provided with the drug at the time of discharge
    ..... carePlan 0..* Base Care plan and other recommendations after discharge.
    ...... narrative 0..1 string Narrative content of the 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.
    .... attachmentsEHDSAttachment EHDSAttachment
    .... attachmentsEHDSMedia EHDSMedia

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevelpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseTypepreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaptionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditionspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyCompositionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatuspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibilitypreferred
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. EHDSDischargeReport 0..* EHDSDocument
    Elements defined in Ancestors:header, presentedForm, header, knowledgeResources
    Discharge Report model
    Instances of this logical model can be the target of a Reference
    ... header 1..1 Base Document header elements
    .... subject 1..1 EHDSPatient Subject
    .... identifier 1..* Identifier Document ID
    .... authorship 1..* Base Authorship
    ..... author[x] 1..1 Author
    ...... authorEHDSHealthProfessional EHDSHealthProfessional
    ...... authorEHDSOrganisation EHDSOrganisation
    ...... authorEHDSDevice EHDSDevice
    ..... datetime 1..1 dateTime Date and time of authoring/issuing
    .... lastUpdate 0..1 dateTime Date and time of the last update to the resource
    .... status 1..1 CodeableConcept Status of the resource
    .... statusReason[x] 0..1 Reason for the current status of the resource.
    ..... statusReasonCodeableConcept CodeableConcept
    ..... statusReasonString string
    .... language 0..1 CodeableConcept Language
    Binding Description: (preferred): BCP 47
    .... version 0..1 string Version
    .... documentType 1..1 CodeableConcept Document type
    Binding Description: (preferred): LOINC
    .... documentTitle 1..1 string Document title
    .... documentStatus 1..1 CodeableConcept Document status
    Binding Description: (preferred): hl7:CompositionStatus
    .... period 0..1 Period Period
    .... attestation 0..* Base Attestation
    ..... attester 1..1 EHDSHealthProfessional Attester
    ..... datetime 1..1 dateTime DateTime
    .... legalAuthentication 0..1 Base Legal authentication
    ..... legalAuthenticator 1..1 EHDSHealthProfessional Legal authenticator
    ..... datetime 1..1 dateTime DateTime
    .... eventType 0..* CodeableConcept Event type
    Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
    .... authorSpecialty 0..* CodeableConcept Specialty
    Binding Description: (preferred): SNOMED CT
    .... custodian 1..1 EHDSOrganisation Document custodian
    .... documentFormat 0..1 CodeableConcept Document format
    Binding Description: (preferred): HL7 Document Format Codes
    .... confidentiality 0..1 CodeableConcept Confidentiality
    Binding Description: (preferred): hl7:Confidentiality
    .... intendedRecipient[x] 0..* Intended recipient
    ..... intendedRecipientEHDSPatient EHDSPatient
    ..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
    ..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
    ..... intendedRecipientEHDSOrganisation EHDSOrganisation
    ..... intendedRecipientEHDSDevice EHDSDevice
    .... healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information
    ... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
    ... body 0..1 Base Structured body of the discharge report document
    .... advanceDirectives 0..1 Base Section: Advance Directives.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the section
    ..... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
    .... alerts 0..1 Base Section: Alerts.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the 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.
    ..... allergyAndIntolerance 0..* EHDSAllergyIntolerance Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
    .... encounterInformation 1..1 Base Section: Encounter information.
    ..... narrative 1..1 string Narrative, potentially formatted, content of the section
    ..... encounter 0..1 EHDSEncounter Encounter information
    .... admissionEvaluation 0..1 Base Section: Admission evaluation
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ...... time 0..1 dateTime Date and time of the admission evaluation examination
    ...... performer 0..* EHDSHealthProfessional Health professional(s) responsible for the admission evaluation examination.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    .... patientHistory 0..1 Base Section: Patient health history (anamnesis).
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ..... medicalHistory 1..1 Base Medical history subsection.
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pastProblems 1..* EHDSCondition Past problems
    ...... devicesAndImplants 1..* EHDSDeviceUse Devices and Implants
    ...... historyOfProcedures 0..* EHDSProcedure History of procedures
    ...... vaccination 0..* EHDSImmunisation Vaccination history of the patient.
    ...... epidemiologicalHistory 0..1 Base Epidemiological history
    ....... infectiousContacts 0..* EHDSInfectiousContact Infectious contacts of the patient
    ....... travelHistory 0..* EHDSTravelHistory Travel history reported by the patient. Multiple records could be provided.
    ...... pregnancyHistory 0..1 Base Section: Pregnancy history
    ....... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
