EHDSDischargeReport
type: StructureDefinition
node role: treeRoot
id:
  v: EHDSDischargeReport
text:
  status:
    v: extensions
  div: Generated Narrative: StructureDefinition EHDSDischargeReport Name Flags Card. Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> EHDSDischargeReport 0..* EHDSDocument Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Discharge Report model Instances of this logical model can be the target of a Reference #xD; header #xD; intendedRecipient[x] 0..* Intended recipient #xD; intendedRecipientEHDSPatient EHDSPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientEHDSHealthProfessional EHDSHealthProfessional #xD; intendedRecipientEHDSOrganisation EHDSOrganisation #xD; intendedRecipientEHDSDevice EHDSDevice #xD; healthInsuranceAndPaymentInformation 0..* EHDSCoverage Health insurance and payment information #xD; knowledgeResources 0..0 #xD; body 0..1 Base Structured body of the discharge report document #xD; advanceDirectives 0..1 Base Section: Advance Directives. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions #xD; alerts 0..1 Base Section: Alerts. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat. #xD; 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 encounter). #xD; encounterInformation 1..1 Base Section: Encounter information. #xD; narrative 1..1 string Narrative, potentially formatted, content of the section #xD; encounter 0..1 EHDSEncounter Encounter information #xD; admissionEvaluation 0..1 Base Section: Admi…
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-type-characteristics
  value: code
    v: can-be-target
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-type-characteristics
  value: code
    v: can-be-target
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-type-characteristics
  value: code
    v: can-be-target
url:
  v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDischargeReport
version:
  v: 0.1.0
name:
  v: EHDSDischargeReport
title:
  v: Discharge Report model
status:
  v: draft
date:
  v: 2025-08-25T17:05:40+00:00
publisher:
  v: Xt-EHR
contact:
  name:
    v: Xt-EHR
  telecom:
    system:
      v: url
    value:
      v: http://Xt-EHR.eu
description:
  v: EHDS refined base model for Discharge Report
fhir version:
  v: 5.0.0
mapping:
  identity:
    v: rim
  uri:
    v: http://hl7.org/v3
  name:
    v: RIM Mapping
kind:
  v: logical
abstract:
  v: false
type:
  v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDischargeReport
base definition:
  v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDocument
  link: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDocument
derivation:
  v: specialization
snapshot:
  extension:
    url:
      v: http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version
    value: string
      v: 0.1.0
  element:
    id:
      v: EHDSDischargeReport
    path:
      v: EHDSDischargeReport
    short:
      v: Discharge Report model
    definition:
      v: EHDS refined base model for Discharge Report
    min:
      v: 0
    max:
      v: *
    base:
      path:
        v: Base
      min:
        v: 0
      max:
        v: *
    is modifier:
      v: false
    mapping:
      identity:
        v: rim
      map:
        v: n/a
  element:
    id:
      v: EHDSDischargeReport.header
    path:
      v: EHDSDischargeReport.header
    short:
      v: Document header elements
    definition:
      v: Common header for all patient-related data
    min:
      v: 1
    max:
      v: 1
    base:
      path:
        v: EHDSDataSet.header
      min:
        v: 1
      max:
        v: 1
    type:
      code:
        v: Base
  element:
    id:
      v: EHDSDischargeReport.header.subject
    path:
      v: EHDSDischargeReport.header.subject
    short:
      v: Subject
    definition:
      v: Patient/subject information
    min:
      v: 1
    max:
      v: 1
    base:
      path:
        v: EHDSDataSet.header.subject
      min:
        v: 1
      max:
        v: 1
    type:
      code:
        v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
  element:
    id:
      v: EHDSDischargeReport.header.identifier
    path:
      v: EHDSDischargeReport.header.identifier
    short:
      v: Document ID
    definition:
      v: Unique identifier of the document
    min:
      v: 1
    max:
      v: *
    base:
      path:
        v: EHDSDataSet.header.identifier
      min:
        v: 0
      max:
        v: *
    type:
      code:
        v: Identifier
  element:
    id:
      v: EHDSDischargeReport.header.authorship
    path:
      v: EHDSDischargeReport.header.authorship
    short:
      v: Authorship
    definition:
      v: Resource authoring details
    min:
      v: 1
    max:
      v: *
    base:
      path:
        v: EHDSDataSet.header.authorship
      min:
        v: 1
      max:
        v: *
    type:
      code:
        v: Base
  element:
    id:
      v: EHDSDischargeReport.header.authorship.author[x]
    path:
      v: EHDSDischargeReport.header.authorship.author[x]
    short:
      v: Author
    definition:
      v: Author(s) by whom the resource was/were authored. Multiple authors could be provided.
    min:
      v: 1

v: 1

path:
  v: EHDSDataSet.header.authorship.author[x]
min:
  v: 1
max:
  v: 1

id:
  v: EHDSDischargeReport.header.authorship.datetime
path:
  v: EHDSDischargeReport.header.authorship.datetime
short:
  v: Date and time of authoring/issuing
definition:
  v: Date and time of the issuing the document/resource by its author.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDataSet.header.authorship.datetime
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: dateTime

id:
  v: EHDSDischargeReport.header.lastUpdate
path:
  v: EHDSDischargeReport.header.lastUpdate
short:
  v: Date and time of the last update to the resource
definition:
  v: Date and time of the last update to the document/information
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDataSet.header.lastUpdate
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: dateTime

id:
  v: EHDSDischargeReport.header.status
path:
  v: EHDSDischargeReport.header.status
short:
  v: Status of the resource
definition:
  v: Status of the resource
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDataSet.header.status
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: CodeableConcept

id:
  v: EHDSDischargeReport.header.statusReason[x]
path:
  v: EHDSDischargeReport.header.statusReason[x]
short:
  v: Reason for the current status of the resource.
definition:
  v: Reason for the current status of the resource.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDataSet.header.statusReason[x]
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: CodeableConcept
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.header.language
path:
  v: EHDSDischargeReport.header.language
short:
  v: Language
definition:
  v: Language in which the resource is written. Language is expressed by the IETF language tag.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDataSet.header.language
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: BCP 47

id:
  v: EHDSDischargeReport.header.version
path:
  v: EHDSDischargeReport.header.version
short:
  v: Version
definition:
  v: Business version of the resource.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDataSet.header.version
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.presentedForm
path:
  v: EHDSDischargeReport.presentedForm
short:
  v: A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
definition:
  v: A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDataSet.presentedForm
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment

id:
  v: EHDSDischargeReport.header.documentType
path:
  v: EHDSDischargeReport.header.documentType
short:
  v: Document type
definition:
  v: Identifies the type of document at hand, e.g. Discharge report.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.documentType
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: LOINC

id:
  v: EHDSDischargeReport.header.documentTitle
path:
  v: EHDSDischargeReport.header.documentTitle
short:
  v: Document title
definition:
  v: Document title, such as Discharge Report, Laboratory Result Report, etc.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.documentTitle
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.header.documentStatus
path:
  v: EHDSDischargeReport.header.documentStatus
short:
  v: Document status
definition:
  v: The status of the Discharge report. E.g., preliminary, final.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.documentStatus
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: hl7:CompositionStatus

id:
  v: EHDSDischargeReport.header.period
path:
  v: EHDSDischargeReport.header.period
short:
  v: Period
definition:
  v: Time of service that is being documented
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.period
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: Period

id:
  v: EHDSDischargeReport.header.attestation
path:
  v: EHDSDischargeReport.header.attestation
short:
  v: Attestation
definition:
  v: Document attestation details
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDocument.header.attestation
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.header.attestation.attester
path:
  v: EHDSDischargeReport.header.attestation.attester
short:
  v: Attester
definition:
  v: Attester who validated the document. Mulitple attesters could be provided.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.attestation.attester
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional

id:
  v: EHDSDischargeReport.header.attestation.datetime
path:
  v: EHDSDischargeReport.header.attestation.datetime
short:
  v: DateTime
definition:
  v: Date and time of the approval of the document by Attester.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.attestation.datetime
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: dateTime

id:
  v: EHDSDischargeReport.header.legalAuthentication
path:
  v: EHDSDischargeReport.header.legalAuthentication
short:
  v: Legal authentication
definition:
  v: Document legal authentication
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.legalAuthentication
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.header.legalAuthentication.legalAuthenticator
path:
  v: EHDSDischargeReport.header.legalAuthentication.legalAuthenticator
short:
  v: Legal authenticator
definition:
  v: The person taking responsibility for the medical content of the document
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.legalAuthentication.legalAuthenticator
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional

id:
  v: EHDSDischargeReport.header.legalAuthentication.datetime
path:
  v: EHDSDischargeReport.header.legalAuthentication.datetime
short:
  v: DateTime
definition:
  v: Date and time when the document was authorized.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.legalAuthentication.datetime
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: dateTime

id:
  v: EHDSDischargeReport.header.eventType
path:
  v: EHDSDischargeReport.header.eventType
short:
  v: Event type
definition:
  v: Categorization of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDocument.header.eventType
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: LOINC, SNOMED CT, dicom-cid-33-Modality

id:
  v: EHDSDischargeReport.header.authorSpecialty
path:
  v: EHDSDischargeReport.header.authorSpecialty
short:
  v: Specialty
definition:
  v: Additional details about where the content was created (e.g. clinical specialty)
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDocument.header.authorSpecialty
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: SNOMED CT

id:
  v: EHDSDischargeReport.header.custodian
path:
  v: EHDSDischargeReport.header.custodian
short:
  v: Document custodian
definition:
  v: Organisation that is in charge of maintaining the document/report.
min:
  v: 1
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.custodian
  min:
    v: 1
  max:
    v: 1
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation

id:
  v: EHDSDischargeReport.header.documentFormat
path:
  v: EHDSDischargeReport.header.documentFormat
short:
  v: Document format
definition:
  v: An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.documentFormat
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: HL7 Document Format Codes

id:
  v: EHDSDischargeReport.header.confidentiality
path:
  v: EHDSDischargeReport.header.confidentiality
short:
  v: Confidentiality
definition:
  v: Level of confidentiality of the document. Implicit value is normal.
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDocument.header.confidentiality
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: hl7:Confidentiality

id:
  v: EHDSDischargeReport.knowledgeResources
path:
  v: EHDSDischargeReport.knowledgeResources
short:
  v: Related documents and information sources
definition:
  v: Related documents and information sources
min:
  v: 0
max:
  v: 0
base:
  path:
    v: EHDSDocument.knowledgeResources
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.knowledgeResources.externalReference
path:
  v: EHDSDischargeReport.knowledgeResources.externalReference
short:
  v: ...
definition:
  v: ...
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDocument.knowledgeResources.externalReference
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: RelatedArtifact

id:
  v: EHDSDischargeReport.knowledgeResources.relatedTo
path:
  v: EHDSDischargeReport.knowledgeResources.relatedTo
short:
  v: ...
definition:
  v: ...
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDocument.knowledgeResources.relatedTo
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: Reference

id:
  v: EHDSDischargeReport.header.intendedRecipient[x]
path:
  v: EHDSDischargeReport.header.intendedRecipient[x]
short:
  v: Intended recipient
definition:
  v: Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDischargeReport.header.intendedRecipient[x]
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSRelatedPerson
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice

id:
  v: EHDSDischargeReport.header.healthInsuranceAndPaymentInformation
path:
  v: EHDSDischargeReport.header.healthInsuranceAndPaymentInformation
short:
  v: Health insurance and payment information
definition:
  v: Health insurance and payment information
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDischargeReport.header.healthInsuranceAndPaymentInformation
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCoverage

id:
  v: EHDSDischargeReport.body
path:
  v: EHDSDischargeReport.body
short:
  v: Structured body of the discharge report document
definition:
  v: Structured body of the discharge report document
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDischargeReport.body
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.advanceDirectives
path:
  v: EHDSDischargeReport.body.advanceDirectives
short:
  v: Section: Advance Directives.
definition:
  v: Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.2
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDischargeReport.body.advanceDirectives
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.advanceDirectives.narrative
path:
  v: EHDSDischargeReport.body.advanceDirectives.narrative
short:
  v: Narrative, potentially formatted, content of the section
definition:
  v: Narrative, potentially formatted, content of the section
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDischargeReport.body.advanceDirectives.narrative
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.advanceDirectives.advanceDirective
path:
  v: EHDSDischargeReport.body.advanceDirectives.advanceDirective
short:
  v: Provision for healthcare decisions if, in the future, a person is unable to make those decisions
definition:
  v: Provision for healthcare decisions if, in the future, a person is unable to make those decisions
min:
  v: 0
max:
  v: *
base:
  path:
    v: EHDSDischargeReport.body.advanceDirectives.advanceDirective
  min:
    v: 0
  max:
    v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAdvanceDirective

id:
  v: EHDSDischargeReport.body.alerts
path:
  v: EHDSDischargeReport.body.alerts
short:
  v: Section: Alerts.
definition:
  v: Information about substantial alerts or warnings that health professionals should be aware of.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.2
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDischargeReport.body.alerts
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.alerts.narrative
path:
  v: EHDSDischargeReport.body.alerts.narrative
short:
  v: Narrative, potentially formatted, content of the section
definition:
  v: Narrative, potentially formatted, content of the section
min:
  v: 0
max:
  v: 1
base:
  path:
    v: EHDSDischargeReport.body.alerts.narrative
  min:
    v: 0
  max:
    v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.alerts.medicalAlert
path:
  v: EHDSDischargeReport.body.alerts.medicalAlert
short:
  v: Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
definition:
  v: Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.2.2
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max:
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base:
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  max:
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id:
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path:
  v: EHDSDischargeReport.body.alerts.allergyAndIntolerance
short:
  v: Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
definition:
  v: Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
requirements:
  v: eHN Guideline HDR (v1.1): A.2.2.1
min:
  v: 0
max:
  v: *
base:
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  max:
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id:
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path:
  v: EHDSDischargeReport.body.encounterInformation
short:
  v: Section: Encounter information.
definition:
  v: Section: Encounter information.
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max:
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base:
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max:
  v: 1
base:
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path:
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short:
  v: Encounter information
definition:
  v: Encounter information
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  v: 0
max:
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base:
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  max:
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type:
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    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter

id:
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path:
  v: EHDSDischargeReport.body.admissionEvaluation
short:
  v: Section: Admission evaluation
definition:
  v: Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
requirements:
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min:
  v: 0
max:
  v: 1
base:
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id:
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path:
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short:
  v: 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.
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  v: 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.
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id:
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path:
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short:
  v: Objective findings
definition:
  v: Sub-section with objective findings.
requirements:
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min:
  v: 0
max:
  v: 1
base:
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  v: 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.
definition:
  v: 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.
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max:
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id:
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path:
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short:
  v: Date and time of the admission evaluation examination
definition:
  v: Date and time of the admission evaluation examination
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min:
  v: 0
max:
  v: 1
base:
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path:
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  v: Health professional(s) responsible for the admission evaluation examination.
definition:
  v: Health professional(s) responsible for the admission evaluation examination.
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  v: 0
max:
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base:
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id:
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path:
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short:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
definition:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
requirements:
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min:
  v: 0
max:
  v: *
base:
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type:
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id:
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short:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
definition:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
requirements:
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min:
  v: 0
max:
  v: *
base:
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id:
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  v: Physical examination
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  v: Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
requirements:
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min:
  v: 0
max:
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base:
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id:
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  v: Section: Functional status
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  v: Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
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max:
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  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
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  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
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id:
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path:
  v: EHDSDischargeReport.body.patientHistory
short:
  v: Section: Patient health history (anamnesis).
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  v: Section: Patient health history (anamnesis).
requirements:
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max:
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id:
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short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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short:
  v: Medical history subsection.
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  v: Medical history subsection.
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min:
  v: 1
max:
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base:
  path:
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  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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id:
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  v: Past problems
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  v: A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
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max:
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id:
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short:
  v: Devices and Implants
definition:
  v: Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
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min:
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max:
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base:
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  v: History of procedures
definition:
  v: Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
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max:
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id:
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  v: Vaccination history of the patient.
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max:
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id:
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  v: Epidemiological history
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max:
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  v: Travel history reported by the patient. Multiple records could be provided.
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id:
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  v: Section: Pregnancy history
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  v: To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
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max:
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max:
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id:
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max:
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  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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  v: Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
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max:
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id:
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short:
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definition:
  v: Information about social determinants of health.
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max:
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    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition

id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantProcedures
path:
  v: EHDSDischargeReport.body.courseOfEncounter.significantProcedures
short:
  v: Significant procedures section
definition:
  v: Significant surgical and non-surgical procedures performed during encounter which are significant for continuity of care, e.g. surgeries and other instrumental interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.2
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max:
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path:
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short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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id:
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short:
  v: Structured procedure entry.
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max:
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id:
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path:
  v: EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
short:
  v: Medical devices and implants section
definition:
  v: Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.3
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  v: 1
max:
  v: 1
base:
  path:
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type:
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id:
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path:
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short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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path:
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short:
  v: Medical devices and implants
definition:
  v: Medical devices and implants
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  v: 1
max:
  v: *
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type:
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id:
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path:
  v: EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
short:
  v: Pharmacotherapy section
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  v: Selected drug treatment during encounter. Medicinal products that were administered during encounter and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section. Medicinal products, the administration of which was started during encounter, but is also recommended after discharge, will be listed in the summary table in the recommendation section.
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  v: 0
max:
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short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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  v: Pharmacotherapy structured entry.
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max:
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id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults
path:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults
short:
  v: Significant Observation Results
definition:
  v: Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during encounter. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.6
min:
  v: 0
max:
  v: 1
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path:
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short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
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id:
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path:
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short:
  v: Significant Observation Result
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  v: Structured significant observation entry.
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max:
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type:
  code:
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type:
  code:
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id:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis
path:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis
short:
  v: Synthesis
definition:
  v: This section provides clinical synthesis (e.g. description of reasons and course of encounter) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.7
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  v: 1
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  v: 1
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  path:
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id:
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short:
  v: Summary description of the reason and course of hospitalisation for a specific problem.
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  v: Summary description of the reason and course of hospitalisation for a specific problem.
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  v: 1
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  v: Clinical reasoning
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  v: The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
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  v: 0
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  v: 1
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id:
  v: EHDSDischargeReport.body.dischargeDetails
path:
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short:
  v: Discharge details
definition:
  v: Structured information should be provided, however if not available, at least a section narrative should be present.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7
min:
  v: 1
max:
  v: 1
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  path:
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id:
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short:
  v: 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.
definition:
  v: 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.
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id:
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path:
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short:
  v: Objective findings
definition:
  v: Sub-section with objective findings.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1
min:
  v: 0
max:
  v: 1
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id:
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  v: Narrative content of the section.
definition:
  v: Narrative content of the section.
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id:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.anthropometricObservations
path:
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short:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
definition:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1.3
min:
  v: 0
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  v: *
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  path:
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  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation

id:
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path:
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short:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
definition:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1.4
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  v: 0
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id:
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path:
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short:
  v: Physical examination
definition:
  v: Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1.5
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  v: 0
max:
  v: *
base:
  path:
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id:
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path:
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short:
  v: Section: Functional status
definition:
  v: Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
requirements:
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  v: 0
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id:
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  v: Narrative, potentially formatted, content of the section
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path:
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short:
  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
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  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
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id:
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path:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary
short:
  v: 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.
definition:
  v: 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.
requirements:
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id:
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  v: Structured medication entry
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  v: Details about medication and dosaging
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  v: Details about medication and dosaging
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  v: 1
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id:
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path:
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short:
  v: Number of days for which the patient was provided with the drug at the time of discharge
definition:
  v: Supply is intended to either hand over the medicine or write out a prescription. A 0 value indicates that the patient has not been provided with the drug (e.g. if the patient has a sufficient supply of the drug)
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id:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan
path:
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short:
  v: Care plan and other recommendations after discharge.
definition:
  v: Care plan and other recommendations after discharge section.
requirements:
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  v: 0
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  v: Narrative content of the section.
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  v: Structured care plan after discharge. Multiple care plans could be provided.
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  v: Structured care plan after discharge. Multiple care plans could be provided.
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id:
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  v: Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
definition:
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id:
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  v: Report attachments data elements
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  v: Report attachments data elements
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base:
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    v: Intended recipient
  definition:
    v: Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
  min:
    v: 0
  max:
    v: *
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSRelatedPerson
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
element:
  id:
    v: EHDSDischargeReport.header.healthInsuranceAndPaymentInformation
  path:
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  short:
    v: Health insurance and payment information
  definition:
    v: Health insurance and payment information
  min:
    v: 0
  max:
    v: *
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCoverage
element:
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  path:
    v: EHDSDischargeReport.knowledgeResources
  max:
    v: 0
element:
  id:
    v: EHDSDischargeReport.body
  path:
    v: EHDSDischargeReport.body
  short:
    v: Structured body of the discharge report document
  definition:
    v: Structured body of the discharge report document
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: Base
element:
  id:
    v: EHDSDischargeReport.body.advanceDirectives
  path:
    v: EHDSDischargeReport.body.advanceDirectives
  short:
    v: Section: Advance Directives.
  definition:
    v: Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
  requirements:
    v: eHN Guideline HDR (v1.1): A.2.2
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: Base
element:
  id:
    v: EHDSDischargeReport.body.advanceDirectives.narrative
  path:
    v: EHDSDischargeReport.body.advanceDirectives.narrative
  short:
    v: Narrative, potentially formatted, content of the section
  definition:
    v: Narrative, potentially formatted, content of the section
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: string
element:
  id:
    v: EHDSDischargeReport.body.advanceDirectives.advanceDirective
  path:
    v: EHDSDischargeReport.body.advanceDirectives.advanceDirective
  short:
    v: Provision for healthcare decisions if, in the future, a person is unable to make those decisions
  definition:
    v: Provision for healthcare decisions if, in the future, a person is unable to make those decisions
  min:
    v: 0
  max:
    v: *
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAdvanceDirective
element:
  id:
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  path:
    v: EHDSDischargeReport.body.alerts
  short:
    v: Section: Alerts.
  definition:
    v: Information about substantial alerts or warnings that health professionals should be aware of.
  requirements:
    v: eHN Guideline HDR (v1.1): A.2.2
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: Base
element:
  id:
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  short:
    v: Narrative, potentially formatted, content of the section
  definition:
    v: Narrative, potentially formatted, content of the section
  min:
    v: 0
  max:
    v: 1
  type:
    code:
      v: string
element:
  id:
    v: EHDSDischargeReport.body.alerts.medicalAlert
  path:
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  short:
    v: Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
  definition:
    v: Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
  requirements:
    v: eHN Guideline HDR (v1.1): A.2.2.2
  min:
    v: 0
  max:
    v: *
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlert
element:
  id:
    v: EHDSDischargeReport.body.alerts.allergyAndIntolerance
  path:
    v: EHDSDischargeReport.body.alerts.allergyAndIntolerance
  short:
    v: Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
  definition:
    v: Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
  requirements:
    v: eHN Guideline HDR (v1.1): A.2.2.1
  min:
    v: 0
  max:
    v: *
  type:
    code:
      v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
element:
  id:
    v: EHDSDischargeReport.body.encounterInformation
  path:
    v: EHDSDischargeReport.body.encounterInformation

v: Section: Encounter information.

v: Section: Encounter information.

v: eHN Guideline HDR (v1.1): A.2.2

v: 1

v: 1

code:
  v: Base

id:
  v: EHDSDischargeReport.body.encounterInformation.narrative
path:
  v: EHDSDischargeReport.body.encounterInformation.narrative
short:
  v: Narrative, potentially formatted, content of the section
definition:
  v: Narrative, potentially formatted, content of the section
min:
  v: 1
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.encounterInformation.encounter
path:
  v: EHDSDischargeReport.body.encounterInformation.encounter
short:
  v: Encounter information
definition:
  v: Encounter information
requirements:
  v: eHN Guideline HDR (v1.1): A.2.3
min:
  v: 0
max:
  v: 1
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter

id:
  v: EHDSDischargeReport.body.admissionEvaluation
path:
  v: EHDSDischargeReport.body.admissionEvaluation
short:
  v: Section: Admission evaluation
definition:
  v: Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.4
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.admissionEvaluation.narrative
path:
  v: EHDSDischargeReport.body.admissionEvaluation.narrative
short:
  v: 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.
definition:
  v: 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.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
path:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
short:
  v: Objective findings
definition:
  v: Sub-section with objective findings.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.4.1
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.narrative
path:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.narrative
short:
  v: 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.
definition:
  v: 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.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.time
path:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.time
short:
  v: Date and time of the admission evaluation examination
definition:
  v: Date and time of the admission evaluation examination
requirements:
  v: eHN Guideline HDR (v1.1): A.2.4.1.1
min:
  v: 0
max:
  v: 1
type:
  code:
    v: dateTime

id:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.performer
path:
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short:
  v: Health professional(s) responsible for the admission evaluation examination.
definition:
  v: Health professional(s) responsible for the admission evaluation examination.
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional

id:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.anthropometricObservations
path:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.anthropometricObservations
short:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
definition:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.4.1.2
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation

id:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.vitalSigns
path:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.vitalSigns
short:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
definition:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
requirements:
  v: eHN Guideline HDR (v1.1): A.2.4.1.3
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation

id:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.physicalExamination
path:
  v: EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.physicalExamination
short:
  v: Physical examination
definition:
  v: Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.4.1.4
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation

id:
  v: EHDSDischargeReport.body.admissionEvaluation.functionalStatus
path:
  v: EHDSDischargeReport.body.admissionEvaluation.functionalStatus
short:
  v: Section: Functional status
definition:
  v: Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
requirements:
  v: eHN Guideline HDR (v1.1): A.2.4.2
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.admissionEvaluation.functionalStatus.narrative
path:
  v: EHDSDischargeReport.body.admissionEvaluation.functionalStatus.narrative
short:
  v: Narrative, potentially formatted, content of the section
definition:
  v: Narrative, potentially formatted, content of the section
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.admissionEvaluation.functionalStatus.functionalStatusAssessment
path:
  v: EHDSDischargeReport.body.admissionEvaluation.functionalStatus.functionalStatusAssessment
short:
  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
definition:
  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus

id:
  v: EHDSDischargeReport.body.patientHistory
path:
  v: EHDSDischargeReport.body.patientHistory
short:
  v: Section: Patient health history (anamnesis).
definition:
  v: Section: Patient health history (anamnesis).
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.narrative
path:
  v: EHDSDischargeReport.body.patientHistory.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory
short:
  v: Medical history subsection.
definition:
  v: Medical history subsection.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1
min:
  v: 1
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.narrative
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pastProblems
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pastProblems
short:
  v: Past problems
definition:
  v: A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1.1
min:
  v: 1
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.devicesAndImplants
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.devicesAndImplants
short:
  v: Devices and Implants
definition:
  v: Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1.2
min:
  v: 1
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.historyOfProcedures
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.historyOfProcedures
short:
  v: History of procedures
definition:
  v: Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1.3
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.vaccination
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.vaccination
short:
  v: Vaccination history of the patient.
definition:
  v: Vaccination history of the patient.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1.4
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunisation

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory
short:
  v: Epidemiological history
definition:
  v: Travel history and infectious contacts
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1.5
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
short:
  v: Infectious contacts of the patient
definition:
  v: Infectious contacts of the patient
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1.5.1
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSInfectiousContact

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
short:
  v: Travel history reported by the patient. Multiple records could be provided.
definition:
  v: Travel history reported by the patient. Multiple records could be provided.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.1.5.2
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSTravelHistory

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory
short:
  v: Section: Pregnancy history
definition:
  v: To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
requirements:
  v: eHN Guideline PS (v3.4) A2.6, ISO IPS
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.currentPregnancyStatus
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.currentPregnancyStatus
short:
  v: Current pregnancy status
definition:
  v: Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCurrentPregnancy

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnanciesStatus
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnanciesStatus
short:
  v: Overall status of previous pregnancies
definition:
  v: Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnancies
path:
  v: EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnancies
short:
  v: History of previous pregnancies
definition:
  v: Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPregnancyHistory

id:
  v: EHDSDischargeReport.body.patientHistory.familyHistorySection
path:
  v: EHDSDischargeReport.body.patientHistory.familyHistorySection
short:
  v: Family history section
definition:
  v: Relevant family history section.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.2
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.familyHistorySection.narrative
path:
  v: EHDSDischargeReport.body.patientHistory.familyHistorySection.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.familyHistorySection.familyHistory
path:
  v: EHDSDischargeReport.body.patientHistory.familyHistorySection.familyHistory
short:
  v: Family history
definition:
  v: Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFamilyMemberHistory

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth
short:
  v: Social determinants of health
definition:
  v: Information about social determinants of health.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.3
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.narrative
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.narrative
short:
  v: Sub-section narrative
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
short:
  v: Participation in society
definition:
  v: Participation in society details.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.3.1
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
short:
  v: Work situation
definition:
  v: Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
short:
  v: An activity the patient enjoys doing in their free time.
definition:
  v: An activity the patient enjoys doing in their free time.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
short:
  v: Social network
definition:
  v: A description of the patient’s social network, such as family, neighbours and friends.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection
short:
  v: Education section
definition:
  v: Information about patient education level.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.3.2
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
short:
  v: Education level
definition:
  v: Indication of the highest level of education achieved.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: hl7:v3.EducationLevel

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
short:
  v: If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
definition:
  v: If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation
short:
  v: Living situation - household type and other related living situation information.
definition:
  v: Living situation - household type and other related living situation information.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.3.3
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
short:
  v: Type of home the patient lives in.
definition:
  v: Type of home the patient lives in.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: SNOMED CT

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
short:
  v: 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.
definition:
  v: 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.
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: SNOMED CT

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
short:
  v: Living conditions that affect the accessibility of the home or the stay in the home.
definition:
  v: Living conditions that affect the accessibility of the home or the stay in the home.
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: SNOMED CT

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation
short:
  v: Family situation
definition:
  v: Family situation
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.3.4
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
short:
  v: Comment on the family situation.
definition:
  v: Comment on the family situation.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
short:
  v: Family composition
definition:
  v: The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: SNOMED CT

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
short:
  v: Person’s marital status according to the terms and definition in the national civil code.
definition:
  v: Person’s marital status according to the terms and definition in the national civil code.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: hl7:marital-status

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
short:
  v: Number of children
definition:
  v: The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Quantity

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
short:
  v: Number of children living at home with the patient.
definition:
  v: Number of children living at home with the patient.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Quantity

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
short:
  v: Child details (age, co-living status and comment).
definition:
  v: Child details (age, co-living status and comment).
min:
  v: 0
max:
  v: *
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
short:
  v: Living at home. An indication stating whether the child lives at home.
definition:
  v: Living at home. An indication stating whether the child lives at home.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: boolean

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
short:
  v: Child’s date of birth.
definition:
  v: Child’s date of birth.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: date

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
short:
  v: A comment on the child's family situation.
definition:
  v: A comment on the child's family situation.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
short:
  v: Care responsibility. The activities the patient carries out to care for a dependent family member.
definition:
  v: Care responsibility. The activities the patient carries out to care for a dependent family member.
min:
  v: 0
max:
  v: *
type:
  code:
    v: CodeableConcept
binding:
  strength:
    v: preferred
  description:
    v: SNOMED CT

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
short:
  v: Use of substances
definition:
  v: Information about use and/or abuse of specific substances.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.4
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
short:
  v: Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
definition:
  v: Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.4.1
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
short:
  v: Tobacco use
definition:
  v: Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.4.2
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse

id:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
path:
  v: EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
short:
  v: Consumption of drugs and other substances (in terms of abuse).
definition:
  v: Consumption of drugs and other substances (in terms of abuse).
requirements:
  v: eHN Guideline HDR (v1.1): A.2.5.4.3
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse

id:
  v: EHDSDischargeReport.body.courseOfEncounter
path:
  v: EHDSDischargeReport.body.courseOfEncounter
short:
  v: Course of inpatient or outpatient encounter.
definition:
  v: Course of inpatient or outpatient encounter.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6
min:
  v: 1
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
path:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
short:
  v: Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
definition:
  v: 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.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.1
min:
  v: 1
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.narrative
path:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.narrative
short:
  v: Problem specification in narrative form.
definition:
  v: Problem specification in narrative form.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails
path:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails
short:
  v: Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
definition:
  v: Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one problem should be marked as treated. Other problems are recorded only if they are important for continuity of care (after discharge).
min:
  v: 0
max:
  v: *
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.presentOnAdmission
path:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.presentOnAdmission
short:
  v: Whether the condition was present on admission or acquired during encounter
definition:
  v: Category of the problem allows flagging for conditions acquired during encounter.
comment:
  v: Value set can include Present on admission [POA], Hospital acquired condition [HAC], Not applicable or Unknown
min:
  v: 1
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
path:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
short:
  v: Class of the problem (treated, other) in relation to the encounter.
definition:
  v: Class of the problem (treated, other) in relation to the encounter.
min:
  v: 1
max:
  v: 1
type:
  code:
    v: CodeableConcept

id:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
path:
  v: EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
short:
  v: Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
definition:
  v: Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
min:
  v: 1
max:
  v: 1
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition

id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantProcedures
path:
  v: EHDSDischargeReport.body.courseOfEncounter.significantProcedures
short:
  v: Significant procedures section
definition:
  v: Significant surgical and non-surgical procedures performed during encounter which are significant for continuity of care, e.g. surgeries and other instrumental interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.2
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantProcedures.narrative
path:
  v: EHDSDischargeReport.body.courseOfEncounter.significantProcedures.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantProcedures.procedureEntry
path:
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short:
  v: Structured procedure entry.
definition:
  v: Structured procedure entry.
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure

id:
  v: EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
path:
  v: EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
short:
  v: Medical devices and implants section
definition:
  v: Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.3
min:
  v: 1
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.narrative
path:
  v: EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
path:
  v: EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
short:
  v: Medical devices and implants
definition:
  v: Medical devices and implants
min:
  v: 1
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse

id:
  v: EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
path:
  v: EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
short:
  v: Pharmacotherapy section
definition:
  v: Selected drug treatment during encounter. Medicinal products that were administered during encounter and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section. Medicinal products, the administration of which was started during encounter, but is also recommended after discharge, will be listed in the summary table in the recommendation section.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.5
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.narrative
path:
  v: EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
path:
  v: EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
short:
  v: Pharmacotherapy structured entry.
definition:
  v: Pharmacotherapy structured entry.
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement

id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults
path:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults
short:
  v: Significant Observation Results
definition:
  v: Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during encounter. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.6
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.narrative
path:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.narrative
short:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
definition:
  v: Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
path:
  v: EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
short:
  v: Significant Observation Result
definition:
  v: Structured significant observation entry.
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation

id:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis
path:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis
short:
  v: Synthesis
definition:
  v: This section provides clinical synthesis (e.g. description of reasons and course of encounter) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.6.7
min:
  v: 1
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis.problemSynthesis
path:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis.problemSynthesis
short:
  v: Summary description of the reason and course of hospitalisation for a specific problem.
definition:
  v: Summary description of the reason and course of hospitalisation for a specific problem.
min:
  v: 1
max:
  v: *
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis.clinicalReasoning
path:
  v: EHDSDischargeReport.body.courseOfEncounter.synthesis.clinicalReasoning
short:
  v: Clinical reasoning
definition:
  v: The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.dischargeDetails
path:
  v: EHDSDischargeReport.body.dischargeDetails
short:
  v: Discharge details
definition:
  v: Structured information should be provided, however if not available, at least a section narrative should be present.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7
min:
  v: 1
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.dischargeDetails.narrative
path:
  v: EHDSDischargeReport.body.dischargeDetails.narrative
short:
  v: 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.
definition:
  v: 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.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings
path:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings
short:
  v: Objective findings
definition:
  v: Sub-section with objective findings.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.narrative
path:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.narrative
short:
  v: Narrative content of the section.
definition:
  v: Narrative content of the section.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.anthropometricObservations
path:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.anthropometricObservations
short:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
definition:
  v: Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1.3
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation

id:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.vitalSigns
path:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.vitalSigns
short:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
definition:
  v: Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1.4
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation

id:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.physicalExamination
path:
  v: EHDSDischargeReport.body.dischargeDetails.objectiveFindings.physicalExamination
short:
  v: Physical examination
definition:
  v: Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.1.5
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation

id:
  v: EHDSDischargeReport.body.dischargeDetails.functionalStatus
path:
  v: EHDSDischargeReport.body.dischargeDetails.functionalStatus
short:
  v: Section: Functional status
definition:
  v: Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
requirements:
  v: eHN Guideline HDR (v1.1): A.2.7.2
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.dischargeDetails.functionalStatus.narrative
path:
  v: EHDSDischargeReport.body.dischargeDetails.functionalStatus.narrative
short:
  v: Narrative, potentially formatted, content of the section
definition:
  v: Narrative, potentially formatted, content of the section
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.dischargeDetails.functionalStatus.functionalStatusAssessment
path:
  v: EHDSDischargeReport.body.dischargeDetails.functionalStatus.functionalStatusAssessment
short:
  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
definition:
  v: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus

id:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary
path:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary
short:
  v: 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.
definition:
  v: 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.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.8.1
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.narrative
path:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.narrative
short:
  v: Narrative content of the section.
definition:
  v: Narrative content of the section.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry
path:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry
short:
  v: Structured medication entry
definition:
  v: Structured medication entry
min:
  v: 0
max:
  v: *
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.medicationUse
path:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.medicationUse
short:
  v: Details about medication and dosaging
definition:
  v: Details about medication and dosaging
min:
  v: 1
max:
  v: 1
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement

id:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.daysSupplied
path:
  v: EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.daysSupplied
short:
  v: Number of days for which the patient was provided with the drug at the time of discharge
definition:
  v: Supply is intended to either hand over the medicine or write out a prescription. A 0 value indicates that the patient has not been provided with the drug (e.g. if the patient has a sufficient supply of the drug)
min:
  v: 0
max:
  v: 1
type:
  code:
    v: Quantity

id:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan
path:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan
short:
  v: Care plan and other recommendations after discharge.
definition:
  v: Care plan and other recommendations after discharge section.
requirements:
  v: eHN Guideline HDR (v1.1): A.2.8.3
min:
  v: 0
max:
  v: *
type:
  code:
    v: Base

id:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan.narrative
path:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan.narrative
short:
  v: Narrative content of the section.
definition:
  v: Narrative content of the section.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan.carePlan
path:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan.carePlan
short:
  v: Structured care plan after discharge. Multiple care plans could be provided.
definition:
  v: Structured care plan after discharge. Multiple care plans could be provided.
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan

id:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan.otherRecommendations
path:
  v: EHDSDischargeReport.body.dischargeDetails.carePlan.otherRecommendations
short:
  v: Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
definition:
  v: Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
min:
  v: 0
max:
  v: 1
type:
  code:
    v: string

id:
  v: EHDSDischargeReport.attachments[x]
path:
  v: EHDSDischargeReport.attachments[x]
short:
  v: Report attachments data elements
definition:
  v: Report attachments data elements
min:
  v: 0
max:
  v: *
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
type:
  code:
    v: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedia