EHDS Logical Information Models
0.1.0 - ci-build

EHDS Logical Information Models, published by Xt-EHR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Xt-EHR/xt-ehr-common/tree/stakeholder-consultation-D6-2 and changes regularly. See the Directory of published versions

## Logical Model: EHDSHospitalDischargeReportBody - Detailed Descriptions

Draft as of 2025-05-26

Definitions for the EHDSHospitalDischargeReportBody logical model.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be found here

0. EHDSHospitalDischargeReportBody
Definition | EHDS refined base model for Hospital Discharge Report body Base definition for all types defined in FHIR type system.
Short | Hospital Discharge Report body modelBase for all types and resources
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSHospitalDischargeReportBody.advanceDirectives
Definition | Authored Advance Directive Information
Short | Authored Advance Directive Information
Control | 0..1
Type | Base
4. EHDSHospitalDischargeReportBody.advanceDirectives.livingWill
Definition | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
Short | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
Control | 0..*
Type | Base
6. EHDSHospitalDischargeReportBody.advanceDirectives.dateAndTime
Definition | The date and time on which the living will was recorded.
Short | The date and time on which the living will was recorded.
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
8. EHDSHospitalDischargeReportBody.advanceDirectives.type
Definition | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc.
Short | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc.
Control | 1..1
Binding | SNOMED CT
Type | CodeableConcept
10. EHDSHospitalDischargeReportBody.advanceDirectives.comment
Definition | Comment on the living will.
Short | Comment on the living will.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions
Definition | The problem or disorder to which the living will applies.
Short | The problem or disorder to which the living will applies.
Control | 0..*
Binding | ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
Type | CodeableConcept
14. EHDSHospitalDischargeReportBody.advanceDirectives.livingWillDocument
Definition | Scanned source document with the living will and the patient's signature, such as a PDF.
Short | Living will document
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
16. EHDSHospitalDischargeReportBody.alertsSection
Definition | Alert section includes information about allergies, intolerances and other substantial alerts or warnings that health professionals should be aware of.
Short | Alerts section
Control | 0..1
Type | Base
18. EHDSHospitalDischargeReportBody.alertsSection.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSHospitalDischargeReportBody.alertsSection.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
22. EHDSHospitalDischargeReportBody.alertsSection.medicalAlerts
Definition | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
Short | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
24. EHDSHospitalDischargeReportBody.encounterInformationSection
Definition | Encounter information section.
Short | Encounter information section.
Control | 1..1
Type | Base
26. EHDSHospitalDischargeReportBody.encounterInformationSection.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
28. EHDSHospitalDischargeReportBody.encounterInformationSection.encounterInformationSection
Definition | Encounter information section. Hospital encounter details.
Short | Encounter information section. Hospital encounter details.
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter
30. EHDSHospitalDischargeReportBody.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Admission evaluation section
Control | 0..1
Type | Base
32. EHDSHospitalDischargeReportBody.admissionEvaluation.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
34. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
36. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
40. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
42. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | 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.
Short | Anthropometric observations
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
44. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observation:•Required: Pulse rate, respiratory rate, systolic and diastolic blood preasure with site information•Optional: 02 saturation
Short | Vital signs
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
46. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.physicalExamination
Definition | 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.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
48. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus
Definition | 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/
Short | Functional status
Control | 0..1
Type | Base
50. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
52. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
54. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
56. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.functionalStatusAssessment
Definition | Formalized assessment of the patient's functional status according to the individual assessment categories of the selected assessment system (e.g. WHO-ICF)
Short | Functional status assessment
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
58. EHDSHospitalDischargeReportBody.patientHistory
Definition | Patient health history section (anamnesis).
Short | Patient health history section (anamnesis).
Control | 0..1
Type | Base
60. EHDSHospitalDischargeReportBody.patientHistory.sectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
62. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
64. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.pastProblems
Definition | 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.
Short | Past problems
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
68. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
70. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.historyOfProcedures
Definition | 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.
Short | History of procedures
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
72. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.vaccination
Definition | Vaccination history of the patient.
Short | Vaccination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunization
74. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory
Definition | Travel history and infectious contacts
Short | Epidemiological history
Control | 0..1
Type | Base
76. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
Definition | Infectious contacts of the patient
Short | Infectious contacts
Control | 0..*
Type | Base
78. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.timePeriod
Definition | A date and duration or date time interval of contact. Partial dates are allowed.