    ....... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
    ....... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
    ..... familyHistorySection 0..1 Base Family history section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... familyHistory 0..* EHDSFamilyMemberHistory Family history
    ..... socialDeterminantsOfHealth 0..1 Base Social determinants of health
    ...... narrative 0..1 string Sub-section narrative
    ...... participationInSociety 0..1 Base Participation in society
    ....... workSituation 0..1 string Work situation
    ....... hobby 0..1 string An activity the patient enjoys doing in their free time.
    ....... socialNetwork 0..1 string Social network
    ...... educationSection 0..1 Base Education section
    ....... educationLevel 0..1 CodeableConcept Education level
    Binding Description: (preferred): hl7:v3.EducationLevel
    ....... comment 0..1 string If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
    ...... livingSituation 0..1 Base Living situation - household type and other related living situation information.
    ....... houseType 0..1 CodeableConcept Type of home the patient lives in.
    Binding Description: (preferred): SNOMED CT
    ....... homeAdaption 0..* CodeableConcept Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
    Binding Description: (preferred): SNOMED CT
    ....... livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home.
    Binding Description: (preferred): SNOMED CT
    ...... familySituation 0..1 Base Family situation
    ....... comment 0..1 string Comment on the family situation.
    ....... familyComposition 0..1 CodeableConcept Family composition
    Binding Description: (preferred): SNOMED CT
    ....... maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code.
    Binding Description: (preferred): hl7:marital-status
    ....... numberOfChildren 0..1 Quantity Number of children
    ....... numberOfChildrenAtHome 0..1 Quantity Number of children living at home with the patient.
    ....... childDetails 0..* Base Child details (age, co-living status and comment).
    ........ livingAtHome 0..1 boolean Living at home. An indication stating whether the child lives at home.
    ........ dateOfBirth 0..1 date Child’s date of birth.
    ........ comment 0..1 string A comment on the child's family situation.
    ....... careResponsibility 0..* CodeableConcept Care responsibility. The activities the patient carries out to care for a dependent family member.
    Binding Description: (preferred): SNOMED CT
    ...... useOfSubstances 0..1 Base Use of substances
    ....... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ....... alcoholUse 0..* EHDSSubstanceUse Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
    ....... tobaccoUse 0..* EHDSSubstanceUse Tobacco use
    ....... drugConsumption 0..* EHDSSubstanceUse Consumption of drugs and other substances (in terms of abuse).
    .... courseOfEncounter 1..1 Base Course of inpatient or outpatient encounter.
    ..... diagnosticSummary 1..1 Base Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
    ...... narrative 0..1 string Problem specification in narrative form.
    ...... problemDetails 0..* Base Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
    ....... presentOnAdmission 1..1 CodeableConcept Whether the condition was present on admission or acquired during encounter
    ....... treatmentClass 1..1 CodeableConcept Class of the problem (treated, other) in relation to the encounter.
    ....... problem 1..1 EHDSCondition Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
    ..... significantProcedures 0..1 Base Significant procedures section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... procedureEntry 0..* EHDSProcedure Structured procedure entry.
    ..... medicalDevicesAndImplants 1..1 Base Medical devices and implants section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... medicalDevicesAndImplants 1..* EHDSDeviceUse Medical devices and implants
    ..... pharmacotherapy 0..1 Base Pharmacotherapy section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pharmacotherapy 0..* EHDSMedicationStatement Pharmacotherapy structured entry.
    ..... significantObservationResults 0..1 Base Significant Observation Results
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... significantObservationResult[x] 0..* Significant Observation Result
    ....... significantObservationResultEHDSObservation EHDSObservation
    ....... significantObservationResultEHDSLaboratoryObservation EHDSLaboratoryObservation
    ..... synthesis 1..1 Base Synthesis
    ...... problemSynthesis 1..* string Summary description of the reason and course of hospitalisation for a specific problem.
    ...... clinicalReasoning 0..1 string Clinical reasoning
    .... dischargeDetails 1..1 Base Discharge details
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    ..... medicationSummary 0..1 Base Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
    ...... narrative 0..1 string Narrative content of the section.
    ...... entry 0..* Base Structured medication entry
    ....... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
    ....... daysSupplied 0..1 Quantity Number of days for which the patient was provided with the drug at the time of discharge
    ..... carePlan 0..* Base Care plan and other recommendations after discharge.
    ...... narrative 0..1 string Narrative content of the 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.
    .... attachmentsEHDSAttachment EHDSAttachment
    .... attachmentsEHDSMedia EHDSMedia

