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 (4)

Document Details

Profile: Bundle (HDR)

Final Document at 2025-02-08 10:18:13+0000 by Organization Erasmus MC, Sophia kinderziekenhuis for Fiona XXX_Swart Female, DoB: 1985-12-23 ( http://fhir.nl/fhir/NamingSystem/bsn#999901448) in encounter Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-02-08 10:00:00+0000 --> 2025-02-12 12:00:00+0000; reasonCode = Twin pregnancy

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 note

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

## Hx general Reported

### 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 note

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 (EU core)

> 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: Medical Test Result (EU core)

> status: Final

> category: Laboratory

> code: ABO group [Type] in Blood

> subject: Fiona F XXX_Swart

> effective: 2025-02-08

> performer: Organization Erasmus MC, Sophia kinderziekenhuis

> value: Blood group O

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

Resource Observation:

> Profile: Observation: Medical Test Result (EU core)

> status: Final

> category: Laboratory

> code: D Ag [Presence] in Blood

> subject: Fiona F XXX_Swart

> effective: 2025-02-08

> performer: Organization Erasmus MC, Sophia kinderziekenhuis

> value: RhD positive

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

Resource Observation:

> Profile: Observation: Medical Test Result (EU core)

> status: Final

> category: Laboratory

> code: Hemoglobin [Moles/volume] in Venous blood

> subject: Fiona F XXX_Swart

> effective: 2025-02-08

> performer: Organization Erasmus MC, Sophia kinderziekenhuis

> 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: Medical Test Result (EU core)

> 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: Organization Erasmus MC, Sophia kinderziekenhuis

> 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 (EU core)

> status: Completed

> category: Obstetric procedure

> code: Cesarean section

> subject: Fiona F XXX_Swart