Short | A date and duration or date time interval of contact. Partial dates are allowed.
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent
Definition | Information about a suspected infectious agent or agents the person was exposed to.
Short | Infectious agent
Control | 0..*
Binding | ICD-10*, SNOMED CT
Type | CodeableConcept
82. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.proximity[x]
Definition | 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.
Short | 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.
Control | 0..1
Type | Choice of: CodeableConcept, Quantity
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
84. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country
Definition | Country in which the person was potentially exposed to an infectious agent.
Short | Country in which the person was potentially exposed to an infectious agent.
Control | 0..1
Binding | ISO 3166-1 alpha-2
Type | CodeableConcept
86. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.additionalInformation
Definition | A textual note with additional information about infectious contact.
Short | A textual note with additional information about infectious contact.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
88. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
Definition | Travel history reported by the patient. Multiple records could be provided.
Short | Travel history reported by the patient. Multiple records could be provided.
Control | 0..1
Type | Base
90. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.timePeriod
Definition | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Short | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
92. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited
Definition | Country visited by the patient.
Short | Country visited by the patient.
Control | 1..1
Binding | ISO 3166-1 alpha-2
Type | CodeableConcept
94. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.comment
Definition | Relevant notes on the travel stay.
Short | Relevant notes on the travel stay.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
98. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFamilyMemberHistory
102. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
104. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
108. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | 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.
Short | Work situation
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
110. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
112. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient’s social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
114. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
116. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
118. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
120. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
122. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
124. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | 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.
Short | 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.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
126. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
128. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
130. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
132. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Type | CodeableConcept
134. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person’s marital status according to the terms and definition in the national civil code.
Short | Person’s marital status according to the terms and definition in the national civil code.
Control | 0..1
Type | CodeableConcept
136. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
138. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
140. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
142. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
144. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child’s date of birth.
Short | Child’s date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
146. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
148. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
150. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
152. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
154. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | Base
156. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status
Definition | Status of the patient’s alcohol use.
Short | Status of the patient’s alcohol use.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
158. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity
Definition | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
Short | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
Control | 0..1
Type | Base
160. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity.period
Definition | Time period of alcohol use.
Short | Time period of alcohol use.
Control | 0..1
Type | Period
162. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity.quantity
Definition | Quantity (volume per time unit).
Short | Quantity (volume per time unit).
Control | 1..1
Type | Quantity
164. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
166. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | Base
168. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status
Definition | Status of the patient’s tobacco use.
Short | Status of the patient’s tobacco use.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
170. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity
Definition | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
Short | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
Control | 0..1
Type | Base
172. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity.period
Definition | Time period of tobacco usage.
Short | Time period of tobacco usage.
Control | 0..1
Type | Period
174. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity.quantity
Definition | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
Short | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
Control | 1..1
Type | Quantity
176. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
178. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | Base
180. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status
Definition | The status of the patient’s drug consumption.
Short | The status of the patient’s drug consumption.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
182. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity
Definition | Period of use and amount (The extent of the patient’s drug use in units per time period.)
Short | Period of use and amount (The extent of the patient’s drug use in units per time period.)
Control | 0..1
Type | Base
184. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.period
Definition | Time period of drug use.
Short | Time period of drug use.
Control | 0..1
Type | Period
186. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.quantity
Definition | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
Short | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
Control | 1..1
Type | Quantity
188. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType
Definition | Drug or medication type
Short | Drug or medication type
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
190. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration
Definition | Route or routes of administration
Short | Route or routes of administration
Control | 0..*
Binding | EDQM
Type | CodeableConcept
192. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
194. EHDSHospitalDischargeReportBody.courseOfHospitalisation
Definition | Course of hospital stay.
Short | Course of hospital stay.
Control | 1..1
Type | Base
196. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary
Definition | 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.
Short | 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.
Control | 1..1
Type | Base
198. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary.problemDescription
Definition | Problem specification in narrative form.
Short | Problem specification in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
200. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary.problemDetails
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSConditionHdr
202. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures
Definition | 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.
Short | Significant procedures section
Control | 0..1
Type | Base
204. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
206. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
208. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection
Definition | 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
Short | Medical devices and implants section
Control | 1..1
Type | Base
210. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
212. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
214. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection
Definition | 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.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
216. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
218. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
220. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults
Definition | 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.
