A.1 - EHDS refined base model for Hospital Discharge Report header data elements

Patient/subject information

Patient/subject guardian and related person information

Preferred health professional (HP) - This section can be repeated and linked to any specific information in the document, for example a link between a rare disease problem and the rare disease specialist responsible for the care of the individual patient (this section).

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Information about author or authors of the document

Author by whom the document was/were authored. Multiple authors could be provided.

Date and time of the last modification of the document by its Author.

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Data relevant to document type and its content for administrative and searching purposes.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the document/report. E.g., preliminary, final.

hl7:CompositionStatus, hl7:DiagnosticReportStatus

Documented period service. Typically used for searching purposes.

Date and time of the report creation.

Document title, such as "Hospital discharge report", "Laboratory Result Report" etc..

Categorization of an "event" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

BCP 47

Version of the document

To provide links between specified data elements and external knowledge resources

A reference leading to Clinical Practice Guidelines (CPG), emergency and anesthesia guidelines or other clinical relevant guidelines. This should be used only for providing specific guidance which may not be readily available to the health professional caring for the patient.

Identify the entry or entries of this document or document part for which this additional information relates with, for example a link between a rare disease problem and guidelines for that particular rare disease (this section).

A.1 - EHDS refined base model for Hospital Discharge Report header data elements

Patient/subject information

Patient/subject guardian and related person information

Preferred health professional (HP) - This section can be repeated and linked to any specific information in the document, for example a link between a rare disease problem and the rare disease specialist responsible for the care of the individual patient (this section).

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Information about author or authors of the document

Author by whom the document was/were authored. Multiple authors could be provided.

Date and time of the last modification of the document by its Author.

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Data relevant to document type and its content for administrative and searching purposes.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the document/report. E.g., preliminary, final.

hl7:CompositionStatus, hl7:DiagnosticReportStatus

Documented period service. Typically used for searching purposes.

Date and time of the report creation.

Document title, such as "Hospital discharge report", "Laboratory Result Report" etc..

Categorization of an "event" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

BCP 47

Version of the document

To provide links between specified data elements and external knowledge resources

A reference leading to Clinical Practice Guidelines (CPG), emergency and anesthesia guidelines or other clinical relevant guidelines. This should be used only for providing specific guidance which may not be readily available to the health professional caring for the patient.

Identify the entry or entries of this document or document part for which this additional information relates with, for example a link between a rare disease problem and guidelines for that particular rare disease (this section).

A.1 - EHDS refined base model for Hospital Discharge Report header data elements

Patient/subject information

Patient/subject guardian and related person information

Preferred health professional (HP) - This section can be repeated and linked to any specific information in the document, for example a link between a rare disease problem and the rare disease specialist responsible for the care of the individual patient (this section).

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Information about author or authors of the document

Author by whom the document was/were authored. Multiple authors could be provided.

Date and time of the last modification of the document by its Author.

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Data relevant to document type and its content for administrative and searching purposes.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the document/report. E.g., preliminary, final.

hl7:CompositionStatus, hl7:DiagnosticReportStatus

Documented period service. Typically used for searching purposes.

Date and time of the report creation.

Document title, such as "Hospital discharge report", "Laboratory Result Report" etc..

Categorization of an "event" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

BCP 47

Version of the document

To provide links between specified data elements and external knowledge resources

A reference leading to Clinical Practice Guidelines (CPG), emergency and anesthesia guidelines or other clinical relevant guidelines. This should be used only for providing specific guidance which may not be readily available to the health professional caring for the patient.

Identify the entry or entries of this document or document part for which this additional information relates with, for example a link between a rare disease problem and guidelines for that particular rare disease (this section).