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: Hospital Discharge Report body model

Official URL: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHospitalDischargeReportBody | Version: 0.1.0
Draft as of 2025-05-26 | Computable Name: EHDSHospitalDischargeReportBody

EHDS refined base model for Hospital Discharge Report body

Usage:

- Use this Logical Model Profile: Hospital Discharge Report model

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
EHDSHospitalDischargeReportBody |  | 0..* | Base | Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives |  | 0..1 | Base | Authored Advance Directive Information
livingWill |  | 0..* | Base | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime |  | 1..1 | dateTime | The date and time on which the living will was recorded.
type |  | 1..1 | CodeableConcept | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description (No ValueSet): (preferred): SNOMED CT
comment |  | 0..1 | string | Comment on the living will.
relatedConditions |  | 0..* | CodeableConcept | The problem or disorder to which the living will applies. Binding Description (No ValueSet): (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument |  | 1..* | EHDSAttachment | Living will document
alertsSection |  | 0..1 | Base | Alerts section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
medicalAlerts |  | 0..* | EHDSAlertFlag | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection |  | 1..1 | Base | Encounter information section.
sectionNarrative |  | 1..1 | string | Narrative content of the section.
encounterInformationSection |  | 0..1 | EHDSEncounter | Encounter information section. Hospital encounter details.
admissionEvaluation |  | 0..1 | Base | Admission evaluation section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
patientHistory |  | 0..1 | Base | Patient health history section (anamnesis).
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunization | Vaccination
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | Base | Infectious contacts
timePeriod |  | 0..1 | dateTime | A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent |  | 0..* | CodeableConcept | Infectious agent Binding Description (No ValueSet): (preferred): ICD-10*, SNOMED CT
proximity[x] |  | 0..1 |  | Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept |  |  | CodeableConcept |
proximityQuantity |  |  | Quantity |
country |  | 0..1 | CodeableConcept | Country in which the person was potentially exposed to an infectious agent. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
additionalInformation |  | 0..1 | string | A textual note with additional information about infectious contact.
travelHistory |  | 0..1 | Base | Travel history reported by the patient. Multiple records could be provided.
timePeriod |  | 0..1 | dateTime | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited |  | 1..1 | CodeableConcept | Country visited by the patient. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
comment |  | 0..1 | string | Relevant notes on the travel stay.
familyHistorySection |  | 0..1 | Base | Family history section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
subsectionNarrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | CodeableConcept | Work situation Binding Description (No ValueSet): (preferred): SNOMED CT
hobby |  | 0..1 | CodeableConcept | An activity the patient enjoys doing in their free time. Binding Description (No ValueSet): (preferred): SNOMED CT
socialNetwork |  | 0..1 | CodeableConcept | Social network Binding Description (No ValueSet): (preferred): SNOMED CT
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description (No ValueSet): (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description (No ValueSet): (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description (No ValueSet): (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description (No ValueSet): (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code.
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description (No ValueSet): (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | Base | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status |  | 0..1 | CodeableConcept | Status of the patient’s alcohol use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period |  | 0..1 | Period | Time period of alcohol use.
quantity |  | 1..1 | Quantity | Quantity (volume per time unit).
comment |  | 0..1 | string | Textual comment.
tobaccoUse |  | 0..* | Base | Tobacco use
status |  | 0..1 | CodeableConcept | Status of the patient’s tobacco use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period |  | 0..1 | Period | Time period of tobacco usage.
quantity |  | 1..1 | Quantity | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment |  | 0..1 | string | Textual comment.
drugConsumption |  | 0..* | Base | Consumption of drugs and other substances (in terms of abuse).
status |  | 0..1 | CodeableConcept | The status of the patient’s drug consumption. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s drug use in units per time period.)
period |  | 0..1 | Period | Time period of drug use.
quantity |  | 1..1 | Quantity | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType |  | 0..1 | CodeableConcept | Drug or medication type Binding Description (No ValueSet): (preferred): SNOMED CT
routeOfAdministration |  | 0..* | CodeableConcept | Route or routes of administration Binding Description (No ValueSet): (preferred): EDQM
comment |  | 0..1 | string | Textual comment.
courseOfHospitalisation |  | 1..1 | Base | Course of hospital stay.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | EHDSConditionHdr | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplantsSection |  | 1..1 | Base | Medical devices and implants section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapySection |  | 0..1 | Base | Pharmacotherapy section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
medicationDetails |  | 0..* | EHDSMedicationStatement | Medication details
carePlanAndOtherRecommendationsAfterDischarge |  | 0..* | Base | Care plan and other recommendations after discharge.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..* | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