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    EHDSDischargeReport.header.languagepreferred
    EHDSDischargeReport.header.documentTypepreferred
    EHDSDischargeReport.header.documentStatuspreferred
    EHDSDischargeReport.header.eventTypepreferred
    EHDSDischargeReport.header.authorSpecialtypreferred
    EHDSDischargeReport.header.documentFormatpreferred
    EHDSDischargeReport.header.confidentialitypreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevelpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseTypepreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaptionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditionspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyCompositionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatuspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibilitypreferred

    This structure is derived from EHDSDocument

    Summary

    Mandatory: 0 element(16 nested mandatory elements)
    Prohibited: 1 element

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. EHDSDischargeReport 0..* EHDSDocument
    Elements defined in Ancestors:header, presentedForm, header, knowledgeResources
    Discharge Report model
    Instances of this logical model can be the target of a Reference
    ... header 1..1 Base Document header elements
    .... subject 1..1 EHDSPatient Subject
    .... identifier 1..* Identifier Document ID
    .... authorship 1..* Base Authorship
    ..... author[x] 1..1 Author
    ...... authorEHDSHealthProfessional EHDSHealthProfessional
    ...... authorEHDSOrganisation EHDSOrganisation
    ...... authorEHDSDevice EHDSDevice
    ..... datetime 1..1 dateTime Date and time of authoring/issuing
    .... lastUpdate 0..1 dateTime Date and time of the last update to the resource
    .... status 1..1 CodeableConcept Status of the resource
    .... statusReason[x] 0..1 Reason for the current status of the resource.
    ..... statusReasonCodeableConcept CodeableConcept
    ..... statusReasonString string
    .... language 0..1 CodeableConcept Language
    Binding Description: (preferred): BCP 47
    .... version 0..1 string Version
    .... documentType 1..1 CodeableConcept Document type
    Binding Description: (preferred): LOINC
    .... documentTitle 1..1 string Document title
    .... documentStatus 1..1 CodeableConcept Document status
    Binding Description: (preferred): hl7:CompositionStatus
    .... period 0..1 Period Period
    .... attestation 0..* Base Attestation
    ..... attester 1..1 EHDSHealthProfessional Attester
    ..... datetime 1..1 dateTime DateTime
    .... legalAuthentication 0..1 Base Legal authentication
    ..... legalAuthenticator 1..1 EHDSHealthProfessional Legal authenticator
    ..... datetime 1..1 dateTime DateTime
    .... eventType 0..* CodeableConcept Event type
    Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
    .... authorSpecialty 0..* CodeableConcept Specialty
    Binding Description: (preferred): SNOMED CT
    .... custodian 1..1 EHDSOrganisation Document custodian
    .... documentFormat 0..1 CodeableConcept Document format
    Binding Description: (preferred): HL7 Document Format Codes
    .... confidentiality 0..1 CodeableConcept Confidentiality
    Binding Description: (preferred): hl7:Confidentiality
    .... intendedRecipient[x] 0..* Intended recipient
    ..... intendedRecipientEHDSPatient EHDSPatient
    ..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
    ..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
    ..... intendedRecipientEHDSOrganisation EHDSOrganisation
    ..... intendedRecipientEHDSDevice EHDSDevice
    .... healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information
    ... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
    ... body 0..1 Base Structured body of the discharge report document
    .... advanceDirectives 0..1 Base Section: Advance Directives.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the section
    ..... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
    .... alerts 0..1 Base Section: Alerts.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the 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.
    ..... allergyAndIntolerance 0..* EHDSAllergyIntolerance Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
    .... encounterInformation 1..1 Base Section: Encounter information.
    ..... narrative 1..1 string Narrative, potentially formatted, content of the section
    ..... encounter 0..1 EHDSEncounter Encounter information
    .... admissionEvaluation 0..1 Base Section: Admission evaluation
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ...... time 0..1 dateTime Date and time of the admission evaluation examination
    ...... performer 0..* EHDSHealthProfessional Health professional(s) responsible for the admission evaluation examination.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    .... patientHistory 0..1 Base Section: Patient health history (anamnesis).
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ..... medicalHistory 1..1 Base Medical history subsection.
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pastProblems 1..* EHDSCondition Past problems
    ...... devicesAndImplants 1..* EHDSDeviceUse Devices and Implants
    ...... historyOfProcedures 0..* EHDSProcedure History of procedures
    ...... vaccination 0..* EHDSImmunisation Vaccination history of the patient.
    ...... epidemiologicalHistory 0..1 Base Epidemiological history
    ....... infectiousContacts 0..* EHDSInfectiousContact Infectious contacts of the patient
    ....... travelHistory 0..* EHDSTravelHistory Travel history reported by the patient. Multiple records could be provided.
