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

• Content
• Detailed Descriptions
• Mappings
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Logical Model: Hospital Discharge Report body model

EHDS refined base model for Hospital Discharge Report body

Usages:

• Use this Logical Model: Hospital Discharge Report model

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
EHDSHospitalDischargeReportBody		0..*	Base	Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives		0..1	Base	Authored Advance Directive Information
livingWill		0..*	Base	Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime		1..1	dateTime	The date and time on which the living will was recorded.
type		1..1	CodeableConcept	Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description: (preferred): SNOMED CT
comment		0..1	string	Comment on the living will.
relatedConditions		0..*	CodeableConcept	The problem or disorder to which the living will applies. Binding Description: (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument		1..*	EHDSAttachment	Living will document
alertsSection		0..1	Base	Alerts section
sectionNarrative		0..1	string	Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
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 hospital stay).
medicalAlerts		0..*	EHDSAlertFlag	Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection		1..1	Base	Encounter information section.
sectionNarrative		1..1	string	Narrative content of the section.
encounterInformationSection		0..1	EHDSEncounter	Encounter information section. Hospital encounter details.
admissionEvaluation		0..1	Base	Admission evaluation section
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
patientHistory		0..1	Base	Patient health history section (anamnesis).
sectionNarrative		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.
subsectionNarrative		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..*	EHDSImmunization	Vaccination
epidemiologicalHistory		0..1	Base	Epidemiological history
infectiousContacts		0..*	Base	Infectious contacts
timePeriod		0..1	dateTime	A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent		0..*	CodeableConcept	Infectious agent Binding Description: (preferred): ICD-10*, SNOMED CT
proximity[x]		0..1		Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept			CodeableConcept
proximityQuantity			Quantity
country		0..1	CodeableConcept	Country in which the person was potentially exposed to an infectious agent. Binding Description: (preferred): ISO 3166-1 alpha-2
additionalInformation		0..1	string	A textual note with additional information about infectious contact.
travelHistory		0..*	Base	Travel history reported by the patient. Multiple records could be provided.
timePeriod		0..1	dateTime	Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited		1..1	CodeableConcept	Country visited by the patient. Binding Description: (preferred): ISO 3166-1 alpha-2
comment		0..1	string	Relevant notes on the travel stay.
familyHistorySection		0..1	Base	Family history section
subsectionNarrative		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
subsectionNarrative		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
subsectionNarrative		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..*	Base	Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status		0..1	CodeableConcept	Status of the patient’s alcohol use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period		0..1	Period	Time period of alcohol use.
quantity		1..1	Quantity	Quantity (volume per time unit).
comment		0..1	string	Textual comment.
tobaccoUse		0..*	Base	Tobacco use
status		0..1	CodeableConcept	Status of the patient’s tobacco use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period		0..1	Period	Time period of tobacco usage.
quantity		1..1	Quantity	The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment		0..1	string	Textual comment.
drugConsumption		0..*	Base	Consumption of drugs and other substances (in terms of abuse).
status		0..1	CodeableConcept	The status of the patient’s drug consumption. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s drug use in units per time period.)
period		0..1	Period	Time period of drug use.
quantity		1..1	Quantity	The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType		0..1	CodeableConcept	Drug or medication type Binding Description: (preferred): SNOMED CT
routeOfAdministration		0..*	CodeableConcept	Route or routes of administration Binding Description: (preferred): EDQM
comment		0..1	string	Textual comment.
courseOfHospitalisation		1..1	Base	Course of hospital stay.
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. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription		0..1	string	Problem specification in narrative form.
problemDetails		0..*	EHDSConditionHdr	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
subsectionNarrative		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.
medicalDevicesAndImplantsSection		1..1	Base	Medical devices and implants section
subsectionNarrative		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
pharmacotherapySection		0..1	Base	Pharmacotherapy section
subsectionNarrative		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
subsectionNarrative		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
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
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.
sectionNarrative		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.
medicationDetails		0..*	EHDSMedicationStatement	Medication details
carePlanAndOtherRecommendationsAfterDischarge		0..*	Base	Care plan and other recommendations after discharge.
sectionNarrative		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.
carePlan		0..*	EHDSCarePlan	Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations		0..*	string	Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
EHDSHospitalDischargeReportBody.advanceDirectives.type	preferred
EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration	preferred

This structure is derived from Base

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
EHDSHospitalDischargeReportBody		0..*	Base	Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives		0..1	Base	Authored Advance Directive Information
livingWill		0..*	Base	Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime		1..1	dateTime	The date and time on which the living will was recorded.
type		1..1	CodeableConcept	Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description: (preferred): SNOMED CT
comment		0..1	string	Comment on the living will.
relatedConditions		0..*	CodeableConcept	The problem or disorder to which the living will applies. Binding Description: (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument		1..*	EHDSAttachment	Living will document
alertsSection		0..1	Base	Alerts section
sectionNarrative		0..1	string	Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
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 hospital stay).
medicalAlerts		0..*	EHDSAlertFlag	Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection		1..1	Base	Encounter information section.
sectionNarrative		1..1	string	Narrative content of the section.
encounterInformationSection		0..1	EHDSEncounter	Encounter information section. Hospital encounter details.
admissionEvaluation		0..1	Base	Admission evaluation section
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
patientHistory		0..1	Base	Patient health history section (anamnesis).
sectionNarrative		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.
subsectionNarrative		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..*	EHDSImmunization	Vaccination
epidemiologicalHistory		0..1	Base	Epidemiological history
infectiousContacts		0..*	Base	Infectious contacts
timePeriod		0..1	dateTime	A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent		0..*	CodeableConcept	Infectious agent Binding Description: (preferred): ICD-10*, SNOMED CT
proximity[x]		0..1		Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept			CodeableConcept
proximityQuantity			Quantity
country		0..1	CodeableConcept	Country in which the person was potentially exposed to an infectious agent. Binding Description: (preferred): ISO 3166-1 alpha-2
additionalInformation		0..1	string	A textual note with additional information about infectious contact.
travelHistory		0..*	Base	Travel history reported by the patient. Multiple records could be provided.
timePeriod		0..1	dateTime	Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited		1..1	CodeableConcept	Country visited by the patient. Binding Description: (preferred): ISO 3166-1 alpha-2
comment		0..1	string	Relevant notes on the travel stay.
familyHistorySection		0..1	Base	Family history section
subsectionNarrative		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
subsectionNarrative		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
subsectionNarrative		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..*	Base	Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status		0..1	CodeableConcept	Status of the patient’s alcohol use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period		0..1	Period	Time period of alcohol use.
quantity		1..1	Quantity	Quantity (volume per time unit).
comment		0..1	string	Textual comment.
tobaccoUse		0..*	Base	Tobacco use
status		0..1	CodeableConcept	Status of the patient’s tobacco use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period		0..1	Period	Time period of tobacco usage.
quantity		1..1	Quantity	The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment		0..1	string	Textual comment.
drugConsumption		0..*	Base	Consumption of drugs and other substances (in terms of abuse).
status		0..1	CodeableConcept	The status of the patient’s drug consumption. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s drug use in units per time period.)
period		0..1	Period	Time period of drug use.
quantity		1..1	Quantity	The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType		0..1	CodeableConcept	Drug or medication type Binding Description: (preferred): SNOMED CT
routeOfAdministration		0..*	CodeableConcept	Route or routes of administration Binding Description: (preferred): EDQM
comment		0..1	string	Textual comment.
courseOfHospitalisation		1..1	Base	Course of hospital stay.
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. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription		0..1	string	Problem specification in narrative form.
problemDetails		0..*	EHDSConditionHdr	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
subsectionNarrative		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.
medicalDevicesAndImplantsSection		1..1	Base	Medical devices and implants section
subsectionNarrative		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
pharmacotherapySection		0..1	Base	Pharmacotherapy section
subsectionNarrative		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
subsectionNarrative		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
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
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.
sectionNarrative		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.
medicationDetails		0..*	EHDSMedicationStatement	Medication details
carePlanAndOtherRecommendationsAfterDischarge		0..*	Base	Care plan and other recommendations after discharge.
sectionNarrative		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.
carePlan		0..*	EHDSCarePlan	Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations		0..*	string	Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
EHDSHospitalDischargeReportBody.advanceDirectives.type	preferred
EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration	preferred