#### Terminology Bindings

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

This structure is derived from Base

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
EHDSHospitalDischargeReportBody |  | 0..* | Base | Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives |  | 0..1 | Base | Authored Advance Directive Information
livingWill |  | 0..* | Base | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime |  | 1..1 | dateTime | The date and time on which the living will was recorded.
type |  | 1..1 | CodeableConcept | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description (No ValueSet): (preferred): SNOMED CT
comment |  | 0..1 | string | Comment on the living will.
relatedConditions |  | 0..* | CodeableConcept | The problem or disorder to which the living will applies. Binding Description (No ValueSet): (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument |  | 1..* | EHDSAttachment | Living will document
alertsSection |  | 0..1 | Base | Alerts section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
medicalAlerts |  | 0..* | EHDSAlertFlag | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection |  | 1..1 | Base | Encounter information section.
sectionNarrative |  | 1..1 | string | Narrative content of the section.
encounterInformationSection |  | 0..1 | EHDSEncounter | Encounter information section. Hospital encounter details.
admissionEvaluation |  | 0..1 | Base | Admission evaluation section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
patientHistory |  | 0..1 | Base | Patient health history section (anamnesis).
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunization | Vaccination
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | Base | Infectious contacts
timePeriod |  | 0..1 | dateTime | A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent |  | 0..* | CodeableConcept | Infectious agent Binding Description (No ValueSet): (preferred): ICD-10*, SNOMED CT
proximity[x] |  | 0..1 |  | Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept |  |  | CodeableConcept |
proximityQuantity |  |  | Quantity |
country |  | 0..1 | CodeableConcept | Country in which the person was potentially exposed to an infectious agent. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
additionalInformation |  | 0..1 | string | A textual note with additional information about infectious contact.
travelHistory |  | 0..1 | Base | Travel history reported by the patient. Multiple records could be provided.
timePeriod |  | 0..1 | dateTime | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited |  | 1..1 | CodeableConcept | Country visited by the patient. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
comment |  | 0..1 | string | Relevant notes on the travel stay.
familyHistorySection |  | 0..1 | Base | Family history section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
subsectionNarrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | CodeableConcept | Work situation Binding Description (No ValueSet): (preferred): SNOMED CT
hobby |  | 0..1 | CodeableConcept | An activity the patient enjoys doing in their free time. Binding Description (No ValueSet): (preferred): SNOMED CT
socialNetwork |  | 0..1 | CodeableConcept | Social network Binding Description (No ValueSet): (preferred): SNOMED CT
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description (No ValueSet): (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description (No ValueSet): (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description (No ValueSet): (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description (No ValueSet): (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code.
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description (No ValueSet): (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | Base | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status |  | 0..1 | CodeableConcept | Status of the patient’s alcohol use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period |  | 0..1 | Period | Time period of alcohol use.
quantity |  | 1..1 | Quantity | Quantity (volume per time unit).
comment |  | 0..1 | string | Textual comment.
tobaccoUse |  | 0..* | Base | Tobacco use
status |  | 0..1 | CodeableConcept | Status of the patient’s tobacco use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period |  | 0..1 | Period | Time period of tobacco usage.
quantity |  | 1..1 | Quantity | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment |  | 0..1 | string | Textual comment.
drugConsumption |  | 0..* | Base | Consumption of drugs and other substances (in terms of abuse).
status |  | 0..1 | CodeableConcept | The status of the patient’s drug consumption. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s drug use in units per time period.)
period |  | 0..1 | Period | Time period of drug use.
quantity |  | 1..1 | Quantity | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType |  | 0..1 | CodeableConcept | Drug or medication type Binding Description (No ValueSet): (preferred): SNOMED CT
routeOfAdministration |  | 0..* | CodeableConcept | Route or routes of administration Binding Description (No ValueSet): (preferred): EDQM
comment |  | 0..1 | string | Textual comment.
courseOfHospitalisation |  | 1..1 | Base | Course of hospital stay.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | EHDSConditionHdr | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplantsSection |  | 1..1 | Base | Medical devices and implants section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapySection |  | 0..1 | Base | Pharmacotherapy section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
medicationDetails |  | 0..* | EHDSMedicationStatement | Medication details
carePlanAndOtherRecommendationsAfterDischarge |  | 0..* | Base | Care plan and other recommendations after discharge.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..* | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

