Bundle: complete HL7 Europe Hospital Discharge Report (4) - HL7 Europe Hospital Discharge Report v0.1.0-ballot

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

Example Bundle: Bundle: complete HL7 Europe Hospital Discharge Report (4)

Document Details

Profile: Bundle (HDR)

Final Document at 2025-02-08 10:18:13+0000 by Bundle: identifier = urn:ietf:rfc:4122#3e594fe5-3ed5-4305-a214-99c87e1f3bfa; type = document; timestamp = 2025-05-11 10:18:14+0000 for Bundle: identifier = urn:ietf:rfc:4122#3e594fe5-3ed5-4305-a214-99c87e1f3bfa; type = document; timestamp = 2025-05-11 10:18:14+0000 in encounter Bundle: identifier = urn:ietf:rfc:4122#3e594fe5-3ed5-4305-a214-99c87e1f3bfa; type = document; timestamp = 2025-05-11 10:18:14+0000

Document Subject

Fiona XXX_Swart Female, DoB: 1985-12-23 ( http://fhir.nl/fhir/NamingSystem/bsn#999901448)

Multiple Birth:

false

Contact Detail

ph: 0655223366(Mobile)
Knolweg 1000 STITSWERD 9999XA NL (home)

Document Content

Admission evaluation

Patient Fiona Swart was admitted to the hospital for a planned cesarean section.

Vital signs

Body weight	63 kg
Blood pressure panel with all children optional
Systolic blood pressure	120 mmHg
Diastolic blood pressure	70 mmHg
Pattern of fetal movement	Fetal movements present

35090-0

Social history

Alcohol drinking behaviour	Current non-drinker of alcohol
Finding of tobacco use and exposure (finding)	Occasional cigarette smoker
Type of tobacco used (observable entity)	Electronic cigarette user
Tobacco smoking consumption (observable entity)	6 keer per dag inhaleren

Significant procedures

Obstetric procedure

Cesarean section

Problem List

Monochorionic diamniotic twin pregnancy	resolved
Fetal growth restriction	resolved

Hospital Course

The scheduled cesarean section procedure was performed on the day of admission without complications. Intraoperative and postoperative courses were uneventful. Postoperative pain was managed effectively with standard analgesia. Vital signs remained stable throughout the stay, and there were no signs of infection or other complications. The patient was mobilized on postoperative day one and tolerated oral intake well. Mother and newborn received routine postnatal care.

Results

ABO group [Type] in Blood	Blood group O
D Ag [Presence] in Blood	RhD positive
Hemoglobin [Moles/volume] in Venous blood	7.3 mmol/L
HIV 1 Ab [Presence] in Serum or Plasma by Immunoassay	HIV not detected

Discharge details

Patient Fiona Swart was discharged after cesarean section with healthy twin.

Additional Resources Included in Document

Entry 2 - fullUrl = http://example.org/Condition/condition-growth

Resource Condition:

clinicalStatus: Resolved
code: Fetal growth restriction
subject: Fiona F XXX_Swart
onset: 2025-02-08

Entry 3 - fullUrl = http://example.org/Condition/condition-meerling

Resource Condition:

Profile: Condition (HDR)
clinicalStatus: Resolved
code: Monochorionic diamniotic twin pregnancy
subject: Fiona F XXX_Swart
onset: 2025-02-08

Entry 4 - fullUrl = http://example.org/Encounter/ziekenhuisopname-swart

Resource Encounter:

Profile: Encounter (HDR)
status: completed
class: inpatient encounter
subject: Fiona F XXX_Swart
Diagnoses
- Condition
* No display for Encounter.diagnosis.condition (reference: ->monochoriale diamniotische tweelingzwangerschap)

Entry 5 - fullUrl = http://example.org/Observation/alcohol-swart

Resource Observation:

status: Final
code: Alcohol drinking behaviour
subject: Fiona F XXX_Swart
effective: 2025-02-08
value: Current non-drinker of alcohol

Entry 6 - fullUrl = http://example.org/Observation/bloeddruk-swart

Resource Observation:

Profile: Vital Signs Profile
status: Final
category: Vital Signs
code: Blood pressure panel with all children optional
subject: Fiona F XXX_Swart
effective: 2025-02-08
component
code: Systolic blood pressure
value: 120 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
component
code: Diastolic blood pressure
value: 70 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 7 - fullUrl = http://example.org/Observation/gewicht-swart

Resource Observation:

Profile: Vital Signs Profile
status: Final
category: Vital Signs
code: Body weight
subject: Fiona F XXX_Swart
effective: 2025-02-08
value: 63 kg (Details: UCUM codekg = 'kg')

Entry 8 - fullUrl = http://example.org/Observation/lab-swart-3

Resource Observation:

Profile: Observation Results: laboratory
status: Final
category: Laboratory
code: ABO group [Type] in Blood
subject: Fiona F XXX_Swart
effective: 2025-02-08
performer: Bundle: identifier = urn:ietf:rfc:4122#3e594fe5-3ed5-4305-a214-99c87e1f3bfa; type = document; timestamp = 2025-05-11 10:18:14+0000
value: Blood group O

Entry 9 - fullUrl = urn:uuid:a7c687cd-27dd-4b42-88c2-5e32418847ae

Resource Observation:

Profile: Observation Results: laboratory
status: Final
category: Laboratory
code: D Ag [Presence] in Blood
subject: Fiona F XXX_Swart
effective: 2025-02-08
performer: Bundle: identifier = urn:ietf:rfc:4122#3e594fe5-3ed5-4305-a214-99c87e1f3bfa; type = document; timestamp = 2025-05-11 10:18:14+0000
value: RhD positive

Entry 10 - fullUrl = urn:uuid:5863804b-b0aa-4292-8bc2-13a769ad50d7

Resource Observation:

Profile: Observation Results: laboratory
status: Final
category: Laboratory
code: Hemoglobin [Moles/volume] in Venous blood
subject: Fiona F XXX_Swart
effective: 2025-02-08
performer: Bundle: identifier = urn:ietf:rfc:4122#3e594fe5-3ed5-4305-a214-99c87e1f3bfa; type = document; timestamp = 2025-05-11 10:18:14+0000
value: 7.3 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 11 - fullUrl = urn:uuid:2640f290-85c4-426f-b912-4b5051f4f35a

Resource Observation:

Profile: Observation Results: laboratory
status: Final
category: Laboratory
code: HIV 1 Ab [Presence] in Serum or Plasma by Immunoassay
subject: Fiona F XXX_Swart
effective: 2025-02-08
performer: Bundle: identifier = urn:ietf:rfc:4122#3e594fe5-3ed5-4305-a214-99c87e1f3bfa; type = document; timestamp = 2025-05-11 10:18:14+0000
value: HIV not detected

Entry 12 - fullUrl = http://example.org/Observation/levenvoelen-swart

Resource Observation:

identifier: urn:oid:2.16.840.1.113883.2.4.3.11.999.7.6/38e436bf-6b35-11ec-2213-020000000000
status: Final
code: Pattern of fetal movement
subject: Fiona F XXX_Swart
effective: 2025-02-08
value: Fetal movements present

Entry 13 - fullUrl = http://example.org/Observation/tobacco-swart

Resource Observation:

status: Final
code: Finding of tobacco use and exposure (finding)
subject: Fiona F XXX_Swart
effective: 2025-02-08
value: Occasional cigarette smoker
component
code: Type of tobacco used (observable entity)
value: Electronic cigarette user
component
code: Tobacco smoking consumption (observable entity)
value: 6 keer per dag inhaleren (Details: UCUM code{keer per dag inhaleren} = '{keer per dag inhaleren}')

Entry 14 - fullUrl = http://example.org/Organization/organization-sophia

Resource Organization:

identifier: http://fhir.nl/fhir/NamingSystem/agb-z/06020806
type: Medisch specialist
name: Erasmus MC, Sophia kinderziekenhuis
contact
telecom: ph: 0107040116, info@erasmusmc.nl
address: Dr. Molewaterplein 60 ROTTERDAM 3015GJ NL (work)

Entry 15 - fullUrl = http://example.org/Patient/patient-swart

Resource Patient:

Fiona XXX_Swart Female, DoB: 1985-12-23 ( http://fhir.nl/fhir/NamingSystem/bsn#999901448)
Multiple Birth: false
Contact Detail
ph: 0655223366(Mobile)
Knolweg 1000 STITSWERD 9999XA NL (home)

Entry 16 - fullUrl = http://example.org/Procedure/sectio-swart

Resource Procedure:

Profile: Procedure (HDR)
status: Completed
category: Obstetric procedure
code: Cesarean section
subject: Fiona F XXX_Swart

Links: Table of Contents | QA Report

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