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
EHDSHospitalDischargeReportBody		0..*	Base	Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives		0..1	Base	Authored Advance Directive Information
livingWill		0..*	Base	Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime		1..1	dateTime	The date and time on which the living will was recorded.
type		1..1	CodeableConcept	Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description: (preferred): SNOMED CT
comment		0..1	string	Comment on the living will.
relatedConditions		0..*	CodeableConcept	The problem or disorder to which the living will applies. Binding Description: (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument		1..*	EHDSAttachment	Living will document
alertsSection		0..1	Base	Alerts section
sectionNarrative		0..1	string	Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
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 hospital stay).
medicalAlerts		0..*	EHDSAlertFlag	Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection		1..1	Base	Encounter information section.
sectionNarrative		1..1	string	Narrative content of the section.
encounterInformationSection		0..1	EHDSEncounter	Encounter information section. Hospital encounter details.
admissionEvaluation		0..1	Base	Admission evaluation section
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
patientHistory		0..1	Base	Patient health history section (anamnesis).
sectionNarrative		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.
subsectionNarrative		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..*	EHDSImmunization	Vaccination
epidemiologicalHistory		0..1	Base	Epidemiological history
infectiousContacts		0..*	Base	Infectious contacts
timePeriod		0..1	dateTime	A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent		0..*	CodeableConcept	Infectious agent Binding Description: (preferred): ICD-10*, SNOMED CT
proximity[x]		0..1		Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept			CodeableConcept
proximityQuantity			Quantity
country		0..1	CodeableConcept	Country in which the person was potentially exposed to an infectious agent. Binding Description: (preferred): ISO 3166-1 alpha-2
additionalInformation		0..1	string	A textual note with additional information about infectious contact.
travelHistory		0..*	Base	Travel history reported by the patient. Multiple records could be provided.
timePeriod		0..1	dateTime	Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited		1..1	CodeableConcept	Country visited by the patient. Binding Description: (preferred): ISO 3166-1 alpha-2
comment		0..1	string	Relevant notes on the travel stay.
familyHistorySection		0..1	Base	Family history section
subsectionNarrative		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
subsectionNarrative		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
subsectionNarrative		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..*	Base	Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status		0..1	CodeableConcept	Status of the patient’s alcohol use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period		0..1	Period	Time period of alcohol use.
quantity		1..1	Quantity	Quantity (volume per time unit).
comment		0..1	string	Textual comment.
tobaccoUse		0..*	Base	Tobacco use
status		0..1	CodeableConcept	Status of the patient’s tobacco use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period		0..1	Period	Time period of tobacco usage.
quantity		1..1	Quantity	The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment		0..1	string	Textual comment.
drugConsumption		0..*	Base	Consumption of drugs and other substances (in terms of abuse).
status		0..1	CodeableConcept	The status of the patient’s drug consumption. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s drug use in units per time period.)
period		0..1	Period	Time period of drug use.
quantity		1..1	Quantity	The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType		0..1	CodeableConcept	Drug or medication type Binding Description: (preferred): SNOMED CT
routeOfAdministration		0..*	CodeableConcept	Route or routes of administration Binding Description: (preferred): EDQM
comment		0..1	string	Textual comment.
courseOfHospitalisation		1..1	Base	Course of hospital stay.
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. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription		0..1	string	Problem specification in narrative form.
problemDetails		0..*	EHDSConditionHdr	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
subsectionNarrative		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.
medicalDevicesAndImplantsSection		1..1	Base	Medical devices and implants section
subsectionNarrative		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
pharmacotherapySection		0..1	Base	Pharmacotherapy section
subsectionNarrative		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
subsectionNarrative		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
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
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.
sectionNarrative		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.
medicationDetails		0..*	EHDSMedicationStatement	Medication details
carePlanAndOtherRecommendationsAfterDischarge		0..*	Base	Care plan and other recommendations after discharge.
sectionNarrative		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.
carePlan		0..*	EHDSCarePlan	Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations		0..*	string	Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
EHDSHospitalDischargeReportBody.advanceDirectives.type	preferred
EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration	preferred

