EHDS Logical Information Models
0.1.0 - ci-build

EHDS Logical Information Models, published by Xt-EHR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Xt-EHR/xt-ehr-common/tree/stakeholder-consultation-D7-3 and changes regularly. See the Directory of published versions

## Logical Model: EHDSDischargeReport - Detailed Descriptions

Draft as of 2025-08-25

Definitions for the EHDSDischargeReport logical model.

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

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

0. EHDSDischargeReport
Definition | EHDS refined base model for Discharge Report Base definition for all types defined in FHIR type system.
Short | Discharge Report modelBase for all types and resources
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSDischargeReport.header
Definition | Common header for all patient-related data
Short | Document header elements
Control | 1..1
Type | Base
4. EHDSDischargeReport.header.subject
Definition | Patient/subject information
Short | Subject
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
6. EHDSDischargeReport.header.identifier
Definition | Unique identifier of the document
Short | Document ID
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSDischargeReport.header.authorship
Definition | Resource authoring details
Short | Authorship
Control | 1..*
Type | Base
10. EHDSDischargeReport.header.authorship.author[x]
Definition | Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Short | Author
Control | 1..1
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
12. EHDSDischargeReport.header.authorship.datetime
Definition | Date and time of the issuing the document/resource by its author.
Short | Date and time of authoring/issuing
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
14. EHDSDischargeReport.header.lastUpdate
Definition | Date and time of the last update to the document/information
Short | Date and time of the last update to the resource
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSDischargeReport.header.status
Definition | Status of the resource
Short | Status of the resource
Control | 1..1
Type | CodeableConcept
18. EHDSDischargeReport.header.statusReason[x]
Definition | Reason for the current status of the resource.
Short | Reason for the current status of the resource.
Control | 0..1
Type | Choice of: CodeableConcept, string
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSDischargeReport.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
22. EHDSDischargeReport.header.version
Definition | Business version of the resource.
Short | Version
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
24. EHDSDischargeReport.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
26. EHDSDischargeReport.header.documentType
Definition | Identifies the type of document at hand, e.g. Discharge report.
Short | Document type
Control | 1..1
Binding | LOINC
Type | CodeableConcept
28. EHDSDischargeReport.header.documentTitle
Definition | Document title, such as Discharge Report, Laboratory Result Report, etc.
Short | Document title
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
30. EHDSDischargeReport.header.documentStatus
Definition | The status of the Discharge report. E.g., preliminary, final.
Short | Document status
Control | 1..1
Binding | hl7:CompositionStatus
Type | CodeableConcept
32. EHDSDischargeReport.header.period
Definition | Time of service that is being documented
Short | Period
Control | 0..1
Type | Period
34. EHDSDischargeReport.header.attestation
Definition | Document attestation details
Short | Attestation
Control | 0..*
Type | Base
36. EHDSDischargeReport.header.attestation.attester
Definition | Attester who validated the document. Mulitple attesters could be provided.
Short | Attester
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
38. EHDSDischargeReport.header.attestation.datetime
Definition | Date and time of the approval of the document by Attester.
Short | DateTime
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
40. EHDSDischargeReport.header.legalAuthentication
Definition | Document legal authentication
Short | Legal authentication
Control | 0..1
Type | Base
42. EHDSDischargeReport.header.legalAuthentication.legalAuthenticator
Definition | The person taking responsibility for the medical content of the document
Short | Legal authenticator
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
44. EHDSDischargeReport.header.legalAuthentication.datetime
Definition | Date and time when the document was authorized.
Short | DateTime
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
46. EHDSDischargeReport.header.eventType
Definition | 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.
Short | Event type
Control | 0..*
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
48. EHDSDischargeReport.header.authorSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Specialty
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
50. EHDSDischargeReport.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Document custodian
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation
52. EHDSDischargeReport.header.documentFormat
Definition | An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
Short | Document format
Control | 0..1
Binding | HL7 Document Format Codes
Type | CodeableConcept
54. EHDSDischargeReport.header.confidentiality
Definition | Level of confidentiality of the document. Implicit value is normal.
Short | Confidentiality
Control | 0..1
Binding | hl7:Confidentiality
Type | CodeableConcept
56. EHDSDischargeReport.knowledgeResources
Definition | Related documents and information sources
Short | Related documents and information sources
Control | 0..0
Type | Base
60. EHDSDischargeReport.header.intendedRecipient[x]
Definition | 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
Short | Intended recipient
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSRelatedPerson, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
62. EHDSDischargeReport.header.healthInsuranceAndPaymentInformation
Definition | Health insurance and payment information
Short | Health insurance and payment information
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCoverage
64. EHDSDischargeReport.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
66. EHDSDischargeReport.body.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
68. EHDSDischargeReport.body.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSDischargeReport.body.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAdvanceDirective
72. EHDSDischargeReport.body.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
74. EHDSDischargeReport.body.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
76. EHDSDischargeReport.body.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlert
Requirements | eHN Guideline HDR (v1.1): A.2.2.2
78. EHDSDischargeReport.body.alerts.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN Guideline HDR (v1.1): A.2.2.1
80. EHDSDischargeReport.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
82. EHDSDischargeReport.body.encounterInformation.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
84. EHDSDischargeReport.body.encounterInformation.encounter
Definition | Encounter information
Short | Encounter information
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter
Requirements | eHN Guideline HDR (v1.1): A.2.3
86. EHDSDischargeReport.body.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
88. EHDSDischargeReport.body.admissionEvaluation.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4.1
92. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
94. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.time
Definition | Date and time of the admission evaluation examination
Short | Date and time of the admission evaluation examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.1
96. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.performer
Definition | Health professional(s) responsible for the admission evaluation examination.
Short | Health professional(s) responsible for the admission evaluation examination.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
98. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.2
100. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.3
102. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.4
104. EHDSDischargeReport.body.admissionEvaluation.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4.2
106. EHDSDischargeReport.body.admissionEvaluation.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
108. EHDSDischargeReport.body.admissionEvaluation.functionalStatus.functionalStatusAssessment
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
110. EHDSDischargeReport.body.patientHistory
Definition | Section: Patient health history (anamnesis).
Short | Section: Patient health history (anamnesis).
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
112. EHDSDischargeReport.body.patientHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. EHDSDischargeReport.body.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1
116. EHDSDischargeReport.body.patientHistory.medicalHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
118. EHDSDischargeReport.body.patientHistory.medicalHistory.pastProblems
Definition | A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
Short | Past problems
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.1
120. EHDSDischargeReport.body.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.2
122. EHDSDischargeReport.body.patientHistory.medicalHistory.historyOfProcedures
Definition | Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
Short | History of procedures
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.3
124. EHDSDischargeReport.body.patientHistory.medicalHistory.vaccination
Definition | Vaccination history of the patient.
Short | Vaccination history of the patient.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunisation
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.4
126. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory
Definition | Travel history and infectious contacts
Short | Epidemiological history
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5
128. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
Definition | Infectious contacts of the patient
Short | Infectious contacts of the patient
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSInfectiousContact
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5.1
130. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
Definition | Travel history reported by the patient. Multiple records could be provided.
Short | Travel history reported by the patient. Multiple records could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSTravelHistory
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5.2
132. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory
Definition | To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Short | Section: Pregnancy history
Control | 0..1
Type | Base
Requirements | eHN Guideline PS (v3.4) A2.6, ISO IPS
134. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.currentPregnancyStatus
Definition | Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Short | Current pregnancy status
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCurrentPregnancy
136. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnanciesStatus
Definition | Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown
Short | Overall status of previous pregnancies
Control | 0..1
Type | CodeableConcept
138. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnancies
Definition | Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Short | History of previous pregnancies
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPregnancyHistory
140. EHDSDischargeReport.body.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.2
142. EHDSDischargeReport.body.patientHistory.familyHistorySection.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
144. EHDSDischargeReport.body.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFamilyMemberHistory
146. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3
148. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
150. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.1
152. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
Short | Work situation
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
154. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
156. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient’s social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
158. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.2
160. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
162. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
164. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.3
166. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
168. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Short | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
170. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
172. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.4
174. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
176. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
178. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person’s marital status according to the terms and definition in the national civil code.
Short | Person’s marital status according to the terms and definition in the national civil code.
Control | 0..1
Binding | hl7:marital-status
Type | CodeableConcept
180. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
182. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
184. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
186. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
188. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child’s date of birth.
Short | Child’s date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
190. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
192. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
194. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.4
196. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
198. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.1
200. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.2
202. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.3
204. EHDSDischargeReport.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
206. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
Definition | The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Short | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
208. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.narrative
Definition | Problem specification in narrative form.
Short | Problem specification in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
210. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails
Definition | 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).
Short | 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).
Control | 0..*
Type | Base
212. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.presentOnAdmission
Definition | Category of the problem allows flagging for conditions acquired during encounter.
Short | Whether the condition was present on admission or acquired during encounter
Comments | Value set can include Present on admission [POA], Hospital acquired condition [HAC], Not applicable or Unknown
Control | 1..1
Type | CodeableConcept
214. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
Definition | Class of the problem (treated, other) in relation to the encounter.
Short | Class of the problem (treated, other) in relation to the encounter.
Control | 1..1
Type | CodeableConcept
216. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
218. EHDSDischargeReport.body.courseOfEncounter.significantProcedures
Definition | 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.
Short | Significant procedures section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
220. EHDSDischargeReport.body.courseOfEncounter.significantProcedures.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
222. EHDSDischargeReport.body.courseOfEncounter.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
224. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Short | Medical devices and implants section
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
226. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
228. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
230. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
Definition | 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.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
232. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
234. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
236. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults
Definition | 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.
Short | Significant Observation Results
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.6
238. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
240. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
242. EHDSDischargeReport.body.courseOfEncounter.synthesis
Definition | 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.
Short | Synthesis
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
244. EHDSDischargeReport.body.courseOfEncounter.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
246. EHDSDischargeReport.body.courseOfEncounter.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
248. EHDSDischargeReport.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
250. EHDSDischargeReport.body.dischargeDetails.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
252. EHDSDischargeReport.body.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
254. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
256. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.3
258. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.4
260. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.5
262. EHDSDischargeReport.body.dischargeDetails.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
264. EHDSDischargeReport.body.dischargeDetails.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
266. EHDSDischargeReport.body.dischargeDetails.functionalStatus.functionalStatusAssessment
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
268. EHDSDischargeReport.body.dischargeDetails.medicationSummary
Definition | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
Short | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.1
270. EHDSDischargeReport.body.dischargeDetails.medicationSummary.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
272. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry
Definition | Structured medication entry
Short | Structured medication entry
Control | 0..*
Type | Base
274. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.medicationUse
Definition | Details about medication and dosaging
Short | Details about medication and dosaging
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
276. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.daysSupplied
Definition | 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)
Short | Number of days for which the patient was provided with the drug at the time of discharge
Control | 0..1
Type | Quantity
278. EHDSDischargeReport.body.dischargeDetails.carePlan
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
280. EHDSDischargeReport.body.dischargeDetails.carePlan.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
282. EHDSDischargeReport.body.dischargeDetails.carePlan.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan
284. EHDSDischargeReport.body.dischargeDetails.carePlan.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
286. EHDSDischargeReport.attachments[x]
Definition | Report attachments data elements
Short | Report attachments data elements
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedia
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]

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

0. EHDSDischargeReport
Definition | EHDS refined base model for Discharge Report
Short | Discharge Report model
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSDischargeReport.header
4. EHDSDischargeReport.header.intendedRecipient[x]
Definition | 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
Short | Intended recipient
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSRelatedPerson, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
6. EHDSDischargeReport.header.healthInsuranceAndPaymentInformation
Definition | Health insurance and payment information
Short | Health insurance and payment information
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCoverage
8. EHDSDischargeReport.knowledgeResources
Control | 0..0
10. EHDSDischargeReport.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
12. EHDSDischargeReport.body.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
14. EHDSDischargeReport.body.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSDischargeReport.body.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAdvanceDirective
18. EHDSDischargeReport.body.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
20. EHDSDischargeReport.body.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. EHDSDischargeReport.body.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlert
Requirements | eHN Guideline HDR (v1.1): A.2.2.2
24. EHDSDischargeReport.body.alerts.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN Guideline HDR (v1.1): A.2.2.1
26. EHDSDischargeReport.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
28. EHDSDischargeReport.body.encounterInformation.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
30. EHDSDischargeReport.body.encounterInformation.encounter
Definition | Encounter information
Short | Encounter information
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter
Requirements | eHN Guideline HDR (v1.1): A.2.3
32. EHDSDischargeReport.body.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
34. EHDSDischargeReport.body.admissionEvaluation.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
36. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4.1
38. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
40. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.time
Definition | Date and time of the admission evaluation examination
Short | Date and time of the admission evaluation examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.1
42. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.performer
Definition | Health professional(s) responsible for the admission evaluation examination.
Short | Health professional(s) responsible for the admission evaluation examination.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
44. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.2
46. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.3
48. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.4
50. EHDSDischargeReport.body.admissionEvaluation.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4.2
52. EHDSDischargeReport.body.admissionEvaluation.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
54. EHDSDischargeReport.body.admissionEvaluation.functionalStatus.functionalStatusAssessment
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
56. EHDSDischargeReport.body.patientHistory
Definition | Section: Patient health history (anamnesis).
Short | Section: Patient health history (anamnesis).
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
58. EHDSDischargeReport.body.patientHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
60. EHDSDischargeReport.body.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1
62. EHDSDischargeReport.body.patientHistory.medicalHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
64. EHDSDischargeReport.body.patientHistory.medicalHistory.pastProblems
Definition | A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
Short | Past problems
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.1
66. EHDSDischargeReport.body.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.2
68. EHDSDischargeReport.body.patientHistory.medicalHistory.historyOfProcedures
Definition | Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
Short | History of procedures
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.3
70. EHDSDischargeReport.body.patientHistory.medicalHistory.vaccination
Definition | Vaccination history of the patient.
Short | Vaccination history of the patient.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunisation
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.4
72. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory
Definition | Travel history and infectious contacts
Short | Epidemiological history
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5
74. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
Definition | Infectious contacts of the patient
Short | Infectious contacts of the patient
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSInfectiousContact
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5.1
76. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
Definition | Travel history reported by the patient. Multiple records could be provided.
Short | Travel history reported by the patient. Multiple records could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSTravelHistory
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5.2
78. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory
Definition | To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Short | Section: Pregnancy history
Control | 0..1
Type | Base
Requirements | eHN Guideline PS (v3.4) A2.6, ISO IPS
80. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.currentPregnancyStatus
Definition | Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Short | Current pregnancy status
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCurrentPregnancy
82. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnanciesStatus
Definition | Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown
Short | Overall status of previous pregnancies
Control | 0..1
Type | CodeableConcept
84. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnancies
Definition | Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Short | History of previous pregnancies
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPregnancyHistory
86. EHDSDischargeReport.body.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.2
88. EHDSDischargeReport.body.patientHistory.familyHistorySection.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSDischargeReport.body.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFamilyMemberHistory
92. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3
94. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.1
98. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
Short | Work situation
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
102. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient’s social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
104. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.2
106. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
108. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.3
112. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
114. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Short | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
116. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
118. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.4
120. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
122. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
124. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person’s marital status according to the terms and definition in the national civil code.
Short | Person’s marital status according to the terms and definition in the national civil code.
Control | 0..1
Binding | hl7:marital-status
Type | CodeableConcept
126. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
128. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
130. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
132. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
134. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child’s date of birth.
Short | Child’s date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
136. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
138. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
140. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.4
142. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
144. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.1
146. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.2
148. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.3
150. EHDSDischargeReport.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
152. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
Definition | The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Short | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
154. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.narrative
Definition | Problem specification in narrative form.
Short | Problem specification in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
156. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails
Definition | 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).
Short | 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).
Control | 0..*
Type | Base
158. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.presentOnAdmission
Definition | Category of the problem allows flagging for conditions acquired during encounter.
Short | Whether the condition was present on admission or acquired during encounter
Comments | Value set can include Present on admission [POA], Hospital acquired condition [HAC], Not applicable or Unknown
Control | 1..1
Type | CodeableConcept
160. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
Definition | Class of the problem (treated, other) in relation to the encounter.
Short | Class of the problem (treated, other) in relation to the encounter.
Control | 1..1
Type | CodeableConcept
162. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
164. EHDSDischargeReport.body.courseOfEncounter.significantProcedures
Definition | 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.
Short | Significant procedures section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
166. EHDSDischargeReport.body.courseOfEncounter.significantProcedures.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
168. EHDSDischargeReport.body.courseOfEncounter.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
170. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Short | Medical devices and implants section
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
172. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
174. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
176. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
Definition | 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.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
178. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
180. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
182. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults
Definition | 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.
Short | Significant Observation Results
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.6
184. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
186. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
188. EHDSDischargeReport.body.courseOfEncounter.synthesis
Definition | 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.
Short | Synthesis
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
190. EHDSDischargeReport.body.courseOfEncounter.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
192. EHDSDischargeReport.body.courseOfEncounter.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
194. EHDSDischargeReport.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
196. EHDSDischargeReport.body.dischargeDetails.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
198. EHDSDischargeReport.body.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
200. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
202. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.3
204. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.4
206. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.5
208. EHDSDischargeReport.body.dischargeDetails.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
210. EHDSDischargeReport.body.dischargeDetails.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
212. EHDSDischargeReport.body.dischargeDetails.functionalStatus.functionalStatusAssessment
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
214. EHDSDischargeReport.body.dischargeDetails.medicationSummary
Definition | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
Short | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.1
216. EHDSDischargeReport.body.dischargeDetails.medicationSummary.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
218. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry
Definition | Structured medication entry
Short | Structured medication entry
Control | 0..*
Type | Base
220. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.medicationUse
Definition | Details about medication and dosaging
Short | Details about medication and dosaging
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
222. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.daysSupplied
Definition | 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)
Short | Number of days for which the patient was provided with the drug at the time of discharge
Control | 0..1
Type | Quantity
224. EHDSDischargeReport.body.dischargeDetails.carePlan
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
226. EHDSDischargeReport.body.dischargeDetails.carePlan.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
228. EHDSDischargeReport.body.dischargeDetails.carePlan.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan
230. EHDSDischargeReport.body.dischargeDetails.carePlan.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
232. EHDSDischargeReport.attachments[x]
Definition | Report attachments data elements
Short | Report attachments data elements
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedia
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]

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

0. EHDSDischargeReport
Definition | EHDS refined base model for Discharge Report
Short | Discharge Report model
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSDischargeReport.header
Definition | Common header for all patient-related data
Short | Document header elements
Control | 1..1
Type | Base
4. EHDSDischargeReport.header.subject
Definition | Patient/subject information
Short | Subject
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
6. EHDSDischargeReport.header.identifier
Definition | Unique identifier of the document
Short | Document ID
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSDischargeReport.header.authorship
Definition | Resource authoring details
Short | Authorship
Control | 1..*
Type | Base
10. EHDSDischargeReport.header.authorship.author[x]
Definition | Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Short | Author
Control | 1..1
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
12. EHDSDischargeReport.header.authorship.datetime
Definition | Date and time of the issuing the document/resource by its author.
Short | Date and time of authoring/issuing
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
14. EHDSDischargeReport.header.lastUpdate
Definition | Date and time of the last update to the document/information
Short | Date and time of the last update to the resource
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSDischargeReport.header.status
Definition | Status of the resource
Short | Status of the resource
Control | 1..1
Type | CodeableConcept
18. EHDSDischargeReport.header.statusReason[x]
Definition | Reason for the current status of the resource.
Short | Reason for the current status of the resource.
Control | 0..1
Type | Choice of: CodeableConcept, string
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSDischargeReport.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
22. EHDSDischargeReport.header.version
Definition | Business version of the resource.
Short | Version
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
24. EHDSDischargeReport.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
26. EHDSDischargeReport.header.documentType
Definition | Identifies the type of document at hand, e.g. Discharge report.
Short | Document type
Control | 1..1
Binding | LOINC
Type | CodeableConcept
28. EHDSDischargeReport.header.documentTitle
Definition | Document title, such as Discharge Report, Laboratory Result Report, etc.
Short | Document title
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
30. EHDSDischargeReport.header.documentStatus
Definition | The status of the Discharge report. E.g., preliminary, final.
Short | Document status
Control | 1..1
Binding | hl7:CompositionStatus
Type | CodeableConcept
32. EHDSDischargeReport.header.period
Definition | Time of service that is being documented
Short | Period
Control | 0..1
Type | Period
34. EHDSDischargeReport.header.attestation
Definition | Document attestation details
Short | Attestation
Control | 0..*
Type | Base
36. EHDSDischargeReport.header.attestation.attester
Definition | Attester who validated the document. Mulitple attesters could be provided.
Short | Attester
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
38. EHDSDischargeReport.header.attestation.datetime
Definition | Date and time of the approval of the document by Attester.
Short | DateTime
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
40. EHDSDischargeReport.header.legalAuthentication
Definition | Document legal authentication
Short | Legal authentication
Control | 0..1
Type | Base
42. EHDSDischargeReport.header.legalAuthentication.legalAuthenticator
Definition | The person taking responsibility for the medical content of the document
Short | Legal authenticator
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
44. EHDSDischargeReport.header.legalAuthentication.datetime
Definition | Date and time when the document was authorized.
Short | DateTime
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
46. EHDSDischargeReport.header.eventType
Definition | 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.
Short | Event type
Control | 0..*
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
48. EHDSDischargeReport.header.authorSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Specialty
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
50. EHDSDischargeReport.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Document custodian
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation
52. EHDSDischargeReport.header.documentFormat
Definition | An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
Short | Document format
Control | 0..1
Binding | HL7 Document Format Codes
Type | CodeableConcept
54. EHDSDischargeReport.header.confidentiality
Definition | Level of confidentiality of the document. Implicit value is normal.
Short | Confidentiality
Control | 0..1
Binding | hl7:Confidentiality
Type | CodeableConcept
56. EHDSDischargeReport.knowledgeResources
Definition | Related documents and information sources
Short | Related documents and information sources
Control | 0..0
Type | Base
60. EHDSDischargeReport.header.intendedRecipient[x]
Definition | 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
Short | Intended recipient
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSRelatedPerson, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganisation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
62. EHDSDischargeReport.header.healthInsuranceAndPaymentInformation
Definition | Health insurance and payment information
Short | Health insurance and payment information
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCoverage
64. EHDSDischargeReport.body
Definition | Structured body of the discharge report document
Short | Structured body of the discharge report document
Control | 0..1
Type | Base
66. EHDSDischargeReport.body.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
68. EHDSDischargeReport.body.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSDischargeReport.body.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAdvanceDirective
72. EHDSDischargeReport.body.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
74. EHDSDischargeReport.body.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
76. EHDSDischargeReport.body.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlert
Requirements | eHN Guideline HDR (v1.1): A.2.2.2
78. EHDSDischargeReport.body.alerts.allergyAndIntolerance
Definition | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Short | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN Guideline HDR (v1.1): A.2.2.1
80. EHDSDischargeReport.body.encounterInformation
Definition | Section: Encounter information.
Short | Section: Encounter information.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.2
82. EHDSDischargeReport.body.encounterInformation.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
84. EHDSDischargeReport.body.encounterInformation.encounter
Definition | Encounter information
Short | Encounter information
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSEncounter
Requirements | eHN Guideline HDR (v1.1): A.2.3
86. EHDSDischargeReport.body.admissionEvaluation
Definition | Admission evaluation section should be reported exceptionally only if it is relevant to ensure continuity of care.
Short | Section: Admission evaluation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4
88. EHDSDischargeReport.body.admissionEvaluation.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4.1
92. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
94. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.time
Definition | Date and time of the admission evaluation examination
Short | Date and time of the admission evaluation examination
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.1
96. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.performer
Definition | Health professional(s) responsible for the admission evaluation examination.
Short | Health professional(s) responsible for the admission evaluation examination.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional
98. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.2
100. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.3
102. EHDSDischargeReport.body.admissionEvaluation.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.4.1.4
104. EHDSDischargeReport.body.admissionEvaluation.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.4.2
106. EHDSDischargeReport.body.admissionEvaluation.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
108. EHDSDischargeReport.body.admissionEvaluation.functionalStatus.functionalStatusAssessment
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
110. EHDSDischargeReport.body.patientHistory
Definition | Section: Patient health history (anamnesis).
Short | Section: Patient health history (anamnesis).
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5
112. EHDSDischargeReport.body.patientHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. EHDSDischargeReport.body.patientHistory.medicalHistory
Definition | Medical history subsection.
Short | Medical history subsection.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1
116. EHDSDischargeReport.body.patientHistory.medicalHistory.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
118. EHDSDischargeReport.body.patientHistory.medicalHistory.pastProblems
Definition | A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.
Short | Past problems
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.1
120. EHDSDischargeReport.body.patientHistory.medicalHistory.devicesAndImplants
Definition | Devices and implants in patient anamnesis. Negative statement must be explicitly stated.
Short | Devices and Implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.2
122. EHDSDischargeReport.body.patientHistory.medicalHistory.historyOfProcedures
Definition | Historical procedures performed on or for a patient, relevant for the current encounter.Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, personal support services, adult day care services, etc.
Short | History of procedures
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.3
124. EHDSDischargeReport.body.patientHistory.medicalHistory.vaccination
Definition | Vaccination history of the patient.
Short | Vaccination history of the patient.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunisation
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.4
126. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory
Definition | Travel history and infectious contacts
Short | Epidemiological history
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5
128. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.infectiousContacts
Definition | Infectious contacts of the patient
Short | Infectious contacts of the patient
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSInfectiousContact
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5.1
130. EHDSDischargeReport.body.patientHistory.medicalHistory.epidemiologicalHistory.travelHistory
Definition | Travel history reported by the patient. Multiple records could be provided.
Short | Travel history reported by the patient. Multiple records could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSTravelHistory
Requirements | eHN Guideline HDR (v1.1): A.2.5.1.5.2
132. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory
Definition | To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Short | Section: Pregnancy history
Control | 0..1
Type | Base
Requirements | eHN Guideline PS (v3.4) A2.6, ISO IPS
134. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.currentPregnancyStatus
Definition | Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Short | Current pregnancy status
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCurrentPregnancy
136. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnanciesStatus
Definition | Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown
Short | Overall status of previous pregnancies
Control | 0..1
Type | CodeableConcept
138. EHDSDischargeReport.body.patientHistory.medicalHistory.pregnancyHistory.previousPregnancies
Definition | Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Short | History of previous pregnancies
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPregnancyHistory
140. EHDSDischargeReport.body.patientHistory.familyHistorySection
Definition | Relevant family history section.
Short | Family history section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.2
142. EHDSDischargeReport.body.patientHistory.familyHistorySection.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
144. EHDSDischargeReport.body.patientHistory.familyHistorySection.familyHistory
Definition | Information about serious illnesses in close blood relatives with known or suspected genetic potential or with possible impact on patient care.
Short | Family history
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFamilyMemberHistory
146. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth
Definition | Information about social determinants of health.
Short | Social determinants of health
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3
148. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Sub-section narrative
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
150. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety
Definition | Participation in society details.
Short | Participation in society
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.1
152. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.workSituation
Definition | Work Situation describes the extent to which and in what way the patient participates in the workforce. Work is meant in the broadest sense of the word: activities that contribute to the person themselves, their environment or society. This includes both paid and unpaid work.
Short | Work situation
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
154. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.hobby
Definition | An activity the patient enjoys doing in their free time.
Short | An activity the patient enjoys doing in their free time.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
156. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.participationInSociety.socialNetwork
Definition | A description of the patient’s social network, such as family, neighbours and friends.
Short | Social network
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
158. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection
Definition | Information about patient education level.
Short | Education section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.2
160. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel
Definition | Indication of the highest level of education achieved.
Short | Education level
Control | 0..1
Binding | hl7:v3.EducationLevel
Type | CodeableConcept
162. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.comment
Definition | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Short | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
164. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation
Definition | Living situation - household type and other related living situation information.
Short | Living situation - household type and other related living situation information.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.3
166. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType
Definition | Type of home the patient lives in.
Short | Type of home the patient lives in.
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
168. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption
Definition | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Short | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
170. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions
Definition | Living conditions that affect the accessibility of the home or the stay in the home.
Short | Living conditions that affect the accessibility of the home or the stay in the home.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
172. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation
Definition | Family situation
Short | Family situation
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.3.4
174. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.comment
Definition | Comment on the family situation.
Short | Comment on the family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
176. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition
Definition | The family composition describes the patient’s home situation and the form of cohabitation. A family can consist of one or more people.
Short | Family composition
Control | 0..1
Binding | SNOMED CT
Type | CodeableConcept
178. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus
Definition | Person’s marital status according to the terms and definition in the national civil code.
Short | Person’s marital status according to the terms and definition in the national civil code.
Control | 0..1
Binding | hl7:marital-status
Type | CodeableConcept
180. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildren
Definition | The number of children the patient has. Children in the context of this information model include step children, foster children, biological and adopted children.
Short | Number of children
Control | 0..1
Type | Quantity
182. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.numberOfChildrenAtHome
Definition | Number of children living at home with the patient.
Short | Number of children living at home with the patient.
Control | 0..1
Type | Quantity
184. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails
Definition | Child details (age, co-living status and comment).
Short | Child details (age, co-living status and comment).
Control | 0..*
Type | Base
186. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.livingAtHome
Definition | Living at home. An indication stating whether the child lives at home.
Short | Living at home. An indication stating whether the child lives at home.
Control | 0..1
Type | boolean
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
188. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.dateOfBirth
Definition | Child’s date of birth.
Short | Child’s date of birth.
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
190. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.childDetails.comment
Definition | A comment on the child's family situation.
Short | A comment on the child's family situation.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
192. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility
Definition | Care responsibility. The activities the patient carries out to care for a dependent family member.
Short | Care responsibility. The activities the patient carries out to care for a dependent family member.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
194. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances
Definition | Information about use and/or abuse of specific substances.
Short | Use of substances
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.5.4
196. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
198. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.alcoholUse
Definition | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Short | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.1
200. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.tobaccoUse
Definition | Represent smoking or tobacco habits. Multiple records on tobacco use could be provided.
Short | Tobacco use
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.2
202. EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.useOfSubstances.drugConsumption
Definition | Consumption of drugs and other substances (in terms of abuse).
Short | Consumption of drugs and other substances (in terms of abuse).
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSSubstanceUse
Requirements | eHN Guideline HDR (v1.1): A.2.5.4.3
204. EHDSDischargeReport.body.courseOfEncounter
Definition | Course of inpatient or outpatient encounter.
Short | Course of inpatient or outpatient encounter.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6
206. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary
Definition | The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.
Short | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.1
208. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.narrative
Definition | Problem specification in narrative form.
Short | Problem specification in narrative form.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
210. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails
Definition | 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).
Short | 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).
Control | 0..*
Type | Base
212. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.presentOnAdmission
Definition | Category of the problem allows flagging for conditions acquired during encounter.
Short | Whether the condition was present on admission or acquired during encounter
Comments | Value set can include Present on admission [POA], Hospital acquired condition [HAC], Not applicable or Unknown
Control | 1..1
Type | CodeableConcept
214. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.treatmentClass
Definition | Class of the problem (treated, other) in relation to the encounter.
Short | Class of the problem (treated, other) in relation to the encounter.
Control | 1..1
Type | CodeableConcept
216. EHDSDischargeReport.body.courseOfEncounter.diagnosticSummary.problemDetails.problem
Definition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Short | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
218. EHDSDischargeReport.body.courseOfEncounter.significantProcedures
Definition | 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.
Short | Significant procedures section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.2
220. EHDSDischargeReport.body.courseOfEncounter.significantProcedures.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
222. EHDSDischargeReport.body.courseOfEncounter.significantProcedures.procedureEntry
Definition | Structured procedure entry.
Short | Structured procedure entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
224. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants
Definition | Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during encounter. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system
Short | Medical devices and implants section
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.3
226. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
228. EHDSDischargeReport.body.courseOfEncounter.medicalDevicesAndImplants.medicalDevicesAndImplants
Definition | Medical devices and implants
Short | Medical devices and implants
Control | 1..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
230. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy
Definition | 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.
Short | Pharmacotherapy section
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.5
232. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
234. EHDSDischargeReport.body.courseOfEncounter.pharmacotherapy.pharmacotherapy
Definition | Pharmacotherapy structured entry.
Short | Pharmacotherapy structured entry.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
236. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults
Definition | 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.
Short | Significant Observation Results
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.6
238. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
240. EHDSDischargeReport.body.courseOfEncounter.significantObservationResults.significantObservationResult[x]
Definition | Structured significant observation entry.
Short | Significant Observation Result
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
242. EHDSDischargeReport.body.courseOfEncounter.synthesis
Definition | 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.
Short | Synthesis
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.6.7
244. EHDSDischargeReport.body.courseOfEncounter.synthesis.problemSynthesis
Definition | Summary description of the reason and course of hospitalisation for a specific problem.
Short | Summary description of the reason and course of hospitalisation for a specific problem.
Control | 1..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
246. EHDSDischargeReport.body.courseOfEncounter.synthesis.clinicalReasoning
Definition | The clinical summary can be concluded with a clinical consideration (diff. diagnosis, explanation of context, etc.) for clinically complex conditions.
Short | Clinical reasoning
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
248. EHDSDischargeReport.body.dischargeDetails
Definition | Structured information should be provided, however if not available, at least a section narrative should be present.
Short | Discharge details
Control | 1..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7
250. EHDSDischargeReport.body.dischargeDetails.narrative
Definition | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Short | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
252. EHDSDischargeReport.body.dischargeDetails.objectiveFindings
Definition | Sub-section with objective findings.
Short | Objective findings
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.1
254. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
256. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.anthropometricObservations
Definition | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Short | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.3
258. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.vitalSigns
Definition | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Short | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.4
260. EHDSDischargeReport.body.dischargeDetails.objectiveFindings.physicalExamination
Definition | Physical examination is the process of evaluating objective anatomical findings. It is typically the first diagnostic measure performed after taking the patient's history, which allows an initial assessment of symptoms and is useful for determining the differential diagnoses and further steps. Physical examination can be performed through observation, palpation, percussion, and auscultation.
Short | Physical examination
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
Requirements | eHN Guideline HDR (v1.1): A.2.7.1.5
262. EHDSDischargeReport.body.dischargeDetails.functionalStatus
Definition | Functional status can be assessed in several different ways, usually with a focus on the person’s abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one’s own affairs.For details see: https://paciowg.github.io/functional-status-ig/
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.7.2
264. EHDSDischargeReport.body.dischargeDetails.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
266. EHDSDischargeReport.body.dischargeDetails.functionalStatus.functionalStatusAssessment
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
268. EHDSDischargeReport.body.dischargeDetails.medicationSummary
Definition | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
Short | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
Control | 0..1
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.1
270. EHDSDischargeReport.body.dischargeDetails.medicationSummary.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
272. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry
Definition | Structured medication entry
Short | Structured medication entry
Control | 0..*
Type | Base
274. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.medicationUse
Definition | Details about medication and dosaging
Short | Details about medication and dosaging
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationStatement
276. EHDSDischargeReport.body.dischargeDetails.medicationSummary.entry.daysSupplied
Definition | 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)
Short | Number of days for which the patient was provided with the drug at the time of discharge
Control | 0..1
Type | Quantity
278. EHDSDischargeReport.body.dischargeDetails.carePlan
Definition | Care plan and other recommendations after discharge section.
Short | Care plan and other recommendations after discharge.
Control | 0..*
Type | Base
Requirements | eHN Guideline HDR (v1.1): A.2.8.3
280. EHDSDischargeReport.body.dischargeDetails.carePlan.narrative
Definition | Narrative content of the section.
Short | Narrative content of the section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
282. EHDSDischargeReport.body.dischargeDetails.carePlan.carePlan
Definition | Structured care plan after discharge. Multiple care plans could be provided.
Short | Structured care plan after discharge. Multiple care plans could be provided.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan
284. EHDSDischargeReport.body.dischargeDetails.carePlan.otherRecommendations
Definition | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Short | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
286. EHDSDischargeReport.attachments[x]
Definition | Report attachments data elements
Short | Report attachments data elements
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedia
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]