#### Terminology Bindings (Differential)

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

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
EHDSHospitalDischargeReportBody |  | 0..* | Base | Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives |  | 0..1 | Base | Authored Advance Directive Information
livingWill |  | 0..* | Base | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime |  | 1..1 | dateTime | The date and time on which the living will was recorded.
type |  | 1..1 | CodeableConcept | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description (No ValueSet): (preferred): SNOMED CT
comment |  | 0..1 | string | Comment on the living will.
relatedConditions |  | 0..* | CodeableConcept | The problem or disorder to which the living will applies. Binding Description (No ValueSet): (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument |  | 1..* | EHDSAttachment | Living will document
alertsSection |  | 0..1 | Base | Alerts section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
medicalAlerts |  | 0..* | EHDSAlertFlag | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection |  | 1..1 | Base | Encounter information section.
sectionNarrative |  | 1..1 | string | Narrative content of the section.
encounterInformationSection |  | 0..1 | EHDSEncounter | Encounter information section. Hospital encounter details.
admissionEvaluation |  | 0..1 | Base | Admission evaluation section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
patientHistory |  | 0..1 | Base | Patient health history section (anamnesis).
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunization | Vaccination
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | Base | Infectious contacts
timePeriod |  | 0..1 | dateTime | A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent |  | 0..* | CodeableConcept | Infectious agent Binding Description (No ValueSet): (preferred): ICD-10*, SNOMED CT
proximity[x] |  | 0..1 |  | Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept |  |  | CodeableConcept |
proximityQuantity |  |  | Quantity |
country |  | 0..1 | CodeableConcept | Country in which the person was potentially exposed to an infectious agent. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
additionalInformation |  | 0..1 | string | A textual note with additional information about infectious contact.
travelHistory |  | 0..1 | Base | Travel history reported by the patient. Multiple records could be provided.
timePeriod |  | 0..1 | dateTime | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited |  | 1..1 | CodeableConcept | Country visited by the patient. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
comment |  | 0..1 | string | Relevant notes on the travel stay.
familyHistorySection |  | 0..1 | Base | Family history section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
subsectionNarrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | CodeableConcept | Work situation Binding Description (No ValueSet): (preferred): SNOMED CT
hobby |  | 0..1 | CodeableConcept | An activity the patient enjoys doing in their free time. Binding Description (No ValueSet): (preferred): SNOMED CT
socialNetwork |  | 0..1 | CodeableConcept | Social network Binding Description (No ValueSet): (preferred): SNOMED CT
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description (No ValueSet): (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description (No ValueSet): (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description (No ValueSet): (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description (No ValueSet): (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code.
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description (No ValueSet): (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | Base | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status |  | 0..1 | CodeableConcept | Status of the patient’s alcohol use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period |  | 0..1 | Period | Time period of alcohol use.
quantity |  | 1..1 | Quantity | Quantity (volume per time unit).
comment |  | 0..1 | string | Textual comment.
tobaccoUse |  | 0..* | Base | Tobacco use
status |  | 0..1 | CodeableConcept | Status of the patient’s tobacco use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period |  | 0..1 | Period | Time period of tobacco usage.
quantity |  | 1..1 | Quantity | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment |  | 0..1 | string | Textual comment.
drugConsumption |  | 0..* | Base | Consumption of drugs and other substances (in terms of abuse).
status |  | 0..1 | CodeableConcept | The status of the patient’s drug consumption. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s drug use in units per time period.)
period |  | 0..1 | Period | Time period of drug use.
quantity |  | 1..1 | Quantity | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType |  | 0..1 | CodeableConcept | Drug or medication type Binding Description (No ValueSet): (preferred): SNOMED CT
routeOfAdministration |  | 0..* | CodeableConcept | Route or routes of administration Binding Description (No ValueSet): (preferred): EDQM
comment |  | 0..1 | string | Textual comment.
courseOfHospitalisation |  | 1..1 | Base | Course of hospital stay.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | EHDSConditionHdr | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplantsSection |  | 1..1 | Base | Medical devices and implants section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapySection |  | 0..1 | Base | Pharmacotherapy section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
medicationDetails |  | 0..* | EHDSMedicationStatement | Medication details
carePlanAndOtherRecommendationsAfterDischarge |  | 0..* | Base | Care plan and other recommendations after discharge.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..* | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