    ...... pregnancyHistory 0..1 Base Section: Pregnancy history
    ....... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
    ....... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
    ....... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
    ..... familyHistorySection 0..1 Base Family history section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... familyHistory 0..* EHDSFamilyMemberHistory Family history
    ..... socialDeterminantsOfHealth 0..1 Base Social determinants of health
    ...... narrative 0..1 string Sub-section narrative
    ...... participationInSociety 0..1 Base Participation in society
    ....... workSituation 0..1 string Work situation
    ....... hobby 0..1 string An activity the patient enjoys doing in their free time.
    ....... socialNetwork 0..1 string Social network
    ...... educationSection 0..1 Base Education section
    ....... educationLevel 0..1 CodeableConcept Education level
    Binding Description: (preferred): hl7:v3.EducationLevel
    ....... comment 0..1 string If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
    ...... livingSituation 0..1 Base Living situation - household type and other related living situation information.
    ....... houseType 0..1 CodeableConcept Type of home the patient lives in.
    Binding Description: (preferred): SNOMED CT
    ....... homeAdaption 0..* CodeableConcept Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
    Binding Description: (preferred): SNOMED CT
    ....... livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home.
    Binding Description: (preferred): SNOMED CT
    ...... familySituation 0..1 Base Family situation
    ....... comment 0..1 string Comment on the family situation.
    ....... familyComposition 0..1 CodeableConcept Family composition
    Binding Description: (preferred): SNOMED CT
    ....... maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code.
    Binding Description: (preferred): hl7:marital-status
    ....... numberOfChildren 0..1 Quantity Number of children
    ....... numberOfChildrenAtHome 0..1 Quantity Number of children living at home with the patient.
    ....... childDetails 0..* Base Child details (age, co-living status and comment).
    ........ livingAtHome 0..1 boolean Living at home. An indication stating whether the child lives at home.
    ........ dateOfBirth 0..1 date Child’s date of birth.
    ........ comment 0..1 string A comment on the child's family situation.
    ....... careResponsibility 0..* CodeableConcept Care responsibility. The activities the patient carries out to care for a dependent family member.
    Binding Description: (preferred): SNOMED CT
    ...... useOfSubstances 0..1 Base Use of substances
    ....... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ....... alcoholUse 0..* EHDSSubstanceUse Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
    ....... tobaccoUse 0..* EHDSSubstanceUse Tobacco use
    ....... drugConsumption 0..* EHDSSubstanceUse Consumption of drugs and other substances (in terms of abuse).
    .... courseOfEncounter 1..1 Base Course of inpatient or outpatient encounter.
    ..... diagnosticSummary 1..1 Base Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
    ...... narrative 0..1 string Problem specification in narrative form.
    ...... problemDetails 0..* Base Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
    ....... presentOnAdmission 1..1 CodeableConcept Whether the condition was present on admission or acquired during encounter
    ....... treatmentClass 1..1 CodeableConcept Class of the problem (treated, other) in relation to the encounter.
    ....... problem 1..1 EHDSCondition Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
    ..... significantProcedures 0..1 Base Significant procedures section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... procedureEntry 0..* EHDSProcedure Structured procedure entry.
    ..... medicalDevicesAndImplants 1..1 Base Medical devices and implants section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... medicalDevicesAndImplants 1..* EHDSDeviceUse Medical devices and implants
    ..... pharmacotherapy 0..1 Base Pharmacotherapy section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pharmacotherapy 0..* EHDSMedicationStatement Pharmacotherapy structured entry.
    ..... significantObservationResults 0..1 Base Significant Observation Results
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... significantObservationResult[x] 0..* Significant Observation Result
    ....... significantObservationResultEHDSObservation EHDSObservation
    ....... significantObservationResultEHDSLaboratoryObservation EHDSLaboratoryObservation
    ..... synthesis 1..1 Base Synthesis
    ...... problemSynthesis 1..* string Summary description of the reason and course of hospitalisation for a specific problem.
    ...... clinicalReasoning 0..1 string Clinical reasoning
    .... dischargeDetails 1..1 Base Discharge details
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    ..... medicationSummary 0..1 Base Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
    ...... narrative 0..1 string Narrative content of the section.
    ...... entry 0..* Base Structured medication entry
    ....... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
    ....... daysSupplied 0..1 Quantity Number of days for which the patient was provided with the drug at the time of discharge
    ..... carePlan 0..* Base Care plan and other recommendations after discharge.
    ...... narrative 0..1 string Narrative content of the 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.
    .... attachmentsEHDSAttachment EHDSAttachment
    .... attachmentsEHDSMedia EHDSMedia