This structure is derived from Base

Summary

Mandatory: 0 element(19 nested mandatory elements)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
EHDSHospitalDischargeReportBody		0..*	Base	Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives		0..1	Base	Authored Advance Directive Information
livingWill		0..*	Base	Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime		1..1	dateTime	The date and time on which the living will was recorded.
type		1..1	CodeableConcept	Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description: (preferred): SNOMED CT
comment		0..1	string	Comment on the living will.
relatedConditions		0..*	CodeableConcept	The problem or disorder to which the living will applies. Binding Description: (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument		1..*	EHDSAttachment	Living will document
alertsSection		0..1	Base	Alerts section
sectionNarrative		0..1	string	Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
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 hospital stay).
medicalAlerts		0..*	EHDSAlertFlag	Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection		1..1	Base	Encounter information section.
sectionNarrative		1..1	string	Narrative content of the section.
encounterInformationSection		0..1	EHDSEncounter	Encounter information section. Hospital encounter details.
admissionEvaluation		0..1	Base	Admission evaluation section
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
patientHistory		0..1	Base	Patient health history section (anamnesis).
sectionNarrative		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.
subsectionNarrative		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..*	EHDSImmunization	Vaccination
epidemiologicalHistory		0..1	Base	Epidemiological history
infectiousContacts		0..*	Base	Infectious contacts
timePeriod		0..1	dateTime	A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent		0..*	CodeableConcept	Infectious agent Binding Description: (preferred): ICD-10*, SNOMED CT
proximity[x]		0..1		Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept			CodeableConcept
proximityQuantity			Quantity
country		0..1	CodeableConcept	Country in which the person was potentially exposed to an infectious agent. Binding Description: (preferred): ISO 3166-1 alpha-2
additionalInformation		0..1	string	A textual note with additional information about infectious contact.
travelHistory		0..*	Base	Travel history reported by the patient. Multiple records could be provided.
timePeriod		0..1	dateTime	Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited		1..1	CodeableConcept	Country visited by the patient. Binding Description: (preferred): ISO 3166-1 alpha-2
comment		0..1	string	Relevant notes on the travel stay.
familyHistorySection		0..1	Base	Family history section
subsectionNarrative		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
subsectionNarrative		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
subsectionNarrative		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..*	Base	Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status		0..1	CodeableConcept	Status of the patient’s alcohol use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period		0..1	Period	Time period of alcohol use.
quantity		1..1	Quantity	Quantity (volume per time unit).
comment		0..1	string	Textual comment.
tobaccoUse		0..*	Base	Tobacco use
status		0..1	CodeableConcept	Status of the patient’s tobacco use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period		0..1	Period	Time period of tobacco usage.
quantity		1..1	Quantity	The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment		0..1	string	Textual comment.
drugConsumption		0..*	Base	Consumption of drugs and other substances (in terms of abuse).
status		0..1	CodeableConcept	The status of the patient’s drug consumption. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s drug use in units per time period.)
period		0..1	Period	Time period of drug use.
quantity		1..1	Quantity	The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType		0..1	CodeableConcept	Drug or medication type Binding Description: (preferred): SNOMED CT
routeOfAdministration		0..*	CodeableConcept	Route or routes of administration Binding Description: (preferred): EDQM
comment		0..1	string	Textual comment.
courseOfHospitalisation		1..1	Base	Course of hospital stay.
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. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription		0..1	string	Problem specification in narrative form.
problemDetails		0..*	EHDSConditionHdr	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
subsectionNarrative		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.
medicalDevicesAndImplantsSection		1..1	Base	Medical devices and implants section
subsectionNarrative		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
pharmacotherapySection		0..1	Base	Pharmacotherapy section
subsectionNarrative		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
subsectionNarrative		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
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
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.
sectionNarrative		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.
medicationDetails		0..*	EHDSMedicationStatement	Medication details
carePlanAndOtherRecommendationsAfterDischarge		0..*	Base	Care plan and other recommendations after discharge.
sectionNarrative		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.
carePlan		0..*	EHDSCarePlan	Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations		0..*	string	Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
EHDSHospitalDischargeReportBody.advanceDirectives.type	preferred
EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration	preferred