#### Terminology Bindings

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

This structure is derived from Base

Summary

Mandatory: 0 element(19 nested mandatory elements)

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
EHDSHospitalDischargeReportBody |  | 0..* | Base | Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives |  | 0..1 | Base | Authored Advance Directive Information
livingWill |  | 0..* | Base | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime |  | 1..1 | dateTime | The date and time on which the living will was recorded.
type |  | 1..1 | CodeableConcept | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description (No ValueSet): (preferred): SNOMED CT
comment |  | 0..1 | string | Comment on the living will.
relatedConditions |  | 0..* | CodeableConcept | The problem or disorder to which the living will applies. Binding Description (No ValueSet): (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument |  | 1..* | EHDSAttachment | Living will document
alertsSection |  | 0..1 | Base | Alerts section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
medicalAlerts |  | 0..* | EHDSAlertFlag | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection |  | 1..1 | Base | Encounter information section.
sectionNarrative |  | 1..1 | string | Narrative content of the section.
encounterInformationSection |  | 0..1 | EHDSEncounter | Encounter information section. Hospital encounter details.
admissionEvaluation |  | 0..1 | Base | Admission evaluation section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
patientHistory |  | 0..1 | Base | Patient health history section (anamnesis).
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunization | Vaccination
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | Base | Infectious contacts
timePeriod |  | 0..1 | dateTime | A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent |  | 0..* | CodeableConcept | Infectious agent Binding Description (No ValueSet): (preferred): ICD-10*, SNOMED CT
proximity[x] |  | 0..1 |  | Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept |  |  | CodeableConcept |
proximityQuantity |  |  | Quantity |
country |  | 0..1 | CodeableConcept | Country in which the person was potentially exposed to an infectious agent. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
additionalInformation |  | 0..1 | string | A textual note with additional information about infectious contact.
travelHistory |  | 0..1 | Base | Travel history reported by the patient. Multiple records could be provided.
timePeriod |  | 0..1 | dateTime | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited |  | 1..1 | CodeableConcept | Country visited by the patient. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
comment |  | 0..1 | string | Relevant notes on the travel stay.
familyHistorySection |  | 0..1 | Base | Family history section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
subsectionNarrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | CodeableConcept | Work situation Binding Description (No ValueSet): (preferred): SNOMED CT
hobby |  | 0..1 | CodeableConcept | An activity the patient enjoys doing in their free time. Binding Description (No ValueSet): (preferred): SNOMED CT
socialNetwork |  | 0..1 | CodeableConcept | Social network Binding Description (No ValueSet): (preferred): SNOMED CT
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description (No ValueSet): (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description (No ValueSet): (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description (No ValueSet): (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description (No ValueSet): (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code.
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description (No ValueSet): (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | Base | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status |  | 0..1 | CodeableConcept | Status of the patient’s alcohol use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period |  | 0..1 | Period | Time period of alcohol use.
quantity |  | 1..1 | Quantity | Quantity (volume per time unit).
comment |  | 0..1 | string | Textual comment.
tobaccoUse |  | 0..* | Base | Tobacco use
status |  | 0..1 | CodeableConcept | Status of the patient’s tobacco use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period |  | 0..1 | Period | Time period of tobacco usage.
quantity |  | 1..1 | Quantity | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment |  | 0..1 | string | Textual comment.
drugConsumption |  | 0..* | Base | Consumption of drugs and other substances (in terms of abuse).
status |  | 0..1 | CodeableConcept | The status of the patient’s drug consumption. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s drug use in units per time period.)
period |  | 0..1 | Period | Time period of drug use.
quantity |  | 1..1 | Quantity | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType |  | 0..1 | CodeableConcept | Drug or medication type Binding Description (No ValueSet): (preferred): SNOMED CT
routeOfAdministration |  | 0..* | CodeableConcept | Route or routes of administration Binding Description (No ValueSet): (preferred): EDQM
comment |  | 0..1 | string | Textual comment.
courseOfHospitalisation |  | 1..1 | Base | Course of hospital stay.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | EHDSConditionHdr | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplantsSection |  | 1..1 | Base | Medical devices and implants section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapySection |  | 0..1 | Base | Pharmacotherapy section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
medicationDetails |  | 0..* | EHDSMedicationStatement | Medication details
carePlanAndOtherRecommendationsAfterDischarge |  | 0..* | Base | Care plan and other recommendations after discharge.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..* | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