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    EHDSDischargeReport.header.languagepreferred
    EHDSDischargeReport.header.documentTypepreferred
    EHDSDischargeReport.header.documentStatuspreferred
    EHDSDischargeReport.header.eventTypepreferred
    EHDSDischargeReport.header.authorSpecialtypreferred
    EHDSDischargeReport.header.documentFormatpreferred
    EHDSDischargeReport.header.confidentialitypreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevelpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseTypepreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaptionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditionspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyCompositionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatuspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibilitypreferred

    Differential View

    This structure is derived from EHDSDocument

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. EHDSDischargeReport 0..* EHDSDocument
    Elements defined in Ancestors:header, presentedForm, header, knowledgeResources
    Discharge Report model
    Instances of this logical model can be the target of a Reference
    ... header
    .... intendedRecipient[x] 0..* Intended recipient
    ..... intendedRecipientEHDSPatient EHDSPatient
    ..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
    ..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
    ..... intendedRecipientEHDSOrganisation EHDSOrganisation
    ..... intendedRecipientEHDSDevice EHDSDevice
    .... healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information
    ... knowledgeResources 0..0
    ... body 0..1 Base Structured body of the discharge report document
    .... advanceDirectives 0..1 Base Section: Advance Directives.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the section
    ..... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
    .... alerts 0..1 Base Section: Alerts.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the 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.
    ..... allergyAndIntolerance 0..* EHDSAllergyIntolerance Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
    .... encounterInformation 1..1 Base Section: Encounter information.
    ..... narrative 1..1 string Narrative, potentially formatted, content of the section
    ..... encounter 0..1 EHDSEncounter Encounter information
    .... admissionEvaluation 0..1 Base Section: Admission evaluation
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ...... time 0..1 dateTime Date and time of the admission evaluation examination
    ...... performer 0..* EHDSHealthProfessional Health professional(s) responsible for the admission evaluation examination.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    .... patientHistory 0..1 Base Section: Patient health history (anamnesis).
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ..... medicalHistory 1..1 Base Medical history subsection.
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pastProblems 1..* EHDSCondition Past problems
    ...... devicesAndImplants 1..* EHDSDeviceUse Devices and Implants
    ...... historyOfProcedures 0..* EHDSProcedure History of procedures
    ...... vaccination 0..* EHDSImmunisation Vaccination history of the patient.
    ...... epidemiologicalHistory 0..1 Base Epidemiological history
    ....... infectiousContacts 0..* EHDSInfectiousContact Infectious contacts of the patient
    ....... travelHistory 0..* EHDSTravelHistory Travel history reported by the patient. Multiple records could be provided.
    ...... pregnancyHistory 0..1 Base Section: Pregnancy history
    ....... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
    ....... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
    ....... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
    ..... familyHistorySection 0..1 Base Family history section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... familyHistory 0..* EHDSFamilyMemberHistory Family history
    ..... socialDeterminantsOfHealth 0..1 Base Social determinants of health
    ...... narrative 0..1 string Sub-section narrative
    ...... participationInSociety 0..1 Base Participation in society
    ....... workSituation 0..1 string Work situation
    ....... hobby 0..1 string An activity the patient enjoys doing in their free time.
    ....... socialNetwork 0..1 string Social network
    ...... educationSection 0..1 Base Education section
    ....... educationLevel 0..1 CodeableConcept Education level
    Binding Description: (preferred): hl7:v3.EducationLevel
    ....... comment 0..1 string If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
