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/main and changes regularly. See the Directory of published versions
Discharge Report
Conceptual view
Discharge report could be divided into several parts: document header, body and optionally it could also have various attachments.
Discharge Report
Discharge Report Header Subject Identifier Authorship Author Datetime Last Update Status Status Reason Language Version Document Type Document Title Document Status Period Attestation Attester Datetime Legal Authentication Legal Authenticator Datetime Event Type Author Specialty Custodian Document Format Confidentiality Intended Recipient Health Insurance And Payment Information Presented Form Body Advance Directives Narrative Advance Directive Alerts Narrative Medical Alert Allergy And Intolerance Encounter Information Narrative Encounter Admission Evaluation Narrative Objective Findings Narrative Time Performer Anthropometric Observations Vital Signs Physical Examination Functional Status Narrative Functional Status Assessment Patient History Narrative Medical History Narrative Past Problems Devices And Implants History Of Procedures Vaccination Epidemiological History Infectious Contacts Travel History Pregnancy History Current Pregnancy Status Previous Pregnancies Status Previous Pregnancies Family History Section Narrative Family History Social Determinants Of Health Narrative Participation In Society Work Situation Hobby Social Network Education Section Education Level Comment Living Situation House Type Home Adaption Living Conditions Family Situation Comment Family Composition Marital Status Number Of Children Number Of Children At Home Child Details Living At Home Date Of Birth Comment Care Responsibility Use Of Substances Narrative Alcohol Use Tobacco Use Drug Consumption Course Of Encounter Diagnostic Summary Narrative Problem Details Present On Admission Treatment Class Problem Significant Procedures Narrative Procedure Entry Medical Devices And Implants Narrative Medical Devices And Implants Pharmacotherapy Narrative Pharmacotherapy Significant Observation Results Narrative Significant Observation Result Synthesis Problem Synthesis Clinical Reasoning Discharge Details Narrative Objective Findings Narrative Anthropometric Observations Vital Signs Physical Examination Functional Status Narrative Functional Status Assessment Medication Summary Narrative Entry Medication Use Days Supplied Care Plan Narrative Care Plan Other Recommendations Attachments
FHIR Implementation Guide
The work for building the European FHIR specification for Hospital Discharge Report is ongoing in a joint working group of Xt-EHR, XpanDH, xShare and HL7 Europe. Any interested stakeholder is welcome to join the group - please see the detailed information about the meetings .
The Hospital Discharge Report FHIR Implementation Guide:
