HL7 Europe Hospital Discharge Report
0.1.0-ballot - draft
150
HL7 Europe Hospital Discharge Report
0.1.0-ballot - draft
150
This page is part of the HL7 Europe Hospital Discharge Report (v0.1.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition b9dc409d-ec81-4556-9fac-4dc3f731c199</b></p><a name=\"b9dc409d-ec81-4556-9fac-4dc3f731c199\"> </a><a name=\"hcb9dc409d-ec81-4556-9fac-4dc3f731c199\"> </a><a name=\"b9dc409d-ec81-4556-9fac-4dc3f731c199-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-composition-eu-hdr.html\">Composition (HDR)</a></p></div><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 34105-7}\">Hospital Discharge summary</span></p><p><b>encounter</b>: <a href=\"Bundle-HDR-Luigi-De-Luca-Example.html#urn-uuid-7c9a2bf1-507f-4d43-b06e-d78e9670379d\">Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000</a></p><p><b>date</b>: 2025-04-29 13:30:00+0100</p><p><b>author</b>: <a href=\"Bundle-HDR-Luigi-De-Luca-Example.html#urn-uuid-74403dd8-bb1b-45f9-bb69-e843dfaf45e9\">Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000</a></p><p><b>title</b>: Hospital Discharge Report</p><p><b>custodian</b>: <a href=\"Bundle-HDR-Luigi-De-Luca-Example.html#urn-uuid-a61a91f8-b8f2-4947-9a64-5165ea380a38\">Bundle: identifier = Provider number; type = document; timestamp = 2025-04-29 14:00:00+0000</a></p></div>"
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"title" : "Hospital Discharge Report",
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"section" : [
{
"title" : "Admission evaluation",
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi De Luca, a 57-year-old male, was admitted on 1st April following a pre-diabetic episode characterized by episodes of fatigue, polyuria, and increased thirst. Recent routine blood tests showed elevated fasting blood glucose and HbA1c levels that required further investigation.<p/>When Mr De Luca arrived in the morning we recorded a fasting blood glucose level at 180 mg/dL. His HbA1c level was 7.8%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.</div>"
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},
{
"title" : "Family History",
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).</div>"
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"entry" : [
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{
"title" : "Vital signs",
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"display" : "Vital signs"
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"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Vital signs</th><th>1st April</th><th>10th April</th></tr></thead><tbody><tr><td>Body weight</td><td>109 kg</td><td>108 kg</td></tr><tr><td>Body height</td><td>177 cm</td><td/></tr><tr><td>Blood Pressure</td><td>155 / 95 mmHg</td><td>150 / 90 mmHg</td></tr></tbody></table></div>"
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{
"title" : "Tobacco use",
"code" : {
"coding" : [
{
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"code" : "11367-0",
"display" : "History of Tobacco use"
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"text" : {
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">The patient smokes "a few" cigarettes per day.</div>"
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{
"title" : "Hospital Course",
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment.<p/>Throughout his hospital stay, Mr. De Luca was monitored closely. His blood sugar levels improved modestly with the introduction of Metformin, and no acute complications were observed.</div>"
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{
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Blood Glucose Monitoring Regular monitoring of fasting blood glucose levels and random blood glucose levels. Fasting glucose levels consistently ranged between 140-180 mg/dL.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Fasting glucose [Moles/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>2 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>3 April 2025</td><td>150 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>5 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table>HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Hemoglobin A1c [Mass/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>7.2%</td><td>< 5.7%</td></tr></tbody></table>Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Glucose [Mass/volume] in Serum or Plasma --1 hour post dose glucose</th><th>Range</th></tr></thead><tbody><tr><td>2 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table></div>"
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},
{
"title" : "Significant procedures",
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"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Lifestyle Consultation: Mr. De Luca met with a dietitian to discuss necessary changes in his diet, focusing on a low glycemic index diet and the need to monitor carbohydrate intake. He was also advised to engage in regular physical activity.<p/>Diabetes Education: Mr. De Luca attended educational sessions on diabetes management, including the importance of regular blood sugar monitoring, recognizing hypoglycemia and hyperglycemia symptoms, and foot care.<p/>Starting Pharmacotherapy with Metformin.</div>"
},
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{
"title" : "Medications",
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},
"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels.<table class=\"hl7__hdr\"><thead><tr><th>Medication administrations</th><th>Dose/Frequency</th><th>SNOMED</th></tr></thead><tbody><tr><td>Metformin, oral tbl</td><td>500 mg, twice / day</td><td>765507008</td></tr><tr><td>Multivitamines</td><td>daily</td><td/></tr></tbody></table></div>"
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},
{
"title" : "Follow-up",
"code" : {
"coding" : [
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"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Follow-up</th><th>Activity</th><th>SNOMED</th></tr></thead><tbody><tr><td>Endocrinology Clinic</td><td>Follow-up appointment in 2 weeks to assess response to treatment</td><td>306118006 Referral to endocrinology service (procedure)</td></tr><tr><td>Dietitian Consultation</td><td>Appointment in 1 month for further dietary planning</td><td>103699006 Referral to dietitian (procedure)</td></tr><tr><td>Routine Blood tests</td><td>Repeat HbA1c in 3 months</td><td>43396009 Hemoglobin A1c measurement (procedure)</td></tr></tbody></table></div>"
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{
"title" : "Diagnosis at Discharge",
"code" : {
"coding" : [
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"system" : "http://loinc.org",
"code" : "11535-2",
"display" : "Hospital discharge Dx Narrative"
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"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Discharge Diagnoses</th><th>Codes</th></tr></thead><tbody><tr><td>Type 2 Diabetes Mellitus – Newly diagnosed.</td><td><ul><li>Type 2 diabetes mellitus E11 (ICD-10)</li><li>Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)</li></ul></td></tr></tbody></table></div>"
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},
{
"title" : "Hospital Discharge Instructions",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8653-8",
"display" : "Hospital Discharge Instructions"
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},
"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Instructions at Discharge to Mr. De Luca<ul><li>Continue home glucose monitoring and to maintain a log for review at follow-up appointments.</li><li>Continue with the prescribed medication and lifestyle changes.</li><li>Monitor blood sugar levels at home regularly.</li><li>Adhere to the diabetic diet plan.</li><li>Stay physically active, with at least 30 minutes of moderate exercise most days of the week.</li><li>Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).</li></ul></div>"
}
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}
IG © 2024+ HL7 Europe. Package hl7.fhir.eu.hdr#0.1.0-ballot based on FHIR 4.0.1. Generated 2025-06-03