    ...... livingSituation 0..1 Base Living situation - household type and other related living situation information.
    ....... houseType 0..1 CodeableConcept Type of home the patient lives in.
    Binding Description: (preferred): SNOMED CT
    ....... homeAdaption 0..* CodeableConcept Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
    Binding Description: (preferred): SNOMED CT
    ....... livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home.
    Binding Description: (preferred): SNOMED CT
    ...... familySituation 0..1 Base Family situation
    ....... comment 0..1 string Comment on the family situation.
    ....... familyComposition 0..1 CodeableConcept Family composition
    Binding Description: (preferred): SNOMED CT
    ....... maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code.
    Binding Description: (preferred): hl7:marital-status
    ....... numberOfChildren 0..1 Quantity Number of children
    ....... numberOfChildrenAtHome 0..1 Quantity Number of children living at home with the patient.
    ....... childDetails 0..* Base Child details (age, co-living status and comment).
    ........ livingAtHome 0..1 boolean Living at home. An indication stating whether the child lives at home.
    ........ dateOfBirth 0..1 date Child’s date of birth.
    ........ comment 0..1 string A comment on the child's family situation.
    ....... careResponsibility 0..* CodeableConcept Care responsibility. The activities the patient carries out to care for a dependent family member.
    Binding Description: (preferred): SNOMED CT
    ...... useOfSubstances 0..1 Base Use of substances
    ....... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ....... alcoholUse 0..* EHDSSubstanceUse Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
    ....... tobaccoUse 0..* EHDSSubstanceUse Tobacco use
    ....... drugConsumption 0..* EHDSSubstanceUse Consumption of drugs and other substances (in terms of abuse).
    .... courseOfEncounter 1..1 Base Course of inpatient or outpatient encounter.
    ..... diagnosticSummary 1..1 Base Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
    ...... narrative 0..1 string Problem specification in narrative form.
    ...... problemDetails 0..* Base Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
    ....... presentOnAdmission 1..1 CodeableConcept Whether the condition was present on admission or acquired during encounter
    ....... treatmentClass 1..1 CodeableConcept Class of the problem (treated, other) in relation to the encounter.
    ....... problem 1..1 EHDSCondition Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
    ..... significantProcedures 0..1 Base Significant procedures section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... procedureEntry 0..* EHDSProcedure Structured procedure entry.
    ..... medicalDevicesAndImplants 1..1 Base Medical devices and implants section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... medicalDevicesAndImplants 1..* EHDSDeviceUse Medical devices and implants
    ..... pharmacotherapy 0..1 Base Pharmacotherapy section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pharmacotherapy 0..* EHDSMedicationStatement Pharmacotherapy structured entry.
    ..... significantObservationResults 0..1 Base Significant Observation Results
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... significantObservationResult[x] 0..* Significant Observation Result
    ....... significantObservationResultEHDSObservation EHDSObservation
    ....... significantObservationResultEHDSLaboratoryObservation EHDSLaboratoryObservation
    ..... synthesis 1..1 Base Synthesis
    ...... problemSynthesis 1..* string Summary description of the reason and course of hospitalisation for a specific problem.
    ...... clinicalReasoning 0..1 string Clinical reasoning
    .... dischargeDetails 1..1 Base Discharge details
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    ..... medicationSummary 0..1 Base Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
    ...... narrative 0..1 string Narrative content of the section.
    ...... entry 0..* Base Structured medication entry
    ....... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
    ....... daysSupplied 0..1 Quantity Number of days for which the patient was provided with the drug at the time of discharge
    ..... carePlan 0..* Base Care plan and other recommendations after discharge.
    ...... narrative 0..1 string Narrative content of the 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.
    .... attachmentsEHDSAttachment EHDSAttachment
    .... attachmentsEHDSMedia EHDSMedia

