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: Discharge Report model

Official URL: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDischargeReport | Version: 0.1.0
Draft as of 2025-08-25 | Computable Name: EHDSDischargeReport

EHDS refined base model for Discharge Report

Feedback is welcome on any aspect of the content.
However, the following topics have been identified as areas where input would be particularly valuable:
- Pharmacotherapy section. Is the section's purpose clear and the section useful in its current definition? Are the current implementations using the same approach, or is the section's content conveyed in the Medication Summary section?
- Diagnostic Summary section. Is the section together with EHDSCondition model sufficient for capturing details related to a hospital encounter diagnostics?
- Medication Summary section. In some jurisdictions, any handover of a medication to the patient at the time of discharge is marked in the report. Is the model capturing the information expected for this use case, or would it be captured better using EHDSMedicationDispense model. </div>

Usages:

- This Logical Model is not used by any profiles in this Implementation Guide

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
EHDSDischargeReport |  | 0..* | EHDSDocument | Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Discharge Report model Instances of this logical model can be the target of a Reference
header |  | 1..1 | Base | Document header elements
subject |  | 1..1 | EHDSPatient | Subject
identifier |  | 1..* | Identifier | Document ID
authorship |  | 1..* | Base | Authorship
author[x] |  | 1..1 |  | Author
authorEHDSHealthProfessional |  |  | EHDSHealthProfessional |
authorEHDSOrganisation |  |  | EHDSOrganisation |
authorEHDSDevice |  |  | EHDSDevice |
datetime |  | 1..1 | dateTime | Date and time of authoring/issuing
lastUpdate |  | 0..1 | dateTime | Date and time of the last update to the resource
status |  | 1..1 | CodeableConcept | Status of the resource
statusReason[x] |  | 0..1 |  | Reason for the current status of the resource.
statusReasonCodeableConcept |  |  | CodeableConcept |
statusReasonString |  |  | string |
language |  | 0..1 | CodeableConcept | Language Binding Description: (preferred): BCP 47
version |  | 0..1 | string | Version
documentType |  | 1..1 | CodeableConcept | Document type Binding Description: (preferred): LOINC
documentTitle |  | 1..1 | string | Document title
documentStatus |  | 1..1 | CodeableConcept | Document status Binding Description: (preferred): hl7:CompositionStatus
period |  | 0..1 | Period | Period
attestation |  | 0..* | Base | Attestation
attester |  | 1..1 | EHDSHealthProfessional | Attester
datetime |  | 1..1 | dateTime | DateTime
legalAuthentication |  | 0..1 | Base | Legal authentication
legalAuthenticator |  | 1..1 | EHDSHealthProfessional | Legal authenticator
datetime |  | 1..1 | dateTime | DateTime
eventType |  | 0..* | CodeableConcept | Event type Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
authorSpecialty |  | 0..* | CodeableConcept | Specialty Binding Description: (preferred): SNOMED CT
custodian |  | 1..1 | EHDSOrganisation | Document custodian
documentFormat |  | 0..1 | CodeableConcept | Document format Binding Description: (preferred): HL7 Document Format Codes
confidentiality |  | 0..1 | CodeableConcept | Confidentiality Binding Description: (preferred): hl7:Confidentiality
intendedRecipient[x] |  | 0..* |  | Intended recipient
intendedRecipientEHDSPatient |  |  | EHDSPatient |
intendedRecipientEHDSRelatedPerson |  |  | EHDSRelatedPerson |
intendedRecipientEHDSHealthProfessional |  |  | EHDSHealthProfessional |
intendedRecipientEHDSOrganisation |  |  | EHDSOrganisation |
intendedRecipientEHDSDevice |  |  | EHDSDevice |
healthInsuranceAndPaymentInformation |  | 0..* | EHDSCoverage | Health insurance and payment information
presentedForm |  | 0..* | EHDSAttachment | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
body |  | 0..1 | Base | Structured body of the discharge report document
advanceDirectives |  | 0..1 | Base | Section: Advance Directives.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
advanceDirective |  | 0..* | EHDSAdvanceDirective | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
alerts |  | 0..1 | Base | Section: Alerts.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
medicalAlert |  | 0..* | EHDSAlert | Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
encounterInformation |  | 1..1 | Base | Section: Encounter information.
narrative |  | 1..1 | string | Narrative, potentially formatted, content of the section
encounter |  | 0..1 | EHDSEncounter | Encounter information
admissionEvaluation |  | 0..1 | Base | Section: Admission evaluation
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
time |  | 0..1 | dateTime | Date and time of the admission evaluation examination
performer |  | 0..* | EHDSHealthProfessional | Health professional(s) responsible for the admission evaluation examination.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
patientHistory |  | 0..1 | Base | Section: Patient health history (anamnesis).
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunisation | Vaccination history of the patient.
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | EHDSInfectiousContact | Infectious contacts of the patient
travelHistory |  | 0..* | EHDSTravelHistory | Travel history reported by the patient. Multiple records could be provided.
pregnancyHistory |  | 0..1 | Base | Section: Pregnancy history
currentPregnancyStatus |  | 0..1 | EHDSCurrentPregnancy | Current pregnancy status
previousPregnanciesStatus |  | 0..1 | CodeableConcept | Overall status of previous pregnancies
previousPregnancies |  | 0..* | EHDSPregnancyHistory | History of previous pregnancies
familyHistorySection |  | 0..1 | Base | Family history section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
narrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | string | Work situation
hobby |  | 0..1 | string | An activity the patient enjoys doing in their free time.
socialNetwork |  | 0..1 | string | Social network
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description: (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description: (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description: (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description: (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition Binding Description: (preferred): SNOMED CT
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code. Binding Description: (preferred): hl7:marital-status
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description: (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | EHDSSubstanceUse | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
tobaccoUse |  | 0..* | EHDSSubstanceUse | Tobacco use
drugConsumption |  | 0..* | EHDSSubstanceUse | Consumption of drugs and other substances (in terms of abuse).
courseOfEncounter |  | 1..1 | Base | Course of inpatient or outpatient encounter.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
narrative |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | Base | 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).
presentOnAdmission |  | 1..1 | CodeableConcept | Whether the condition was present on admission or acquired during encounter
treatmentClass |  | 1..1 | CodeableConcept | Class of the problem (treated, other) in relation to the encounter.
problem |  | 1..1 | EHDSCondition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplants |  | 1..1 | Base | Medical devices and implants section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapy |  | 0..1 | Base | Pharmacotherapy section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
narrative |  | 0..1 | string | Narrative content of the section.
entry |  | 0..* | Base | Structured medication entry
medicationUse |  | 1..1 | EHDSMedicationStatement | Details about medication and dosaging
daysSupplied |  | 0..1 | Quantity | Number of days for which the patient was provided with the drug at the time of discharge
carePlan |  | 0..* | Base | Care plan and other recommendations after discharge.
narrative |  | 0..1 | string | Narrative content of the section.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..1 | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
attachments[x] |  | 0..* |  | Report attachments data elements
attachmentsEHDSAttachment |  |  | EHDSAttachment |
attachmentsEHDSMedia |  |  | EHDSMedia |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
EHDSDischargeReport.header.language | preferred |
EHDSDischargeReport.header.documentType | preferred |
EHDSDischargeReport.header.documentStatus | preferred |
EHDSDischargeReport.header.eventType | preferred |
EHDSDischargeReport.header.authorSpecialty | preferred |
EHDSDischargeReport.header.documentFormat | preferred |
EHDSDischargeReport.header.confidentiality | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility | preferred |

This structure is derived from EHDSDocument

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
EHDSDischargeReport |  | 0..* | EHDSDocument | Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Discharge Report model Instances of this logical model can be the target of a Reference
header |  |  |  |
intendedRecipient[x] |  | 0..* |  | Intended recipient
intendedRecipientEHDSPatient |  |  | EHDSPatient |
intendedRecipientEHDSRelatedPerson |  |  | EHDSRelatedPerson |
intendedRecipientEHDSHealthProfessional |  |  | EHDSHealthProfessional |
intendedRecipientEHDSOrganisation |  |  | EHDSOrganisation |
intendedRecipientEHDSDevice |  |  | EHDSDevice |
healthInsuranceAndPaymentInformation |  | 0..* | EHDSCoverage | Health insurance and payment information
knowledgeResources |  | 0..0 |  |
body |  | 0..1 | Base | Structured body of the discharge report document
advanceDirectives |  | 0..1 | Base | Section: Advance Directives.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
advanceDirective |  | 0..* | EHDSAdvanceDirective | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
alerts |  | 0..1 | Base | Section: Alerts.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
medicalAlert |  | 0..* | EHDSAlert | Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
encounterInformation |  | 1..1 | Base | Section: Encounter information.
narrative |  | 1..1 | string | Narrative, potentially formatted, content of the section
encounter |  | 0..1 | EHDSEncounter | Encounter information
admissionEvaluation |  | 0..1 | Base | Section: Admission evaluation
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
time |  | 0..1 | dateTime | Date and time of the admission evaluation examination
performer |  | 0..* | EHDSHealthProfessional | Health professional(s) responsible for the admission evaluation examination.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
patientHistory |  | 0..1 | Base | Section: Patient health history (anamnesis).
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunisation | Vaccination history of the patient.
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | EHDSInfectiousContact | Infectious contacts of the patient
travelHistory |  | 0..* | EHDSTravelHistory | Travel history reported by the patient. Multiple records could be provided.
pregnancyHistory |  | 0..1 | Base | Section: Pregnancy history
currentPregnancyStatus |  | 0..1 | EHDSCurrentPregnancy | Current pregnancy status
previousPregnanciesStatus |  | 0..1 | CodeableConcept | Overall status of previous pregnancies
previousPregnancies |  | 0..* | EHDSPregnancyHistory | History of previous pregnancies
familyHistorySection |  | 0..1 | Base | Family history section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
narrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | string | Work situation
hobby |  | 0..1 | string | An activity the patient enjoys doing in their free time.
socialNetwork |  | 0..1 | string | Social network
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description: (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description: (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description: (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description: (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition Binding Description: (preferred): SNOMED CT
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code. Binding Description: (preferred): hl7:marital-status
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description: (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | EHDSSubstanceUse | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
tobaccoUse |  | 0..* | EHDSSubstanceUse | Tobacco use
drugConsumption |  | 0..* | EHDSSubstanceUse | Consumption of drugs and other substances (in terms of abuse).
courseOfEncounter |  | 1..1 | Base | Course of inpatient or outpatient encounter.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
narrative |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | Base | 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).
presentOnAdmission |  | 1..1 | CodeableConcept | Whether the condition was present on admission or acquired during encounter
treatmentClass |  | 1..1 | CodeableConcept | Class of the problem (treated, other) in relation to the encounter.
problem |  | 1..1 | EHDSCondition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplants |  | 1..1 | Base | Medical devices and implants section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapy |  | 0..1 | Base | Pharmacotherapy section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
narrative |  | 0..1 | string | Narrative content of the section.
entry |  | 0..* | Base | Structured medication entry
medicationUse |  | 1..1 | EHDSMedicationStatement | Details about medication and dosaging
daysSupplied |  | 0..1 | Quantity | Number of days for which the patient was provided with the drug at the time of discharge
carePlan |  | 0..* | Base | Care plan and other recommendations after discharge.
narrative |  | 0..1 | string | Narrative content of the section.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..1 | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
attachments[x] |  | 0..* |  | Report attachments data elements
attachmentsEHDSAttachment |  |  | EHDSAttachment |
attachmentsEHDSMedia |  |  | EHDSMedia |
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility | preferred |

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
EHDSDischargeReport |  | 0..* | EHDSDocument | Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Discharge Report model Instances of this logical model can be the target of a Reference
header |  | 1..1 | Base | Document header elements
subject |  | 1..1 | EHDSPatient | Subject
identifier |  | 1..* | Identifier | Document ID
authorship |  | 1..* | Base | Authorship
author[x] |  | 1..1 |  | Author
authorEHDSHealthProfessional |  |  | EHDSHealthProfessional |
authorEHDSOrganisation |  |  | EHDSOrganisation |
authorEHDSDevice |  |  | EHDSDevice |
datetime |  | 1..1 | dateTime | Date and time of authoring/issuing
lastUpdate |  | 0..1 | dateTime | Date and time of the last update to the resource
status |  | 1..1 | CodeableConcept | Status of the resource
statusReason[x] |  | 0..1 |  | Reason for the current status of the resource.
statusReasonCodeableConcept |  |  | CodeableConcept |
statusReasonString |  |  | string |
language |  | 0..1 | CodeableConcept | Language Binding Description: (preferred): BCP 47
version |  | 0..1 | string | Version
documentType |  | 1..1 | CodeableConcept | Document type Binding Description: (preferred): LOINC
documentTitle |  | 1..1 | string | Document title
documentStatus |  | 1..1 | CodeableConcept | Document status Binding Description: (preferred): hl7:CompositionStatus
period |  | 0..1 | Period | Period
attestation |  | 0..* | Base | Attestation
attester |  | 1..1 | EHDSHealthProfessional | Attester
datetime |  | 1..1 | dateTime | DateTime
legalAuthentication |  | 0..1 | Base | Legal authentication
legalAuthenticator |  | 1..1 | EHDSHealthProfessional | Legal authenticator
datetime |  | 1..1 | dateTime | DateTime
eventType |  | 0..* | CodeableConcept | Event type Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
authorSpecialty |  | 0..* | CodeableConcept | Specialty Binding Description: (preferred): SNOMED CT
custodian |  | 1..1 | EHDSOrganisation | Document custodian
documentFormat |  | 0..1 | CodeableConcept | Document format Binding Description: (preferred): HL7 Document Format Codes
confidentiality |  | 0..1 | CodeableConcept | Confidentiality Binding Description: (preferred): hl7:Confidentiality
intendedRecipient[x] |  | 0..* |  | Intended recipient
intendedRecipientEHDSPatient |  |  | EHDSPatient |
intendedRecipientEHDSRelatedPerson |  |  | EHDSRelatedPerson |
intendedRecipientEHDSHealthProfessional |  |  | EHDSHealthProfessional |
intendedRecipientEHDSOrganisation |  |  | EHDSOrganisation |
intendedRecipientEHDSDevice |  |  | EHDSDevice |
healthInsuranceAndPaymentInformation |  | 0..* | EHDSCoverage | Health insurance and payment information
presentedForm |  | 0..* | EHDSAttachment | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
body |  | 0..1 | Base | Structured body of the discharge report document
advanceDirectives |  | 0..1 | Base | Section: Advance Directives.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
advanceDirective |  | 0..* | EHDSAdvanceDirective | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
alerts |  | 0..1 | Base | Section: Alerts.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
medicalAlert |  | 0..* | EHDSAlert | Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
encounterInformation |  | 1..1 | Base | Section: Encounter information.
narrative |  | 1..1 | string | Narrative, potentially formatted, content of the section
encounter |  | 0..1 | EHDSEncounter | Encounter information
admissionEvaluation |  | 0..1 | Base | Section: Admission evaluation
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
time |  | 0..1 | dateTime | Date and time of the admission evaluation examination
performer |  | 0..* | EHDSHealthProfessional | Health professional(s) responsible for the admission evaluation examination.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
patientHistory |  | 0..1 | Base | Section: Patient health history (anamnesis).
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunisation | Vaccination history of the patient.
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | EHDSInfectiousContact | Infectious contacts of the patient
travelHistory |  | 0..* | EHDSTravelHistory | Travel history reported by the patient. Multiple records could be provided.
pregnancyHistory |  | 0..1 | Base | Section: Pregnancy history
currentPregnancyStatus |  | 0..1 | EHDSCurrentPregnancy | Current pregnancy status
previousPregnanciesStatus |  | 0..1 | CodeableConcept | Overall status of previous pregnancies
previousPregnancies |  | 0..* | EHDSPregnancyHistory | History of previous pregnancies
familyHistorySection |  | 0..1 | Base | Family history section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
narrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | string | Work situation
hobby |  | 0..1 | string | An activity the patient enjoys doing in their free time.
socialNetwork |  | 0..1 | string | Social network
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description: (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description: (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description: (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description: (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition Binding Description: (preferred): SNOMED CT
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code. Binding Description: (preferred): hl7:marital-status
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description: (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | EHDSSubstanceUse | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
tobaccoUse |  | 0..* | EHDSSubstanceUse | Tobacco use
drugConsumption |  | 0..* | EHDSSubstanceUse | Consumption of drugs and other substances (in terms of abuse).
courseOfEncounter |  | 1..1 | Base | Course of inpatient or outpatient encounter.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
narrative |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | Base | 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).
presentOnAdmission |  | 1..1 | CodeableConcept | Whether the condition was present on admission or acquired during encounter
treatmentClass |  | 1..1 | CodeableConcept | Class of the problem (treated, other) in relation to the encounter.
problem |  | 1..1 | EHDSCondition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplants |  | 1..1 | Base | Medical devices and implants section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapy |  | 0..1 | Base | Pharmacotherapy section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
narrative |  | 0..1 | string | Narrative content of the section.
entry |  | 0..* | Base | Structured medication entry
medicationUse |  | 1..1 | EHDSMedicationStatement | Details about medication and dosaging
daysSupplied |  | 0..1 | Quantity | Number of days for which the patient was provided with the drug at the time of discharge
carePlan |  | 0..* | Base | Care plan and other recommendations after discharge.
narrative |  | 0..1 | string | Narrative content of the section.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..1 | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
attachments[x] |  | 0..* |  | Report attachments data elements
attachmentsEHDSAttachment |  |  | EHDSAttachment |
attachmentsEHDSMedia |  |  | EHDSMedia |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
EHDSDischargeReport.header.language | preferred |
EHDSDischargeReport.header.documentType | preferred |
EHDSDischargeReport.header.documentStatus | preferred |
EHDSDischargeReport.header.eventType | preferred |
EHDSDischargeReport.header.authorSpecialty | preferred |
EHDSDischargeReport.header.documentFormat | preferred |
EHDSDischargeReport.header.confidentiality | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility | preferred |

This structure is derived from EHDSDocument

Summary

Mandatory: 0 element(16 nested mandatory elements)
Prohibited: 1 element

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
EHDSDischargeReport |  | 0..* | EHDSDocument | Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Discharge Report model Instances of this logical model can be the target of a Reference
header |  | 1..1 | Base | Document header elements
subject |  | 1..1 | EHDSPatient | Subject
identifier |  | 1..* | Identifier | Document ID
authorship |  | 1..* | Base | Authorship
author[x] |  | 1..1 |  | Author
authorEHDSHealthProfessional |  |  | EHDSHealthProfessional |
authorEHDSOrganisation |  |  | EHDSOrganisation |
authorEHDSDevice |  |  | EHDSDevice |
datetime |  | 1..1 | dateTime | Date and time of authoring/issuing
lastUpdate |  | 0..1 | dateTime | Date and time of the last update to the resource
status |  | 1..1 | CodeableConcept | Status of the resource
statusReason[x] |  | 0..1 |  | Reason for the current status of the resource.
statusReasonCodeableConcept |  |  | CodeableConcept |
statusReasonString |  |  | string |
language |  | 0..1 | CodeableConcept | Language Binding Description: (preferred): BCP 47
version |  | 0..1 | string | Version
documentType |  | 1..1 | CodeableConcept | Document type Binding Description: (preferred): LOINC
documentTitle |  | 1..1 | string | Document title
documentStatus |  | 1..1 | CodeableConcept | Document status Binding Description: (preferred): hl7:CompositionStatus
period |  | 0..1 | Period | Period
attestation |  | 0..* | Base | Attestation
attester |  | 1..1 | EHDSHealthProfessional | Attester
datetime |  | 1..1 | dateTime | DateTime
legalAuthentication |  | 0..1 | Base | Legal authentication
legalAuthenticator |  | 1..1 | EHDSHealthProfessional | Legal authenticator
datetime |  | 1..1 | dateTime | DateTime
eventType |  | 0..* | CodeableConcept | Event type Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
authorSpecialty |  | 0..* | CodeableConcept | Specialty Binding Description: (preferred): SNOMED CT
custodian |  | 1..1 | EHDSOrganisation | Document custodian
documentFormat |  | 0..1 | CodeableConcept | Document format Binding Description: (preferred): HL7 Document Format Codes
confidentiality |  | 0..1 | CodeableConcept | Confidentiality Binding Description: (preferred): hl7:Confidentiality
intendedRecipient[x] |  | 0..* |  | Intended recipient
intendedRecipientEHDSPatient |  |  | EHDSPatient |
intendedRecipientEHDSRelatedPerson |  |  | EHDSRelatedPerson |
intendedRecipientEHDSHealthProfessional |  |  | EHDSHealthProfessional |
intendedRecipientEHDSOrganisation |  |  | EHDSOrganisation |
intendedRecipientEHDSDevice |  |  | EHDSDevice |
healthInsuranceAndPaymentInformation |  | 0..* | EHDSCoverage | Health insurance and payment information
presentedForm |  | 0..* | EHDSAttachment | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
body |  | 0..1 | Base | Structured body of the discharge report document
advanceDirectives |  | 0..1 | Base | Section: Advance Directives.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
advanceDirective |  | 0..* | EHDSAdvanceDirective | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
alerts |  | 0..1 | Base | Section: Alerts.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
medicalAlert |  | 0..* | EHDSAlert | Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
encounterInformation |  | 1..1 | Base | Section: Encounter information.
narrative |  | 1..1 | string | Narrative, potentially formatted, content of the section
encounter |  | 0..1 | EHDSEncounter | Encounter information
admissionEvaluation |  | 0..1 | Base | Section: Admission evaluation
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
time |  | 0..1 | dateTime | Date and time of the admission evaluation examination
performer |  | 0..* | EHDSHealthProfessional | Health professional(s) responsible for the admission evaluation examination.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
patientHistory |  | 0..1 | Base | Section: Patient health history (anamnesis).
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunisation | Vaccination history of the patient.
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | EHDSInfectiousContact | Infectious contacts of the patient
travelHistory |  | 0..* | EHDSTravelHistory | Travel history reported by the patient. Multiple records could be provided.
pregnancyHistory |  | 0..1 | Base | Section: Pregnancy history
currentPregnancyStatus |  | 0..1 | EHDSCurrentPregnancy | Current pregnancy status
previousPregnanciesStatus |  | 0..1 | CodeableConcept | Overall status of previous pregnancies
previousPregnancies |  | 0..* | EHDSPregnancyHistory | History of previous pregnancies
familyHistorySection |  | 0..1 | Base | Family history section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
narrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | string | Work situation
hobby |  | 0..1 | string | An activity the patient enjoys doing in their free time.
socialNetwork |  | 0..1 | string | Social network
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description: (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description: (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description: (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description: (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition Binding Description: (preferred): SNOMED CT
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code. Binding Description: (preferred): hl7:marital-status
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description: (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | EHDSSubstanceUse | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
tobaccoUse |  | 0..* | EHDSSubstanceUse | Tobacco use
drugConsumption |  | 0..* | EHDSSubstanceUse | Consumption of drugs and other substances (in terms of abuse).
courseOfEncounter |  | 1..1 | Base | Course of inpatient or outpatient encounter.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
narrative |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | Base | 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).
presentOnAdmission |  | 1..1 | CodeableConcept | Whether the condition was present on admission or acquired during encounter
treatmentClass |  | 1..1 | CodeableConcept | Class of the problem (treated, other) in relation to the encounter.
problem |  | 1..1 | EHDSCondition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplants |  | 1..1 | Base | Medical devices and implants section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapy |  | 0..1 | Base | Pharmacotherapy section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
narrative |  | 0..1 | string | Narrative content of the section.
entry |  | 0..* | Base | Structured medication entry
medicationUse |  | 1..1 | EHDSMedicationStatement | Details about medication and dosaging
daysSupplied |  | 0..1 | Quantity | Number of days for which the patient was provided with the drug at the time of discharge
carePlan |  | 0..* | Base | Care plan and other recommendations after discharge.
narrative |  | 0..1 | string | Narrative content of the section.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..1 | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
attachments[x] |  | 0..* |  | Report attachments data elements
attachmentsEHDSAttachment |  |  | EHDSAttachment |
attachmentsEHDSMedia |  |  | EHDSMedia |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
EHDSDischargeReport.header.language | preferred |
EHDSDischargeReport.header.documentType | preferred |
EHDSDischargeReport.header.documentStatus | preferred |
EHDSDischargeReport.header.eventType | preferred |
EHDSDischargeReport.header.authorSpecialty | preferred |
EHDSDischargeReport.header.documentFormat | preferred |
EHDSDischargeReport.header.confidentiality | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility | preferred |

Differential View

This structure is derived from EHDSDocument

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
EHDSDischargeReport |  | 0..* | EHDSDocument | Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Discharge Report model Instances of this logical model can be the target of a Reference
header |  |  |  |
intendedRecipient[x] |  | 0..* |  | Intended recipient
intendedRecipientEHDSPatient |  |  | EHDSPatient |
intendedRecipientEHDSRelatedPerson |  |  | EHDSRelatedPerson |
intendedRecipientEHDSHealthProfessional |  |  | EHDSHealthProfessional |
intendedRecipientEHDSOrganisation |  |  | EHDSOrganisation |
intendedRecipientEHDSDevice |  |  | EHDSDevice |
healthInsuranceAndPaymentInformation |  | 0..* | EHDSCoverage | Health insurance and payment information
knowledgeResources |  | 0..0 |  |
body |  | 0..1 | Base | Structured body of the discharge report document
advanceDirectives |  | 0..1 | Base | Section: Advance Directives.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
advanceDirective |  | 0..* | EHDSAdvanceDirective | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
alerts |  | 0..1 | Base | Section: Alerts.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
medicalAlert |  | 0..* | EHDSAlert | Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
encounterInformation |  | 1..1 | Base | Section: Encounter information.
narrative |  | 1..1 | string | Narrative, potentially formatted, content of the section
encounter |  | 0..1 | EHDSEncounter | Encounter information
admissionEvaluation |  | 0..1 | Base | Section: Admission evaluation
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
time |  | 0..1 | dateTime | Date and time of the admission evaluation examination
performer |  | 0..* | EHDSHealthProfessional | Health professional(s) responsible for the admission evaluation examination.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
patientHistory |  | 0..1 | Base | Section: Patient health history (anamnesis).
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunisation | Vaccination history of the patient.
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | EHDSInfectiousContact | Infectious contacts of the patient
travelHistory |  | 0..* | EHDSTravelHistory | Travel history reported by the patient. Multiple records could be provided.
pregnancyHistory |  | 0..1 | Base | Section: Pregnancy history
currentPregnancyStatus |  | 0..1 | EHDSCurrentPregnancy | Current pregnancy status
previousPregnanciesStatus |  | 0..1 | CodeableConcept | Overall status of previous pregnancies
previousPregnancies |  | 0..* | EHDSPregnancyHistory | History of previous pregnancies
familyHistorySection |  | 0..1 | Base | Family history section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
narrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | string | Work situation
hobby |  | 0..1 | string | An activity the patient enjoys doing in their free time.
socialNetwork |  | 0..1 | string | Social network
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description: (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description: (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description: (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description: (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition Binding Description: (preferred): SNOMED CT
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code. Binding Description: (preferred): hl7:marital-status
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description: (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | EHDSSubstanceUse | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
tobaccoUse |  | 0..* | EHDSSubstanceUse | Tobacco use
drugConsumption |  | 0..* | EHDSSubstanceUse | Consumption of drugs and other substances (in terms of abuse).
courseOfEncounter |  | 1..1 | Base | Course of inpatient or outpatient encounter.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
narrative |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | Base | 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).
presentOnAdmission |  | 1..1 | CodeableConcept | Whether the condition was present on admission or acquired during encounter
treatmentClass |  | 1..1 | CodeableConcept | Class of the problem (treated, other) in relation to the encounter.
problem |  | 1..1 | EHDSCondition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplants |  | 1..1 | Base | Medical devices and implants section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapy |  | 0..1 | Base | Pharmacotherapy section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
narrative |  | 0..1 | string | Narrative content of the section.
entry |  | 0..* | Base | Structured medication entry
medicationUse |  | 1..1 | EHDSMedicationStatement | Details about medication and dosaging
daysSupplied |  | 0..1 | Quantity | Number of days for which the patient was provided with the drug at the time of discharge
carePlan |  | 0..* | Base | Care plan and other recommendations after discharge.
narrative |  | 0..1 | string | Narrative content of the section.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..1 | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
attachments[x] |  | 0..* |  | Report attachments data elements
attachmentsEHDSAttachment |  |  | EHDSAttachment |
attachmentsEHDSMedia |  |  | EHDSMedia |
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility | preferred |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
EHDSDischargeReport |  | 0..* | EHDSDocument | Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Discharge Report model Instances of this logical model can be the target of a Reference
header |  | 1..1 | Base | Document header elements
subject |  | 1..1 | EHDSPatient | Subject
identifier |  | 1..* | Identifier | Document ID
authorship |  | 1..* | Base | Authorship
author[x] |  | 1..1 |  | Author
authorEHDSHealthProfessional |  |  | EHDSHealthProfessional |
authorEHDSOrganisation |  |  | EHDSOrganisation |
authorEHDSDevice |  |  | EHDSDevice |
datetime |  | 1..1 | dateTime | Date and time of authoring/issuing
lastUpdate |  | 0..1 | dateTime | Date and time of the last update to the resource
status |  | 1..1 | CodeableConcept | Status of the resource
statusReason[x] |  | 0..1 |  | Reason for the current status of the resource.
statusReasonCodeableConcept |  |  | CodeableConcept |
statusReasonString |  |  | string |
language |  | 0..1 | CodeableConcept | Language Binding Description: (preferred): BCP 47
version |  | 0..1 | string | Version
documentType |  | 1..1 | CodeableConcept | Document type Binding Description: (preferred): LOINC
documentTitle |  | 1..1 | string | Document title
documentStatus |  | 1..1 | CodeableConcept | Document status Binding Description: (preferred): hl7:CompositionStatus
period |  | 0..1 | Period | Period
attestation |  | 0..* | Base | Attestation
attester |  | 1..1 | EHDSHealthProfessional | Attester
datetime |  | 1..1 | dateTime | DateTime
legalAuthentication |  | 0..1 | Base | Legal authentication
legalAuthenticator |  | 1..1 | EHDSHealthProfessional | Legal authenticator
datetime |  | 1..1 | dateTime | DateTime
eventType |  | 0..* | CodeableConcept | Event type Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
authorSpecialty |  | 0..* | CodeableConcept | Specialty Binding Description: (preferred): SNOMED CT
custodian |  | 1..1 | EHDSOrganisation | Document custodian
documentFormat |  | 0..1 | CodeableConcept | Document format Binding Description: (preferred): HL7 Document Format Codes
confidentiality |  | 0..1 | CodeableConcept | Confidentiality Binding Description: (preferred): hl7:Confidentiality
intendedRecipient[x] |  | 0..* |  | Intended recipient
intendedRecipientEHDSPatient |  |  | EHDSPatient |
intendedRecipientEHDSRelatedPerson |  |  | EHDSRelatedPerson |
intendedRecipientEHDSHealthProfessional |  |  | EHDSHealthProfessional |
intendedRecipientEHDSOrganisation |  |  | EHDSOrganisation |
intendedRecipientEHDSDevice |  |  | EHDSDevice |
healthInsuranceAndPaymentInformation |  | 0..* | EHDSCoverage | Health insurance and payment information
presentedForm |  | 0..* | EHDSAttachment | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
body |  | 0..1 | Base | Structured body of the discharge report document
advanceDirectives |  | 0..1 | Base | Section: Advance Directives.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
advanceDirective |  | 0..* | EHDSAdvanceDirective | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
alerts |  | 0..1 | Base | Section: Alerts.
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
medicalAlert |  | 0..* | EHDSAlert | Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
allergyAndIntolerance |  | 0..* | EHDSAllergyIntolerance | Allergy and Intolerance. A record of allergies and intolerances (primarily to be used for new allergies or intolerances that occurred during the encounter).
encounterInformation |  | 1..1 | Base | Section: Encounter information.
narrative |  | 1..1 | string | Narrative, potentially formatted, content of the section
encounter |  | 0..1 | EHDSEncounter | Encounter information
admissionEvaluation |  | 0..1 | Base | Section: Admission evaluation
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
time |  | 0..1 | dateTime | Date and time of the admission evaluation examination
performer |  | 0..* | EHDSHealthProfessional | Health professional(s) responsible for the admission evaluation examination.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
patientHistory |  | 0..1 | Base | Section: Patient health history (anamnesis).
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalHistory |  | 1..1 | Base | Medical history subsection.
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pastProblems |  | 1..* | EHDSCondition | Past problems
devicesAndImplants |  | 1..* | EHDSDeviceUse | Devices and Implants
historyOfProcedures |  | 0..* | EHDSProcedure | History of procedures
vaccination |  | 0..* | EHDSImmunisation | Vaccination history of the patient.
epidemiologicalHistory |  | 0..1 | Base | Epidemiological history
infectiousContacts |  | 0..* | EHDSInfectiousContact | Infectious contacts of the patient
travelHistory |  | 0..* | EHDSTravelHistory | Travel history reported by the patient. Multiple records could be provided.
pregnancyHistory |  | 0..1 | Base | Section: Pregnancy history
currentPregnancyStatus |  | 0..1 | EHDSCurrentPregnancy | Current pregnancy status
previousPregnanciesStatus |  | 0..1 | CodeableConcept | Overall status of previous pregnancies
previousPregnancies |  | 0..* | EHDSPregnancyHistory | History of previous pregnancies
familyHistorySection |  | 0..1 | Base | Family history section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
familyHistory |  | 0..* | EHDSFamilyMemberHistory | Family history
socialDeterminantsOfHealth |  | 0..1 | Base | Social determinants of health
narrative |  | 0..1 | string | Sub-section narrative
participationInSociety |  | 0..1 | Base | Participation in society
workSituation |  | 0..1 | string | Work situation
hobby |  | 0..1 | string | An activity the patient enjoys doing in their free time.
socialNetwork |  | 0..1 | string | Social network
educationSection |  | 0..1 | Base | Education section
educationLevel |  | 0..1 | CodeableConcept | Education level Binding Description: (preferred): hl7:v3.EducationLevel
comment |  | 0..1 | string | If deemed relevant, a specification of the degree program can be provided by means of an explanation (e.g.: patient is in medical school).
livingSituation |  | 0..1 | Base | Living situation - household type and other related living situation information.
houseType |  | 0..1 | CodeableConcept | Type of home the patient lives in. Binding Description: (preferred): SNOMED CT
homeAdaption |  | 0..* | CodeableConcept | Home adaptions present in the home that have been made in the context of the illness or disability to make the functioning of the patient safer and more comfortable and to enable independent living. Multiple data elements could be provided. Binding Description: (preferred): SNOMED CT
livingConditions |  | 0..* | CodeableConcept | Living conditions that affect the accessibility of the home or the stay in the home. Binding Description: (preferred): SNOMED CT
familySituation |  | 0..1 | Base | Family situation
comment |  | 0..1 | string | Comment on the family situation.
familyComposition |  | 0..1 | CodeableConcept | Family composition Binding Description: (preferred): SNOMED CT
maritalStatus |  | 0..1 | CodeableConcept | Person’s marital status according to the terms and definition in the national civil code. Binding Description: (preferred): hl7:marital-status
numberOfChildren |  | 0..1 | Quantity | Number of children
numberOfChildrenAtHome |  | 0..1 | Quantity | Number of children living at home with the patient.
childDetails |  | 0..* | Base | Child details (age, co-living status and comment).
livingAtHome |  | 0..1 | boolean | Living at home. An indication stating whether the child lives at home.
dateOfBirth |  | 0..1 | date | Child’s date of birth.
comment |  | 0..1 | string | A comment on the child's family situation.
careResponsibility |  | 0..* | CodeableConcept | Care responsibility. The activities the patient carries out to care for a dependent family member. Binding Description: (preferred): SNOMED CT
useOfSubstances |  | 0..1 | Base | Use of substances
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
alcoholUse |  | 0..* | EHDSSubstanceUse | Alcohol consumption by the patient. Multiple records on alcohol use could be provided.
tobaccoUse |  | 0..* | EHDSSubstanceUse | Tobacco use
drugConsumption |  | 0..* | EHDSSubstanceUse | Consumption of drugs and other substances (in terms of abuse).
courseOfEncounter |  | 1..1 | Base | Course of inpatient or outpatient encounter.
diagnosticSummary |  | 1..1 | Base | Diagnostic summary. All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care.
narrative |  | 0..1 | string | Problem specification in narrative form.
problemDetails |  | 0..* | Base | 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).
presentOnAdmission |  | 1..1 | CodeableConcept | Whether the condition was present on admission or acquired during encounter
treatmentClass |  | 1..1 | CodeableConcept | Class of the problem (treated, other) in relation to the encounter.
problem |  | 1..1 | EHDSCondition | Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.
significantProcedures |  | 0..1 | Base | Significant procedures section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
procedureEntry |  | 0..* | EHDSProcedure | Structured procedure entry.
medicalDevicesAndImplants |  | 1..1 | Base | Medical devices and implants section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
medicalDevicesAndImplants |  | 1..* | EHDSDeviceUse | Medical devices and implants
pharmacotherapy |  | 0..1 | Base | Pharmacotherapy section
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
pharmacotherapy |  | 0..* | EHDSMedicationStatement | Pharmacotherapy structured entry.
significantObservationResults |  | 0..1 | Base | Significant Observation Results
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative subsection elements should be provided.
significantObservationResult[x] |  | 0..* |  | Significant Observation Result
significantObservationResultEHDSObservation |  |  | EHDSObservation |
significantObservationResultEHDSLaboratoryObservation |  |  | EHDSLaboratoryObservation |
synthesis |  | 1..1 | Base | Synthesis
problemSynthesis |  | 1..* | string | Summary description of the reason and course of hospitalisation for a specific problem.
clinicalReasoning |  | 0..1 | string | Clinical reasoning
dischargeDetails |  | 1..1 | Base | Discharge details
narrative |  | 0..1 | string | Narrative content of the section. This narrative shell containing either summary narrative description of all subsections, or similar narrative sub-section elements should be provided.
objectiveFindings |  | 0..1 | Base | Objective findings
narrative |  | 0..1 | string | Narrative content of the section.
anthropometricObservations |  | 0..* | EHDSObservation | Anthropometric observations, such as body weight and height of the patient, BMI, circumference of head, waist, hip, limbs and skin fold thickness.
vitalSigns |  | 0..* | EHDSObservation | Vital signs observations. Mandatory: pulse rate, respiratory rate, systolic and diastolic blood pressure with site information; optional: 02 saturation
physicalExamination |  | 0..* | EHDSObservation | Physical examination
functionalStatus |  | 0..1 | Base | Section: Functional status
narrative |  | 0..1 | string | Narrative, potentially formatted, content of the section
functionalStatusAssessment |  | 0..* | EHDSFunctionalStatus | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
medicationSummary |  | 0..1 | Base | Medication summary. Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.
narrative |  | 0..1 | string | Narrative content of the section.
entry |  | 0..* | Base | Structured medication entry
medicationUse |  | 1..1 | EHDSMedicationStatement | Details about medication and dosaging
daysSupplied |  | 0..1 | Quantity | Number of days for which the patient was provided with the drug at the time of discharge
carePlan |  | 0..* | Base | Care plan and other recommendations after discharge.
narrative |  | 0..1 | string | Narrative content of the section.
carePlan |  | 0..* | EHDSCarePlan | Structured care plan after discharge. Multiple care plans could be provided.
otherRecommendations |  | 0..1 | string | Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.
attachments[x] |  | 0..* |  | Report attachments data elements
attachmentsEHDSAttachment |  |  | EHDSAttachment |
attachmentsEHDSMedia |  |  | EHDSMedia |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
EHDSDischargeReport.header.language | preferred |
EHDSDischargeReport.header.documentType | preferred |
EHDSDischargeReport.header.documentStatus | preferred |
EHDSDischargeReport.header.eventType | preferred |
EHDSDischargeReport.header.authorSpecialty | preferred |
EHDSDischargeReport.header.documentFormat | preferred |
EHDSDischargeReport.header.confidentiality | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.educationSection.educationLevel | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.houseType | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.homeAdaption | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.livingSituation.livingConditions | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.familyComposition | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.maritalStatus | preferred |
EHDSDischargeReport.body.patientHistory.socialDeterminantsOfHealth.familySituation.careResponsibility | preferred |

This structure is derived from EHDSDocument

Summary

Mandatory: 0 element(16 nested mandatory elements)
Prohibited: 1 element

Other representations of profile: CSV, Excel