HL7 Europe Hospital Discharge Report
1.0.0-alpha - qa-preview 150

HL7 Europe Hospital Discharge Report - Downloaded Version 1.0.0-alpha See the Directory of published versions

## Example Bundle: Bundle: complete HL7 Europe Hospital Discharge Report (2)

Document Details

Profile: Bundle (HDR)

Final Document at 2025-04-29 13:30:00+0100 by PractitionerRole for Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier) in encounter Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-04-20 10:00:00+0100 --> 2025-04-29 11:00:00+0100

Document Subject

Profile: Patient (EU core)

Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier)

Other Id: | Medical record number/395922e4-846a-4c18-81e8-9121c77e7bf9
Contact Detail | +31 06-58675866 Nieuweweg 134 Hoogerheide 4631 TC Netherlands (home)

Document Content

## Admission evaluation

Mr. Reijer Wolff was admitted on April 20, 2025, following a fall that resulted in a closed fracture of the tibia and fibula of the left leg.

Problems | SNOMED
--- | ---
Fracture of lower leg, Left lower limb | 414292006

## Procedures

On April 23, 2025, a fixateur externe was applied to stabilize the fracture. The procedure was performed under general anesthesia without complications.

Procedures | SNOMED
--- | ---
Application of external fixator device, Left lower limb | 304527002

## Medications

The patient received paracetamol for pain relief and cefazolin as a prophylactic antibiotic post-surgery.

Medication administrations | SNOMED
--- | ---
Paracetamol | 387517004
Cefazolin | 387458008

## Hospital course note

The patient was monitored for signs of infection, received regular wound care, and started physiotherapy during the stay. No adverse events occurred.

## Discharge and Follow-up

Mr. Doe was discharged in stable condition with instructions to avoid weight-bearing on the left leg and to follow up in the orthopedic clinic.

## Additional Resources Included in Document

Entry 2 - fullUrl = urn:uuid:a1438872-05b1-4868-857d-521c9d586a7e

Resource Patient:

> Profile: Patient (EU core)

> Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier)

> Other Id: | Medical record number/395922e4-846a-4c18-81e8-9121c77e7bf9
> Contact Detail | +31 06-58675866 Nieuweweg 134 Hoogerheide 4631 TC Netherlands (home)

Entry 3 - fullUrl = urn:uuid:cc0ae2a0-980d-4a2b-a4fb-9c71ecc70a15

Resource PractitionerRole:

> Profile: PractitionerRole (EU core)

> practitioner: Practitioner Anna Smit

> organization: Organization Onze Lieve Lucas Gasthuis Hulst

Entry 4 - fullUrl = urn:uuid:b60f89db-36c7-4a23-ab59-ace7089d2387

Resource Practitioner:

> name: Anna Smit

> telecom: anna.smit@olv-hulst.org

Entry 5 - fullUrl = urn:uuid:3f30e341-19c6-484f-827a-0c58545fb2bc

Resource Organization:

> name: Onze Lieve Lucas Gasthuis Hulst

> ### Contacts

> - | Address
> * | Hulst 4561 nl

Entry 6 - fullUrl = urn:uuid:12fef60c-1fe7-4988-8286-af691889a3f3

Resource Encounter:

> Profile: Encounter (HDR)

> status: Completed

> class: inpatient encounter

> subject: Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier)

> serviceProvider: Organization Onze Lieve Lucas Gasthuis Hulst

Entry 7 - fullUrl = urn:uuid:38d0593b-7949-489e-9306-95df81a109df

Resource Condition:

> Profile: Condition (EU core)

> clinicalStatus: Active

> code: Fracture of lower leg (disorder)

> bodySite: Entire left lower limb (body structure)

> subject: Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier)

> onset: 2025-04-20

Entry 8 - fullUrl = urn:uuid:1493fed2-e9ed-4dc1-b107-f077cb1d0d40

Resource Procedure:

> Profile: Procedure (EU core)

> status: Completed

> code: Application of external fixator system (procedure)

> subject: Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier)

> bodySite: Entire left lower limb (body structure)

Entry 9 - fullUrl = urn:uuid:1bcfb26f-6958-4604-a40b-712170c1e536

Resource MedicationAdministration:

> Profile: MedicationAdministration (HDR)

> status: Completed

> subject: Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier)

Entry 10 - fullUrl = urn:uuid:4578e7cd-0d00-4221-9a7f-3e3d6e14a21b

Resource MedicationAdministration:

> Profile: MedicationAdministration (HDR)

> status: Completed

> subject: Reijer Wolff Male, DoB: 1969-02-25 ( National unique individual identifier)