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevelpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseTypepreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaptionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditionspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyCompositionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatuspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibilitypreferred

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. EHDSDischargeReport 0..* EHDSDocument
    Elements defined in Ancestors:header, presentedForm, header, knowledgeResources
    Discharge Report model
    Instances of this logical model can be the target of a Reference
    ... header 1..1 Base Document header elements
    .... subject 1..1 EHDSPatient Subject
    .... identifier 1..* Identifier Document ID
    .... authorship 1..* Base Authorship
    ..... author[x] 1..1 Author
    ...... authorEHDSHealthProfessional EHDSHealthProfessional
    ...... authorEHDSOrganisation EHDSOrganisation
    ...... authorEHDSDevice EHDSDevice
    ..... datetime 1..1 dateTime Date and time of authoring/issuing
    .... lastUpdate 0..1 dateTime Date and time of the last update to the resource
    .... status 1..1 CodeableConcept Status of the resource
    .... statusReason[x] 0..1 Reason for the current status of the resource.
    ..... statusReasonCodeableConcept CodeableConcept
    ..... statusReasonString string
    .... language 0..1 CodeableConcept Language
    Binding Description: (preferred): BCP 47
    .... version 0..1 string Version
    .... documentType 1..1 CodeableConcept Document type
    Binding Description: (preferred): LOINC
    .... documentTitle 1..1 string Document title
    .... documentStatus 1..1 CodeableConcept Document status
    Binding Description: (preferred): hl7:CompositionStatus
    .... period 0..1 Period Period
    .... attestation 0..* Base Attestation
    ..... attester 1..1 EHDSHealthProfessional Attester
    ..... datetime 1..1 dateTime DateTime
    .... legalAuthentication 0..1 Base Legal authentication
    ..... legalAuthenticator 1..1 EHDSHealthProfessional Legal authenticator
    ..... datetime 1..1 dateTime DateTime
    .... eventType 0..* CodeableConcept Event type
    Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
    .... authorSpecialty 0..* CodeableConcept Specialty
    Binding Description: (preferred): SNOMED CT
    .... custodian 1..1 EHDSOrganisation Document custodian
    .... documentFormat 0..1 CodeableConcept Document format
    Binding Description: (preferred): HL7 Document Format Codes
    .... confidentiality 0..1 CodeableConcept Confidentiality
    Binding Description: (preferred): hl7:Confidentiality
    .... intendedRecipient[x] 0..* Intended recipient
    ..... intendedRecipientEHDSPatient EHDSPatient
    ..... intendedRecipientEHDSRelatedPerson EHDSRelatedPerson
    ..... intendedRecipientEHDSHealthProfessional EHDSHealthProfessional
    ..... intendedRecipientEHDSOrganisation EHDSOrganisation
    ..... intendedRecipientEHDSDevice EHDSDevice
    .... healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information
    ... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
    ... body 0..1 Base Structured body of the discharge report document
    .... advanceDirectives 0..1 Base Section: Advance Directives.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the section
    ..... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
    .... alerts 0..1 Base Section: Alerts.
    ..... narrative 0..1 string Narrative, potentially formatted, content of the 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.
    ..... allergyAndIntolerance 0..* EHDSAllergyIntolerance Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
    .... encounterInformation 1..1 Base Section: Encounter information.
    ..... narrative 1..1 string Narrative, potentially formatted, content of the section
    ..... encounter 0..1 EHDSEncounter Encounter information
    .... admissionEvaluation 0..1 Base Section: Admission evaluation
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ...... time 0..1 dateTime Date and time of the admission evaluation examination
    ...... performer 0..* EHDSHealthProfessional Health professional(s) responsible for the admission evaluation examination.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    .... patientHistory 0..1 Base Section: Patient health history (anamnesis).
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ..... medicalHistory 1..1 Base Medical history subsection.
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pastProblems 1..* EHDSCondition Past problems
    ...... devicesAndImplants 1..* EHDSDeviceUse Devices and Implants
    ...... historyOfProcedures 0..* EHDSProcedure History of procedures
    ...... vaccination 0..* EHDSImmunisation Vaccination history of the patient.
    ...... epidemiologicalHistory 0..1 Base Epidemiological history
    ....... infectiousContacts 0..* EHDSInfectiousContact Infectious contacts of the patient
    ....... travelHistory 0..* EHDSTravelHistory Travel history reported by the patient. Multiple records could be provided.
    ...... pregnancyHistory 0..1 Base Section: Pregnancy history
    ....... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
    ....... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
    ....... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
    ..... familyHistorySection 0..1 Base Family history section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... familyHistory 0..* EHDSFamilyMemberHistory Family history
    ..... socialDeterminantsOfHealth 0..1 Base Social determinants of health
    ...... narrative 0..1 string Sub-section narrative
    ...... participationInSociety 0..1 Base Participation in society
    ....... workSituation 0..1 string Work situation
    ....... hobby 0..1 string An activity the patient enjoys doing in their free time.
    ....... socialNetwork 0..1 string Social network
    ...... educationSection 0..1 Base Education section
    ....... educationLevel 0..1 CodeableConcept Education level
    Binding Description: (preferred): hl7:v3.EducationLevel
    ....... comment 0..1 string If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
    ...... livingSituation 0..1 Base Living situation - household type and other related living situation information.
    ....... houseType 0..1 CodeableConcept Type of home the patient lives in.
    Binding Description: (preferred): SNOMED CT
    ....... homeAdaption 0..* CodeableConcept Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
    Binding Description: (preferred): SNOMED CT
    ....... livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home.
    Binding Description: (preferred): SNOMED CT
    ...... familySituation 0..1 Base Family situation
    ....... comment 0..1 string Comment on the family situation.
    ....... familyComposition 0..1 CodeableConcept Family composition
    Binding Description: (preferred): SNOMED CT
    ....... maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code.
    Binding Description: (preferred): hl7:marital-status
    ....... numberOfChildren 0..1 Quantity Number of children
    ....... numberOfChildrenAtHome 0..1 Quantity Number of children living at home with the patient.
    ....... childDetails 0..* Base Child details (age, co-living status and comment).
    ........ livingAtHome 0..1 boolean Living at home. An indication stating whether the child lives at home.
    ........ dateOfBirth 0..1 date Child’s date of birth.
    ........ comment 0..1 string A comment on the child's family situation.
    ....... careResponsibility 0..* CodeableConcept Care responsibility. The activities the patient carries out to care for a dependent family member.
    Binding Description: (preferred): SNOMED CT
    ...... useOfSubstances 0..1 Base Use of substances
    ....... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ....... alcoholUse 0..* EHDSSubstanceUse Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
    ....... tobaccoUse 0..* EHDSSubstanceUse Tobacco use
    ....... drugConsumption 0..* EHDSSubstanceUse Consumption of drugs and other substances (in terms of abuse).
    .... courseOfEncounter 1..1 Base Course of inpatient or outpatient encounter.
    ..... diagnosticSummary 1..1 Base Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
    ...... narrative 0..1 string Problem specification in narrative form.
    ...... problemDetails 0..* Base Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
    ....... presentOnAdmission 1..1 CodeableConcept Whether the condition was present on admission or acquired during encounter
    ....... treatmentClass 1..1 CodeableConcept Class of the problem (treated, other) in relation to the encounter.
    ....... problem 1..1 EHDSCondition Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
    ..... significantProcedures 0..1 Base Significant procedures section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... procedureEntry 0..* EHDSProcedure Structured procedure entry.
    ..... medicalDevicesAndImplants 1..1 Base Medical devices and implants section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... medicalDevicesAndImplants 1..* EHDSDeviceUse Medical devices and implants
    ..... pharmacotherapy 0..1 Base Pharmacotherapy section
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... pharmacotherapy 0..* EHDSMedicationStatement Pharmacotherapy structured entry.
    ..... significantObservationResults 0..1 Base Significant Observation Results
    ...... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
    ...... significantObservationResult[x] 0..* Significant Observation Result
    ....... significantObservationResultEHDSObservation EHDSObservation
    ....... significantObservationResultEHDSLaboratoryObservation EHDSLaboratoryObservation
    ..... synthesis 1..1 Base Synthesis
    ...... problemSynthesis 1..* string Summary description of the reason and course of hospitalisation for a specific problem.
    ...... clinicalReasoning 0..1 string Clinical reasoning
    .... dischargeDetails 1..1 Base Discharge details
    ..... narrative 0..1 string Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
    ..... objectiveFindings 0..1 Base Objective findings
    ...... narrative 0..1 string Narrative content of the section.
    ...... anthropometricObservations 0..* EHDSObservation Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
    ...... vitalSigns 0..* EHDSObservation Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
    ...... physicalExamination 0..* EHDSObservation Physical examination
    ..... functionalStatus 0..1 Base Section: Functional status
    ...... narrative 0..1 string Narrative, potentially formatted, content of the section
    ...... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
    ..... medicationSummary 0..1 Base Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
    ...... narrative 0..1 string Narrative content of the section.
    ...... entry 0..* Base Structured medication entry
    ....... medicationUse 1..1 EHDSMedicationStatement Details about medication and dosaging
    ....... daysSupplied 0..1 Quantity Number of days for which the patient was provided with the drug at the time of discharge
    ..... carePlan 0..* Base Care plan and other recommendations after discharge.
    ...... narrative 0..1 string Narrative content of the 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.
    .... attachmentsEHDSAttachment EHDSAttachment
    .... attachmentsEHDSMedia EHDSMedia

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    EHDSDischargeReport.header.languagepreferred
    EHDSDischargeReport.header.documentTypepreferred
    EHDSDischargeReport.header.documentStatuspreferred
    EHDSDischargeReport.header.eventTypepreferred
    EHDSDischargeReport.header.authorSpecialtypreferred
    EHDSDischargeReport.header.documentFormatpreferred
    EHDSDischargeReport.header.confidentialitypreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevelpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseTypepreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaptionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditionspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyCompositionpreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatuspreferred
    EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibilitypreferred

    This structure is derived from EHDSDocument

    Summary

    Mandatory: 0 element(16 nested mandatory elements)
    Prohibited: 1 element

     

    Other representations of profile: CSV, Excel