#### Terminology Bindings

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

Differential View

This structure is derived from Base

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
EHDSHospitalDischargeReportBody |  | 0..* | Base | Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives |  | 0..1 | Base | Authored Advance Directive Information
livingWill |  | 0..* | Base | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime |  | 1..1 | dateTime | The date and time on which the living will was recorded.
type |  | 1..1 | CodeableConcept | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description (No ValueSet): (preferred): SNOMED CT
comment |  | 0..1 | string | Comment on the living will.
relatedConditions |  | 0..* | CodeableConcept | The problem or disorder to which the living will applies. Binding Description (No ValueSet): (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument |  | 1..* | EHDSAttachment | Living will document
alertsSection |  | 0..1 | Base | Alerts section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
medicalAlerts |  | 0..* | EHDSAlertFlag | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection |  | 1..1 | Base | Encounter information section.
sectionNarrative |  | 1..1 | string | Narrative content of the section.
encounterInformationSection |  | 0..1 | EHDSEncounter | Encounter information section. Hospital encounter details.
admissionEvaluation |  | 0..1 | Base | Admission evaluation section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
patientHistory |  | 0..1 | Base | Patient health history section (anamnesis).
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunization | Vaccination
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | Base | Infectious contacts
timePeriod |  | 0..1 | dateTime | A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent |  | 0..* | CodeableConcept | Infectious agent Binding Description (No ValueSet): (preferred): ICD-10*, SNOMED CT
proximity[x] |  | 0..1 |  | Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept |  |  | CodeableConcept |
proximityQuantity |  |  | Quantity |
country |  | 0..1 | CodeableConcept | Country in which the person was potentially exposed to an infectious agent. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
additionalInformation |  | 0..1 | string | A textual note with additional information about infectious contact.
travelHistory |  | 0..1 | Base | Travel history reported by the patient. Multiple records could be provided.
timePeriod |  | 0..1 | dateTime | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited |  | 1..1 | CodeableConcept | Country visited by the patient. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
comment |  | 0..1 | string | Relevant notes on the travel stay.
familyHistorySection |  | 0..1 | Base | Family history section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
subsectionNarrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | CodeableConcept | Work situation Binding Description (No ValueSet): (preferred): SNOMED CT
hobby |  | 0..1 | CodeableConcept | An activity the patient enjoys doing in their free time. Binding Description (No ValueSet): (preferred): SNOMED CT
socialNetwork |  | 0..1 | CodeableConcept | Social network Binding Description (No ValueSet): (preferred): SNOMED CT
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description (No ValueSet): (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description (No ValueSet): (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description (No ValueSet): (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description (No ValueSet): (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code.
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description (No ValueSet): (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | Base | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status |  | 0..1 | CodeableConcept | Status of the patient’s alcohol use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period |  | 0..1 | Period | Time period of alcohol use.
quantity |  | 1..1 | Quantity | Quantity (volume per time unit).
comment |  | 0..1 | string | Textual comment.
tobaccoUse |  | 0..* | Base | Tobacco use
status |  | 0..1 | CodeableConcept | Status of the patient’s tobacco use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period |  | 0..1 | Period | Time period of tobacco usage.
quantity |  | 1..1 | Quantity | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment |  | 0..1 | string | Textual comment.
drugConsumption |  | 0..* | Base | Consumption of drugs and other substances (in terms of abuse).
status |  | 0..1 | CodeableConcept | The status of the patient’s drug consumption. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s drug use in units per time period.)
period |  | 0..1 | Period | Time period of drug use.
quantity |  | 1..1 | Quantity | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType |  | 0..1 | CodeableConcept | Drug or medication type Binding Description (No ValueSet): (preferred): SNOMED CT
routeOfAdministration |  | 0..* | CodeableConcept | Route or routes of administration Binding Description (No ValueSet): (preferred): EDQM
comment |  | 0..1 | string | Textual comment.
courseOfHospitalisation |  | 1..1 | Base | Course of hospital stay.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | EHDSConditionHdr | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplantsSection |  | 1..1 | Base | Medical devices and implants section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapySection |  | 0..1 | Base | Pharmacotherapy section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
medicationDetails |  | 0..* | EHDSMedicationStatement | Medication details
carePlanAndOtherRecommendationsAfterDischarge |  | 0..* | Base | Care plan and other recommendations after discharge.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..* | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

#### Terminology Bindings (Differential)

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

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
EHDSHospitalDischargeReportBody |  | 0..* | Base | Hospital Discharge Report body model Instances of this logical model can be the target of a Reference
advanceDirectives |  | 0..1 | Base | Authored Advance Directive Information
livingWill |  | 0..* | Base | Living will. Only directives being expressed during current inpatient stay. Multiple records of living wills could be provided.
dateAndTime |  | 1..1 | dateTime | The date and time on which the living will was recorded.
type |  | 1..1 | CodeableConcept | Type of a living will, e.g. Do not resuscitate, donorship statement, power of attorney etc. Binding Description (No ValueSet): (preferred): SNOMED CT
comment |  | 0..1 | string | Comment on the living will.
relatedConditions |  | 0..* | CodeableConcept | The problem or disorder to which the living will applies. Binding Description (No ValueSet): (preferred): ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed
livingWillDocument |  | 1..* | EHDSAttachment | Living will document
alertsSection |  | 0..1 | Base | Alerts section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either narrative description of both allergy and alerts, or similar narrative sub-section elements shell be provided.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the hospital stay).
medicalAlerts |  | 0..* | EHDSAlertFlag | Medical alerts. Specific alerts relevant to the patient’s condition that should be noted (other alerts not included in allergies).
encounterInformationSection |  | 1..1 | Base | Encounter information section.
sectionNarrative |  | 1..1 | string | Narrative content of the section.
encounterInformationSection |  | 0..1 | EHDSEncounter | Encounter information section. Hospital encounter details.
admissionEvaluation |  | 0..1 | Base | Admission evaluation section
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
patientHistory |  | 0..1 | Base | Patient health history section (anamnesis).
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunization | Vaccination
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | Base | Infectious contacts
timePeriod |  | 0..1 | dateTime | A date and duration or date time interval of contact. Partial dates are allowed.
infectiousAgent |  | 0..* | CodeableConcept | Infectious agent Binding Description (No ValueSet): (preferred): ICD-10*, SNOMED CT
proximity[x] |  | 0..1 |  | Proximity to the source/carrier of the infectious agent during exposure. Proximity could be expressed by text, code (direct, indirect) or value specifying distance from the InfectiousAgentCarrier.
proximityCodeableConcept |  |  | CodeableConcept |
proximityQuantity |  |  | Quantity |
country |  | 0..1 | CodeableConcept | Country in which the person was potentially exposed to an infectious agent. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
additionalInformation |  | 0..1 | string | A textual note with additional information about infectious contact.
travelHistory |  | 0..1 | Base | Travel history reported by the patient. Multiple records could be provided.
timePeriod |  | 0..1 | dateTime | Start and end date or end date and duration of stay in a country. Partial dates are allowed.
countryVisited |  | 1..1 | CodeableConcept | Country visited by the patient. Binding Description (No ValueSet): (preferred): ISO 3166-1 alpha-2
comment |  | 0..1 | string | Relevant notes on the travel stay.
familyHistorySection |  | 0..1 | Base | Family history section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
subsectionNarrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | CodeableConcept | Work situation Binding Description (No ValueSet): (preferred): SNOMED CT
hobby |  | 0..1 | CodeableConcept | An activity the patient enjoys doing in their free time. Binding Description (No ValueSet): (preferred): SNOMED CT
socialNetwork |  | 0..1 | CodeableConcept | Social network Binding Description (No ValueSet): (preferred): SNOMED CT
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description (No ValueSet): (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description (No ValueSet): (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description (No ValueSet): (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description (No ValueSet): (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code.
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description (No ValueSet): (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | Base | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
status |  | 0..1 | CodeableConcept | Status of the patient’s alcohol use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount observation (The extent of the patient’s alcohol use in units of alcohol per time period.)
period |  | 0..1 | Period | Time period of alcohol use.
quantity |  | 1..1 | Quantity | Quantity (volume per time unit).
comment |  | 0..1 | string | Textual comment.
tobaccoUse |  | 0..* | Base | Tobacco use
status |  | 0..1 | CodeableConcept | Status of the patient’s tobacco use. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s tobacco use in units per time period.)
period |  | 0..1 | Period | Time period of tobacco usage.
quantity |  | 1..1 | Quantity | The number of cigarettes, cigars or grams of rolling tobacco consumed per day, week, month or year.
comment |  | 0..1 | string | Textual comment.
drugConsumption |  | 0..* | Base | Consumption of drugs and other substances (in terms of abuse).
status |  | 0..1 | CodeableConcept | The status of the patient’s drug consumption. Binding Description (No ValueSet): (preferred): SNOMED CT
periodAndQuantity |  | 0..1 | Base | Period of use and amount (The extent of the patient’s drug use in units per time period.)
period |  | 0..1 | Period | Time period of drug use.
quantity |  | 1..1 | Quantity | The number of units (pills, joints, shots etc.) per day, week, month, or year; or the frequency of use.
drugOrMedicationType |  | 0..1 | CodeableConcept | Drug or medication type Binding Description (No ValueSet): (preferred): SNOMED CT
routeOfAdministration |  | 0..* | CodeableConcept | Route or routes of administration Binding Description (No ValueSet): (preferred): EDQM
comment |  | 0..1 | string | Textual comment.
courseOfHospitalisation |  | 1..1 | Base | Course of hospital stay.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
problemDescription |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | EHDSConditionHdr | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplantsSection |  | 1..1 | Base | Medical devices and implants section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapySection |  | 0..1 | Base | Pharmacotherapy section
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
subsectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations
vitalSigns |  | 0..* | EHDSObservation | Vital signs
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Functional status
dateAndTime |  | 0..1 | dateTime | Date and time of the examination
performer |  | 0..* | EHDSHealthProfessional | Originator/author. Provides provenance information about the source of the results data that may have not originated with the source of the whole document.
sectionNarrative |  | 0..1 | string | Narrative content of the section.
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | Functional status assessment
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
medicationDetails |  | 0..* | EHDSMedicationStatement | Medication details
carePlanAndOtherRecommendationsAfterDischarge |  | 0..* | Base | Care plan and other recommendations after discharge.
sectionNarrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..* | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Documentation for this format

#### Terminology Bindings

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

This structure is derived from Base

Summary

Mandatory: 0 element(19 nested mandatory elements)

Other representations of profile: CSV, Excel