Generated Narrative: StructureDefinition EHDSHospitalDischargeReportBody Name Flags Card. Type Description & Constraints 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 (No ValueSet): (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 (No ValueSet): (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. <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.anthropometricObservations" title="Observation of Body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness. Result of the observation includes text, numeric and coded results of the measurement including measurement units.">anthropometricObservations 0..* EHDSObservation Anthropometric observations vitalSigns 0..* EHDSObservation Vital signs <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.physicalExamination" title="Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.">physicalExamination 0..* EHDSObservation Physical examination <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus" title="Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/">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. <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.pastProblems" title="A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report. ">pastProblems 1..* EHDSCondition Past problems devicesAndImplants 1..* EHDSDeviceUse Devices and Implants <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.historyOfProcedures" title="Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.">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 (No ValueSet): (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 (No ValueSet): (preferred): ISO 3166-1 alpha-2 additionalInformation 0..1 string A textual note with additional information about infectious contact. travelHistory 0..1 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 (No ValueSet): (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 <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation" title="Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.">workSituation 0..1 CodeableConcept Work situation Binding Description (No ValueSet): (preferred): SNOMED CT hobby 0..1 CodeableConcept An activity the patient enjoys doing in their free time. Binding Description (No ValueSet): (preferred): SNOMED CT socialNetwork 0..1 CodeableConcept Social network Binding Description (No ValueSet): (preferred): SNOMED CT educationSection 0..1 Base Education section educationLevel 0..1 CodeableConcept Education level Binding Description (No ValueSet): (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 (No ValueSet): (preferred): SNOMED CT <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption" title="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.">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 (No ValueSet): (preferred): SNOMED CT livingConditions 0..* CodeableConcept Living conditions that affect the accessibility of the home or the stay in the home. Binding Description (No ValueSet): (preferred): SNOMED CT familySituation 0..1 Base Family situation comment 0..1 string Comment on the family situation. familyComposition 0..1 CodeableConcept Family composition maritalStatus 0..1 CodeableConcept Person’s marital status according to the terms and definition in the national civil code. 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 (No ValueSet): (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 (No ValueSet): (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 (No ValueSet): (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 (No ValueSet): (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 (No ValueSet): (preferred): SNOMED CT routeOfAdministration 0..* CodeableConcept Route or routes of administration Binding Description (No ValueSet): (preferred): EDQM comment 0..1 string Textual comment. courseOfHospitalisation 1..1 Base Course of hospital stay. <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary" title="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.">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. <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures" title="Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other "instrumental" interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.">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. <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection" title="Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system">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 <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection" title="Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.Medicinal products, the administration of which was started during hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.">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. <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults" title="Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.">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 <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis" title="This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.">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. <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.anthropometricObservations" title="Observation of Body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness. Result of the observation includes text, numeric and coded results of the measurement including measurement units.">anthropometricObservations 0..* EHDSObservation Anthropometric observations vitalSigns 0..* EHDSObservation Vital signs <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.physicalExamination" title="Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.">physicalExamination 0..* EHDSObservation Physical examination <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus" title="Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/">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 <a href="StructureDefinition-EHDSHospitalDischargeReportBody-definitions.html#EHDSHospitalDischargeReportBody.medicationSummary" title="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.">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
EHDS refined base model for Hospital Discharge Report body
Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
The date and time on which the living will was recorded.
Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc.
The problem or disorder to which the living will applies.
ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
Scanned source document with the living will and the patient's signature, such as a PDF.
Alert section includes information about allergies, intolerances and other substantial alerts or warnings that health professionals should be aware of.
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.
Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
Encounter information section. Hospital encounter details.
Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
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.
Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Observation of Body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness. Result of the observation includes text, numeric and coded results of the measurement including measurement units.
Vital signs observation:•Required: Pulse rate, respiratory rate, systolic and diastolic blood preasure with site information•Optional: 02 saturation
Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Formalized assessment of the patient's functional status according to the individual assessment categories of the selected assessment system (e.g. WHO-ICF)
Patient health history section (anamnesis).
Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
A date and duration or date time interval of contact. Partial dates are allowed.
Information about a suspected infectious agent or agents the person was exposed to.
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.
Country in which the person was potentially exposed to an infectious agent.
A textual note with additional information about infectious contact.
Travel history reported by the patient. Multiple records could be provided.
Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Information about social determinants of health.
Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
An activity the patient enjoys doing in their free time.
A description of the patient’s social network, such as family, neighbours and friends.
Information about patient education level.
Indication of the highest level of education achieved.
If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Living situation - household type and other related living situation information.
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.
Living conditions that affect the accessibility of the home or the stay in the home.
The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Person’s marital status according to the terms and definition in the national civil code.
The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Number of children living at home with the patient.
Child details (age, co-living status and comment).
Living at home. An indication stating whether the child lives at home.
A comment on the child's family situation.
Care responsibility. The activities the patient carries out to care for a dependent family member.
Information about use and/or abuse of specific substances.
Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
Consumption of drugs and other substances (in terms of abuse).
The status of the patient’s drug consumption.
Period of use and amount (The extent of the patient’s drug use in units per time period.)
The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
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.
Problem specification in narrative form.
Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other "instrumental" interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.
Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.Medicinal products, the administration of which was started during hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.
Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
Structured significant observation entry.
This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.
Summary description of the reason and course of hospitalisation for a specific problem.
The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Structured information should be provided, however if not available, at least a section narrative should be present.
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.
Care plan and other recommendations after discharge.
Care plan and other recommendations after discharge section.
Structured care plan after discharge. Multiple care plans could be provided.
Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.