Differential View

This structure is derived from Base

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
EHDSHospitalDischargeReportBody		0..*	Base	Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives		0..1	Base	Authored Advance Directive Information
livingWill		0..*	Base	Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime		1..1	dateTime	The date and time on which the living will was recorded.
type		1..1	CodeableConcept	Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description: (preferred): SNOMED CT
comment		0..1	string	Comment on the living will.
relatedConditions		0..*	CodeableConcept	The problem or disorder to which the living will applies. Binding Description: (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument		1..*	EHDSAttachment	Living will document
alertsSection		0..1	Base	Alerts section
sectionNarrative		0..1	string	Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
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 hospital stay).
medicalAlerts		0..*	EHDSAlertFlag	Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection		1..1	Base	Encounter information section.
sectionNarrative		1..1	string	Narrative content of the section.
encounterInformationSection		0..1	EHDSEncounter	Encounter information section. Hospital encounter details.
admissionEvaluation		0..1	Base	Admission evaluation section
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
patientHistory		0..1	Base	Patient health history section (anamnesis).
sectionNarrative		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.
subsectionNarrative		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..*	EHDSImmunization	Vaccination
epidemiologicalHistory		0..1	Base	Epidemiological history
infectiousContacts		0..*	Base	Infectious contacts
timePeriod		0..1	dateTime	A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent		0..*	CodeableConcept	Infectious agent Binding Description: (preferred): ICD-10*, SNOMED CT
proximity[x]		0..1		Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept			CodeableConcept
proximityQuantity			Quantity
country		0..1	CodeableConcept	Country in which the person was potentially exposed to an infectious agent. Binding Description: (preferred): ISO 3166-1 alpha-2
additionalInformation		0..1	string	A textual note with additional information about infectious contact.
travelHistory		0..*	Base	Travel history reported by the patient. Multiple records could be provided.
timePeriod		0..1	dateTime	Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited		1..1	CodeableConcept	Country visited by the patient. Binding Description: (preferred): ISO 3166-1 alpha-2
comment		0..1	string	Relevant notes on the travel stay.
familyHistorySection		0..1	Base	Family history section
subsectionNarrative		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
subsectionNarrative		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
subsectionNarrative		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..*	Base	Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status		0..1	CodeableConcept	Status of the patient’s alcohol use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period		0..1	Period	Time period of alcohol use.
quantity		1..1	Quantity	Quantity (volume per time unit).
comment		0..1	string	Textual comment.
tobaccoUse		0..*	Base	Tobacco use
status		0..1	CodeableConcept	Status of the patient’s tobacco use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period		0..1	Period	Time period of tobacco usage.
quantity		1..1	Quantity	The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment		0..1	string	Textual comment.
drugConsumption		0..*	Base	Consumption of drugs and other substances (in terms of abuse).
status		0..1	CodeableConcept	The status of the patient’s drug consumption. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s drug use in units per time period.)
period		0..1	Period	Time period of drug use.
quantity		1..1	Quantity	The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType		0..1	CodeableConcept	Drug or medication type Binding Description: (preferred): SNOMED CT
routeOfAdministration		0..*	CodeableConcept	Route or routes of administration Binding Description: (preferred): EDQM
comment		0..1	string	Textual comment.
courseOfHospitalisation		1..1	Base	Course of hospital stay.
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. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription		0..1	string	Problem specification in narrative form.
problemDetails		0..*	EHDSConditionHdr	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
subsectionNarrative		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.
medicalDevicesAndImplantsSection		1..1	Base	Medical devices and implants section
subsectionNarrative		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
pharmacotherapySection		0..1	Base	Pharmacotherapy section
subsectionNarrative		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
subsectionNarrative		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
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
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.
sectionNarrative		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.
medicationDetails		0..*	EHDSMedicationStatement	Medication details
carePlanAndOtherRecommendationsAfterDischarge		0..*	Base	Care plan and other recommendations after discharge.
sectionNarrative		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.
carePlan		0..*	EHDSCarePlan	Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations		0..*	string	Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
EHDSHospitalDischargeReportBody.advanceDirectives.type	preferred
EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration	preferred

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
EHDSHospitalDischargeReportBody		0..*	Base	Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives		0..1	Base	Authored Advance Directive Information
livingWill		0..*	Base	Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime		1..1	dateTime	The date and time on which the living will was recorded.
type		1..1	CodeableConcept	Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description: (preferred): SNOMED CT
comment		0..1	string	Comment on the living will.
relatedConditions		0..*	CodeableConcept	The problem or disorder to which the living will applies. Binding Description: (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument		1..*	EHDSAttachment	Living will document
alertsSection		0..1	Base	Alerts section
sectionNarrative		0..1	string	Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
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 hospital stay).
medicalAlerts		0..*	EHDSAlertFlag	Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection		1..1	Base	Encounter information section.
sectionNarrative		1..1	string	Narrative content of the section.
encounterInformationSection		0..1	EHDSEncounter	Encounter information section. Hospital encounter details.
admissionEvaluation		0..1	Base	Admission evaluation section
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
patientHistory		0..1	Base	Patient health history section (anamnesis).
sectionNarrative		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.
subsectionNarrative		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..*	EHDSImmunization	Vaccination
epidemiologicalHistory		0..1	Base	Epidemiological history
infectiousContacts		0..*	Base	Infectious contacts
timePeriod		0..1	dateTime	A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent		0..*	CodeableConcept	Infectious agent Binding Description: (preferred): ICD-10*, SNOMED CT
proximity[x]		0..1		Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept			CodeableConcept
proximityQuantity			Quantity
country		0..1	CodeableConcept	Country in which the person was potentially exposed to an infectious agent. Binding Description: (preferred): ISO 3166-1 alpha-2
additionalInformation		0..1	string	A textual note with additional information about infectious contact.
travelHistory		0..*	Base	Travel history reported by the patient. Multiple records could be provided.
timePeriod		0..1	dateTime	Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited		1..1	CodeableConcept	Country visited by the patient. Binding Description: (preferred): ISO 3166-1 alpha-2
comment		0..1	string	Relevant notes on the travel stay.
familyHistorySection		0..1	Base	Family history section
subsectionNarrative		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
subsectionNarrative		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
subsectionNarrative		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..*	Base	Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status		0..1	CodeableConcept	Status of the patient’s alcohol use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period		0..1	Period	Time period of alcohol use.
quantity		1..1	Quantity	Quantity (volume per time unit).
comment		0..1	string	Textual comment.
tobaccoUse		0..*	Base	Tobacco use
status		0..1	CodeableConcept	Status of the patient’s tobacco use. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period		0..1	Period	Time period of tobacco usage.
quantity		1..1	Quantity	The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment		0..1	string	Textual comment.
drugConsumption		0..*	Base	Consumption of drugs and other substances (in terms of abuse).
status		0..1	CodeableConcept	The status of the patient’s drug consumption. Binding Description: (preferred): SNOMED CT
periodAndQuantity		0..1	Base	Period of use and amount (The extent of the patient’s drug use in units per time period.)
period		0..1	Period	Time period of drug use.
quantity		1..1	Quantity	The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType		0..1	CodeableConcept	Drug or medication type Binding Description: (preferred): SNOMED CT
routeOfAdministration		0..*	CodeableConcept	Route or routes of administration Binding Description: (preferred): EDQM
comment		0..1	string	Textual comment.
courseOfHospitalisation		1..1	Base	Course of hospital stay.
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. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription		0..1	string	Problem specification in narrative form.
problemDetails		0..*	EHDSConditionHdr	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
subsectionNarrative		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.
medicalDevicesAndImplantsSection		1..1	Base	Medical devices and implants section
subsectionNarrative		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
pharmacotherapySection		0..1	Base	Pharmacotherapy section
subsectionNarrative		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
subsectionNarrative		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
sectionNarrative		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
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		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.
anthropometricObservations		0..*	EHDSObservation	Anthropometric observations
vitalSigns		0..*	EHDSObservation	Vital signs
physicalExamination		0..*	EHDSObservation	Physical examination
functionalStatus		0..1	Base	Functional status
dateAndTime		0..1	dateTime	Date and time of the examination
performer		0..*	EHDSHealthProfessional	Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative		0..1	string	Narrative content of the section.
functionalStatusAssessment		0..*	EHDSFunctionalStatus	Functional status assessment
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.
sectionNarrative		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.
medicationDetails		0..*	EHDSMedicationStatement	Medication details
carePlanAndOtherRecommendationsAfterDischarge		0..*	Base	Care plan and other recommendations after discharge.
sectionNarrative		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.
carePlan		0..*	EHDSCarePlan	Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations		0..*	string	Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
EHDSHospitalDischargeReportBody.advanceDirectives.type	preferred
EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country	preferred
EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus	preferred
EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType	preferred
EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration	preferred

This structure is derived from Base

Summary

Mandatory: 0 element(19 nested mandatory elements)