Short | Significant Observation Results
Control | 0..1
Type | Base
222. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
224. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
226. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis
Definition | 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.
Short | Synthesis
Control | 1..1
Type | Base
228. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
230. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
232. EHDSHospitalDischargeReportBody.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
234. EHDSHospitalDischargeReportBody.dischargeDetails.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
236. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
238. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
240. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
242. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
244. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | 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.
Short | Anthropometric observations
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
246. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observation:•Required: Pulse rate, respiratory rate, systolic and diastolic blood preasure with site information•Optional: 02 saturation
Short | Vital signs
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
248. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.physicalExamination
Definition | 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.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
250. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus
Definition | 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/
Short | Functional status
Control | 0..1
Type | Base
252. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
254. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
256. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
258. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.functionalStatusAssessment
Definition | Formalized assessment of the patient's functional status according to the individual assessment categories of the selected assessment system (e.g. WHO-ICF)
Short | Functional status assessment
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
260. EHDSHospitalDischargeReportBody.medicationSummary
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
262. EHDSHospitalDischargeReportBody.medicationSummary.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
264. EHDSHospitalDischargeReportBody.medicationSummary.medicationDetails
Definition | Structured medication entry.
Short | Medication details
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
266. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
268. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
270. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan
272. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be found here

0. EHDSHospitalDischargeReportBody
Definition | EHDS refined base model for Hospital Discharge Report body
Short | Hospital Discharge Report body model
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSHospitalDischargeReportBody.advanceDirectives
Definition | Authored Advance Directive Information
Short | Authored Advance Directive Information
Control | 0..1
Type | Base
4. EHDSHospitalDischargeReportBody.advanceDirectives.livingWill
Definition | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
Short | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
Control | 0..*
Type | Base
6. EHDSHospitalDischargeReportBody.advanceDirectives.dateAndTime
Definition | The date and time on which the living will was recorded.
Short | The date and time on which the living will was recorded.
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
8. EHDSHospitalDischargeReportBody.advanceDirectives.type
Definition | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc.
Short | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc.
Control | 1..1
Binding | SNOMED CT
Type | CodeableConcept
10. EHDSHospitalDischargeReportBody.advanceDirectives.comment
Definition | Comment on the living will.
Short | Comment on the living will.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions
Definition | The problem or disorder to which the living will applies.
Short | The problem or disorder to which the living will applies.
Control | 0..*
Binding | ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
Type | CodeableConcept
14. EHDSHospitalDischargeReportBody.advanceDirectives.livingWillDocument
Definition | Scanned source document with the living will and the patient's signature, such as a PDF.
Short | Living will document
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
16. EHDSHospitalDischargeReportBody.alertsSection
Definition | Alert section includes information about allergies, intolerances and other substantial alerts or warnings that health professionals should be aware of.
Short | Alerts section
Control | 0..1
Type | Base
18. EHDSHospitalDischargeReportBody.alertsSection.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSHospitalDischargeReportBody.alertsSection.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
22. EHDSHospitalDischargeReportBody.alertsSection.medicalAlerts
Definition | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
Short | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
24. EHDSHospitalDischargeReportBody.encounterInformationSection
Definition | Encounter information section.
Short | Encounter information section.
Control | 1..1
Type | Base
26. EHDSHospitalDischargeReportBody.encounterInformationSection.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
28. EHDSHospitalDischargeReportBody.encounterInformationSection.encounterInformationSection
Definition | Encounter information section. Hospital encounter details.
Short | Encounter information section. Hospital encounter details.
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter
30. EHDSHospitalDischargeReportBody.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Admission evaluation section
Control | 0..1
Type | Base
32. EHDSHospitalDischargeReportBody.admissionEvaluation.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
34. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
36. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
40. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
42. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | 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.
Short | Anthropometric observations
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
44. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observation:•Required: Pulse rate, respiratory rate, systolic and diastolic blood preasure with site information•Optional: 02 saturation
Short | Vital signs
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
46. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.physicalExamination
Definition | 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.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
48. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus
Definition | 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/
Short | Functional status
Control | 0..1
Type | Base
50. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
52. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
54. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
56. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.functionalStatusAssessment
Definition | Formalized assessment of the patient's functional status according to the individual assessment categories of the selected assessment system (e.g. WHO-ICF)
Short | Functional status assessment
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
58. EHDSHospitalDischargeReportBody.patientHistory
Definition | Patient health history section (anamnesis).
Short | Patient health history section (anamnesis).
Control | 0..1
Type | Base
60. EHDSHospitalDischargeReportBody.patientHistory.sectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
62. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
64. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.pastProblems
Definition | 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.
Short | Past problems
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
68. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
70. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.historyOfProcedures
Definition | 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.
Short | History of procedures
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
72. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.vaccination
Definition | Vaccination history of the patient.
Short | Vaccination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunization
74. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory
Definition | Travel history and infectious contacts
Short | Epidemiological history
Control | 0..1
Type | Base
76. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
Definition | Infectious contacts of the patient
Short | Infectious contacts
Control | 0..*
Type | Base
78. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.timePeriod
Definition | A date and duration or date time interval of contact. Partial dates are allowed.
Short | A date and duration or date time interval of contact. Partial dates are allowed.
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent
Definition | Information about a suspected infectious agent or agents the person was exposed to.
Short | Infectious agent
Control | 0..*
Binding | ICD-10*, SNOMED CT
Type | CodeableConcept
82. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.proximity[x]
Definition | 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.
Short | 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.
Control | 0..1
Type | Choice of: CodeableConcept, Quantity
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
84. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country
Definition | Country in which the person was potentially exposed to an infectious agent.
Short | Country in which the person was potentially exposed to an infectious agent.
Control | 0..1
Binding | ISO 3166-1 alpha-2
Type | CodeableConcept
86. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.additionalInformation
Definition | A textual note with additional information about infectious contact.
Short | A textual note with additional information about infectious contact.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
88. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
Definition | Travel history reported by the patient. Multiple records could be provided.
Short | Travel history reported by the patient. Multiple records could be provided.
Control | 0..1
Type | Base
90. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.timePeriod
Definition | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Short | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
92. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited
Definition | Country visited by the patient.
Short | Country visited by the patient.
Control | 1..1
Binding | ISO 3166-1 alpha-2
Type | CodeableConcept
94. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.comment
Definition | Relevant notes on the travel stay.
Short | Relevant notes on the travel stay.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
98. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFamilyMemberHistory
102. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
104. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
108. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | 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.
Short | Work situation
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
110. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
112. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient’s social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
114. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
116. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
118. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
120. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
122. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
124. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | 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.
Short | 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.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
126. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
128. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
130. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
132. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Type | CodeableConcept
134. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person’s marital status according to the terms and definition in the national civil code.
Short | Person’s marital status according to the terms and definition in the national civil code.
Control | 0..1
Type | CodeableConcept
136. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
138. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
140. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
142. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
144. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child’s date of birth.
Short | Child’s date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
146. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
148. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
150. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
152. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
154. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | Base
156. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status
Definition | Status of the patient’s alcohol use.
Short | Status of the patient’s alcohol use.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
158. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity
Definition | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
Short | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
Control | 0..1
Type | Base
160. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity.period
Definition | Time period of alcohol use.
Short | Time period of alcohol use.
Control | 0..1
Type | Period
162. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity.quantity
Definition | Quantity (volume per time unit).
Short | Quantity (volume per time unit).
Control | 1..1
Type | Quantity
164. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
166. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | Base
168. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status
Definition | Status of the patient’s tobacco use.
Short | Status of the patient’s tobacco use.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
170. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity
Definition | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
Short | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
Control | 0..1
Type | Base
172. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity.period
Definition | Time period of tobacco usage.
Short | Time period of tobacco usage.
Control | 0..1
Type | Period
174. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity.quantity
Definition | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
Short | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
Control | 1..1
Type | Quantity
176. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
178. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | Base
180. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status
Definition | The status of the patient’s drug consumption.
Short | The status of the patient’s drug consumption.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
182. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity
Definition | Period of use and amount (The extent of the patient’s drug use in units per time period.)
Short | Period of use and amount (The extent of the patient’s drug use in units per time period.)
Control | 0..1
Type | Base
184. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.period
Definition | Time period of drug use.
Short | Time period of drug use.
Control | 0..1
Type | Period
186. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.quantity
Definition | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
Short | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
Control | 1..1
Type | Quantity
188. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType
Definition | Drug or medication type
Short | Drug or medication type
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
190. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration
Definition | Route or routes of administration
Short | Route or routes of administration
Control | 0..*
Binding | EDQM
Type | CodeableConcept
192. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
194. EHDSHospitalDischargeReportBody.courseOfHospitalisation
Definition | Course of hospital stay.
Short | Course of hospital stay.
Control | 1..1
Type | Base
196. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary
Definition | 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.
Short | 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.
Control | 1..1
Type | Base
198. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary.problemDescription
Definition | Problem specification in narrative form.
Short | Problem specification in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
200. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary.problemDetails
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSConditionHdr
202. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures
Definition | 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.
Short | Significant procedures section
Control | 0..1
Type | Base
204. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
206. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
208. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection
Definition | 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
Short | Medical devices and implants section
Control | 1..1
Type | Base
210. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
212. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
214. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection
Definition | 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.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
216. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
218. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
220. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults
Definition | 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.
Short | Significant Observation Results
Control | 0..1
Type | Base
222. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
224. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
226. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis
Definition | 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.
Short | Synthesis
Control | 1..1
Type | Base
228. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
230. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
232. EHDSHospitalDischargeReportBody.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
234. EHDSHospitalDischargeReportBody.dischargeDetails.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
236. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
238. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
240. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
242. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
244. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | 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.
Short | Anthropometric observations
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
246. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observation:•Required: Pulse rate, respiratory rate, systolic and diastolic blood preasure with site information•Optional: 02 saturation
Short | Vital signs
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
248. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.physicalExamination
Definition | 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.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
250. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus
Definition | 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/
Short | Functional status
Control | 0..1
Type | Base
252. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
254. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
256. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
258. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.functionalStatusAssessment
Definition | Formalized assessment of the patient's functional status according to the individual assessment categories of the selected assessment system (e.g. WHO-ICF)
Short | Functional status assessment
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
260. EHDSHospitalDischargeReportBody.medicationSummary
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
262. EHDSHospitalDischargeReportBody.medicationSummary.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
264. EHDSHospitalDischargeReportBody.medicationSummary.medicationDetails
Definition | Structured medication entry.
Short | Medication details
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
266. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
268. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
270. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan
272. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be found here

0. EHDSHospitalDischargeReportBody
Definition | EHDS refined base model for Hospital Discharge Report body
Short | Hospital Discharge Report body model
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSHospitalDischargeReportBody.advanceDirectives
Definition | Authored Advance Directive Information
Short | Authored Advance Directive Information
Control | 0..1
Type | Base
4. EHDSHospitalDischargeReportBody.advanceDirectives.livingWill
Definition | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
Short | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
Control | 0..*
Type | Base
6. EHDSHospitalDischargeReportBody.advanceDirectives.dateAndTime
Definition | The date and time on which the living will was recorded.
Short | The date and time on which the living will was recorded.
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
8. EHDSHospitalDischargeReportBody.advanceDirectives.type
Definition | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc.
Short | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc.
Control | 1..1
Binding | SNOMED CT
Type | CodeableConcept
10. EHDSHospitalDischargeReportBody.advanceDirectives.comment
Definition | Comment on the living will.
Short | Comment on the living will.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. EHDSHospitalDischargeReportBody.advanceDirectives.relatedConditions
Definition | The problem or disorder to which the living will applies.
Short | The problem or disorder to which the living will applies.
Control | 0..*
Binding | ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
Type | CodeableConcept
14. EHDSHospitalDischargeReportBody.advanceDirectives.livingWillDocument
Definition | Scanned source document with the living will and the patient's signature, such as a PDF.
Short | Living will document
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
16. EHDSHospitalDischargeReportBody.alertsSection
Definition | Alert section includes information about allergies, intolerances and other substantial alerts or warnings that health professionals should be aware of.
Short | Alerts section
Control | 0..1
Type | Base
18. EHDSHospitalDischargeReportBody.alertsSection.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSHospitalDischargeReportBody.alertsSection.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
22. EHDSHospitalDischargeReportBody.alertsSection.medicalAlerts
Definition | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
Short | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
24. EHDSHospitalDischargeReportBody.encounterInformationSection
Definition | Encounter information section.
Short | Encounter information section.
Control | 1..1
Type | Base
26. EHDSHospitalDischargeReportBody.encounterInformationSection.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
28. EHDSHospitalDischargeReportBody.encounterInformationSection.encounterInformationSection
Definition | Encounter information section. Hospital encounter details.
Short | Encounter information section. Hospital encounter details.
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter
30. EHDSHospitalDischargeReportBody.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Admission evaluation section
Control | 0..1
Type | Base
32. EHDSHospitalDischargeReportBody.admissionEvaluation.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
34. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
36. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
40. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
42. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | 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.
Short | Anthropometric observations
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
44. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observation:•Required: Pulse rate, respiratory rate, systolic and diastolic blood preasure with site information•Optional: 02 saturation
Short | Vital signs
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
46. EHDSHospitalDischargeReportBody.admissionEvaluation.objectiveFindings.physicalExamination
Definition | 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.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
48. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus
Definition | 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/
Short | Functional status
Control | 0..1
Type | Base
50. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
52. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
54. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
56. EHDSHospitalDischargeReportBody.admissionEvaluation.functionalStatus.functionalStatusAssessment
Definition | Formalized assessment of the patient's functional status according to the individual assessment categories of the selected assessment system (e.g. WHO-ICF)
Short | Functional status assessment
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
58. EHDSHospitalDischargeReportBody.patientHistory
Definition | Patient health history section (anamnesis).
Short | Patient health history section (anamnesis).
Control | 0..1
Type | Base
60. EHDSHospitalDischargeReportBody.patientHistory.sectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
62. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
64. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.pastProblems
Definition | 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.
Short | Past problems
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
68. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
70. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.historyOfProcedures
Definition | 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.
Short | History of procedures
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
72. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.vaccination
Definition | Vaccination history of the patient.
Short | Vaccination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunization
74. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory
Definition | Travel history and infectious contacts
Short | Epidemiological history
Control | 0..1
Type | Base
76. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
Definition | Infectious contacts of the patient
Short | Infectious contacts
Control | 0..*
Type | Base
78. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.timePeriod
Definition | A date and duration or date time interval of contact. Partial dates are allowed.
Short | A date and duration or date time interval of contact. Partial dates are allowed.
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.infectiousAgent
Definition | Information about a suspected infectious agent or agents the person was exposed to.
Short | Infectious agent
Control | 0..*
Binding | ICD-10*, SNOMED CT
Type | CodeableConcept
82. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.proximity[x]
Definition | 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.
Short | 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.
Control | 0..1
Type | Choice of: CodeableConcept, Quantity
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
84. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.country
Definition | Country in which the person was potentially exposed to an infectious agent.
Short | Country in which the person was potentially exposed to an infectious agent.
Control | 0..1
Binding | ISO 3166-1 alpha-2
Type | CodeableConcept
86. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts.additionalInformation
Definition | A textual note with additional information about infectious contact.
Short | A textual note with additional information about infectious contact.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
88. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
Definition | Travel history reported by the patient. Multiple records could be provided.
Short | Travel history reported by the patient. Multiple records could be provided.
Control | 0..1
Type | Base
90. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.timePeriod
Definition | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Short | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
92. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.countryVisited
Definition | Country visited by the patient.
Short | Country visited by the patient.
Control | 1..1
Binding | ISO 3166-1 alpha-2
Type | CodeableConcept
94. EHDSHospitalDischargeReportBody.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory.comment
Definition | Relevant notes on the travel stay.
Short | Relevant notes on the travel stay.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
98. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSHospitalDischargeReportBody.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFamilyMemberHistory
102. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
104. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
108. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | 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.
Short | Work situation
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
110. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
112. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient’s social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
114. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
116. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
118. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
120. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
122. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
124. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | 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.
Short | 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.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
126. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
128. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
130. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
132. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Type | CodeableConcept
134. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person’s marital status according to the terms and definition in the national civil code.
Short | Person’s marital status according to the terms and definition in the national civil code.
Control | 0..1
Type | CodeableConcept
136. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
138. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
140. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
142. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
144. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child’s date of birth.
Short | Child’s date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
146. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
148. EHDSHospitalDischargeReportBody.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
150. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
152. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
154. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | Base
156. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.status
Definition | Status of the patient’s alcohol use.
Short | Status of the patient’s alcohol use.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
158. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity
Definition | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
Short | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
Control | 0..1
Type | Base
160. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity.period
Definition | Time period of alcohol use.
Short | Time period of alcohol use.
Control | 0..1
Type | Period
162. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.periodAndQuantity.quantity
Definition | Quantity (volume per time unit).
Short | Quantity (volume per time unit).
Control | 1..1
Type | Quantity
164. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.alcoholUse.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
166. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | Base
168. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.status
Definition | Status of the patient’s tobacco use.
Short | Status of the patient’s tobacco use.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
170. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity
Definition | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
Short | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
Control | 0..1
Type | Base
172. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity.period
Definition | Time period of tobacco usage.
Short | Time period of tobacco usage.
Control | 0..1
Type | Period
174. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.periodAndQuantity.quantity
Definition | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
Short | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
Control | 1..1
Type | Quantity
176. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.tobaccoUse.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
178. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | Base
180. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.status
Definition | The status of the patient’s drug consumption.
Short | The status of the patient’s drug consumption.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
182. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity
Definition | Period of use and amount (The extent of the patient’s drug use in units per time period.)
Short | Period of use and amount (The extent of the patient’s drug use in units per time period.)
Control | 0..1
Type | Base
184. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.period
Definition | Time period of drug use.
Short | Time period of drug use.
Control | 0..1
Type | Period
186. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.quantity
Definition | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
Short | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
Control | 1..1
Type | Quantity
188. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.drugOrMedicationType
Definition | Drug or medication type
Short | Drug or medication type
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
190. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.periodAndQuantity.routeOfAdministration
Definition | Route or routes of administration
Short | Route or routes of administration
Control | 0..*
Binding | EDQM
Type | CodeableConcept
192. EHDSHospitalDischargeReportBody.patientHistory.useOfSubstances.drugConsumption.comment
Definition | Textual comment.
Short | Textual comment.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
194. EHDSHospitalDischargeReportBody.courseOfHospitalisation
Definition | Course of hospital stay.
Short | Course of hospital stay.
Control | 1..1
Type | Base
196. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary
Definition | 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.
Short | 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.
Control | 1..1
Type | Base
198. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary.problemDescription
Definition | Problem specification in narrative form.
Short | Problem specification in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
200. EHDSHospitalDischargeReportBody.courseOfHospitalisation.diagnosticSummary.problemDetails
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSConditionHdr
202. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures
Definition | 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.
Short | Significant procedures section
Control | 0..1
Type | Base
204. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
206. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
208. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection
Definition | 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
Short | Medical devices and implants section
Control | 1..1
Type | Base
210. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
212. EHDSHospitalDischargeReportBody.courseOfHospitalisation.medicalDevicesAndImplantsSection.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
214. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection
Definition | 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.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
216. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
218. EHDSHospitalDischargeReportBody.courseOfHospitalisation.pharmacotherapySection.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
220. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults
Definition | 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.
Short | Significant Observation Results
Control | 0..1
Type | Base
222. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults.subsectionNarrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
224. EHDSHospitalDischargeReportBody.courseOfHospitalisation.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
226. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis
Definition | 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.
Short | Synthesis
Control | 1..1
Type | Base
228. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
230. EHDSHospitalDischargeReportBody.courseOfHospitalisation.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
232. EHDSHospitalDischargeReportBody.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
234. EHDSHospitalDischargeReportBody.dischargeDetails.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
236. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
238. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
240. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
242. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
244. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | 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.
Short | Anthropometric observations
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
246. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observation:•Required: Pulse rate, respiratory rate, systolic and diastolic blood preasure with site information•Optional: 02 saturation
Short | Vital signs
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
248. EHDSHospitalDischargeReportBody.dischargeDetails.objectiveFindings.physicalExamination
Definition | 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.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
250. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus
Definition | 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/
Short | Functional status
Control | 0..1
Type | Base
252. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.dateAndTime
Definition | Date and time of the examination
Short | Date and time of the examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
254. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.performer
Definition | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Short | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
256. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.sectionNarrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
258. EHDSHospitalDischargeReportBody.dischargeDetails.functionalStatus.functionalStatusAssessment
Definition | Formalized assessment of the patient's functional status according to the individual assessment categories of the selected assessment system (e.g. WHO-ICF)
Short | Functional status assessment
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
260. EHDSHospitalDischargeReportBody.medicationSummary
Definition | 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.
Short | 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.
Control | 0..1
Type | Base
262. EHDSHospitalDischargeReportBody.medicationSummary.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
264. EHDSHospitalDischargeReportBody.medicationSummary.medicationDetails
Definition | Structured medication entry.
Short | Medication details
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
266. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
268. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.sectionNarrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
270. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan
272. EHDSHospitalDischargeReportBody.carePlanAndOtherRecommendationsAfterDischarge.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension