HL7 Europe Hospital Discharge Report
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## Example Bundle: Bundle: complete HL7 Europe Hospital Discharge Report (1)

Document Details

Profile: Bundle (HDR)

Final Document at 2025-04-29 13:30:00+0100 by PractitionerRole for Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) in encounter Encounter: status = finished; class = inpatient encounter (ActCode#IMP); serviceType = Diabetes mellitus screening (procedure); period = 2025-04-01 08:45:00+0000 --> 2025-04-10 11:00:00+0000; reasonCode = Prediabetes (finding)

Document Subject

Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

Other Id: | Medical record number/8121c77e7bf9
Contact Detail | +39 0334 8920354 Via Zannoni 29 Serso 38057 Italy (home)

Document Content

## Admission evaluation

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.

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.

## Family History

Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).

## Vital signs note

Vital signs | 1st April | 10th April
--- | --- | ---
Body weight | 109 kg | 108 kg
Body height | 177 cm |
Blood Pressure | 155 / 95 mmHg | 150 / 90 mmHg

## Tobacco use

The patient smokes "a few" cigarettes per day.

## Hospital course note

During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment.

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.

## Significant Observation Results

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.

Date | Fasting glucose [Moles/volume] in Blood | Range
--- | --- | ---
1 April 2025 | 180 mg/dL | 70 to 99 mg/dL
2 April 2025 | 140 mg/dL | 70 to 99 mg/dL
3 April 2025 | 150 mg/dL | 70 to 99 mg/dL
5 April 2025 | 140 mg/dL | 70 to 99 mg/dL

HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus.

Date | Hemoglobin A1c [Mass/volume] in Blood | Range
--- | --- | ---
1 April 2025 | 7.2% | < 5.7%

Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance.

Date | Glucose [Mass/volume] in Serum or Plasma --1 hour post dose glucose | Range
--- | --- | ---
2 April 2025 | 180 mg/dL | 70 to 99 mg/dL

## Significant procedures

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.

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.

Starting Pharmacotherapy with Metformin.

## Medications

Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels.

Medication administrations | Dose/Frequency | SNOMED
--- | --- | ---
Metformin, oral tbl | 500 mg, twice / day | 765507008
Multivitamines | daily |

## Follow-up

Follow-up | Activity | SNOMED
--- | --- | ---
Endocrinology Clinic | Follow-up appointment in 2 weeks to assess response to treatment | 306118006 Referral to endocrinology service (procedure)
Dietitian Consultation | Appointment in 1 month for further dietary planning | 103699006 Referral to dietitian (procedure)
Routine Blood tests | Repeat HbA1c in 3 months | 43396009 Hemoglobin A1c measurement (procedure)

## Diagnosis at Discharge

Discharge Diagnoses | Codes
--- | ---
Type 2 Diabetes Mellitus – Newly diagnosed. | Type 2 diabetes mellitus E11 (ICD-10) Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)

## Hospital Discharge Instructions

Instructions at Discharge to Mr. De Luca

- Continue home glucose monitoring and to maintain a log for review at follow-up appointments.
- Continue with the prescribed medication and lifestyle changes.
- Monitor blood sugar levels at home regularly.
- Adhere to the diabetic diet plan.
- Stay physically active, with at least 30 minutes of moderate exercise most days of the week.
- Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).

## Additional Resources Included in Document

Entry 2 - fullUrl = urn:uuid:b01a2623-e219-41d2-8e78-1fa1439751d0

Resource Patient:

> Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> Other Id: | Medical record number/8121c77e7bf9
> Contact Detail | +39 0334 8920354 Via Zannoni 29 Serso 38057 Italy (home)

Entry 3 - fullUrl = urn:uuid:7c9a2bf1-507f-4d43-b06e-d78e9670379d

Resource Encounter:

> Profile: Encounter (HDR)

> status: Completed

> class: inpatient encounter

> serviceType: No display for Encounter.serviceType (concept: Diabetes mellitus screening (procedure))

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> serviceProvider: Organization Casa di cura Villa S. Giuliana

Entry 4 - fullUrl = urn:uuid:74403dd8-bb1b-45f9-bb69-e843dfaf45e9

Resource PractitionerRole:

> practitioner: Practitioner Augusto Zucchero-Combattente

> organization: Organization Casa di cura Villa S. Giuliana

Entry 5 - fullUrl = urn:uuid:0710d9e7-3f1a-4e16-a9b3-5c991fe23c95

Resource Practitioner:

> name: Augusto Zucchero-Combattente

> telecom: augusto@casasgiuliana.osp.venetia.it

Entry 6 - fullUrl = urn:uuid:a61a91f8-b8f2-4947-9a64-5165ea380a38

Resource Organization:

> name: Casa di cura Villa S. Giuliana

> ### Contacts

> - | Address
> * | Verona 37128 it

Entry 7 - fullUrl = urn:uuid:a5bf69e4-24db-48a8-9eda-71516dcaf1d9

Resource Condition:

> Profile: Condition (EU core)

> clinicalStatus: Active

> code: Type 2 diabetes mellitus

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> onset: 2025-04-04

Entry 8 - fullUrl = urn:uuid:b84038f8-9541-4c5b-93b0-a7f1b8e55bd3

Resource CarePlan:

> Profile: Care Plan (HDR)

> status: Active

> intent: Plan

> category: Diabetes clinical management plan

> title: Diabetes Management Plan

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> period: 2025-04-10 --> (ongoing)

> > activity

> > activity

> > activity

Entry 9 - fullUrl = urn:uuid:92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0

Resource Procedure:

> Profile: Procedure (EU core)

> status: Completed

> code: Lifestyle education (procedure)

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

Entry 10 - fullUrl = urn:uuid:a74a3dca-92fa-4b71-8e70-89a07ac74bc3

Resource Procedure:

> Profile: Procedure (EU core)

> status: Completed

> code: Diabetic education (procedure)

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

Entry 11 - fullUrl = urn:uuid:53a8c3c3-5d1b-4950-87bc-fddae2ebc079

Resource Procedure:

> Profile: Procedure (EU core)

> status: In Progress

> code: Metformin therapy (procedure)

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

Entry 12 - fullUrl = urn:uuid:635c22e7-d7f1-45ad-9b4d-d4fe35239085

Resource FamilyMemberHistory:

> status: Completed

> patient: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> relationship: mother

> ### Conditions

> - | Code
> * | Family history of diabetes mellitus type 2 (situation)

Entry 13 - fullUrl = urn:uuid:3fbdfbe1-9d70-47ec-ac05-3e30b063365a

Resource FamilyMemberHistory:

> status: Completed

> patient: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> relationship: maternal grandmother

> ### Conditions

> - | Code
> * | Family history of diabetes mellitus type 2 (situation)

Entry 14 - fullUrl = urn:uuid:f0113857-b9b7-429b-8893-b645a38ae20a

Resource Observation:

> status: Final

> category: Vital Signs

> code: Body weight

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> effective: 2025-04-01

> value: 109 kg (Details: UCUM codekg = 'kg')

Entry 15 - fullUrl = urn:uuid:065c918f-730a-47f8-938a-7ad54618037b

Resource Observation:

> status: Final

> category: Vital Signs

> code: Body weight

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> effective: 2025-04-19

> value: 108 kg (Details: UCUM codekg = 'kg')

Entry 16 - fullUrl = urn:uuid:81783ae4-c36d-424f-8cea-fe7d3407a36b

Resource Observation:

> status: Final

> category: Vital Signs

> code: Body height

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> effective: 2025-04-01

> value: 177 cm (Details: UCUM codecm = 'cm')

Entry 17 - fullUrl = urn:uuid:a19e48e1-2271-4cdb-9c76-b0626c7a5363

Resource Observation:

> status: Final

> category: Vital Signs

> code: Blood pressure panel with all children optional

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> effective: 2025-04-01

> > component

> > code: Systolic blood pressure

> > value: 155 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

> > component

> > code: Diastolic blood pressure

> > value: 95 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 18 - fullUrl = urn:uuid:fd7f7580-5788-45dd-88ec-dca615d69c7d

Resource Observation:

> status: Final

> category: Vital Signs

> code: Blood pressure panel with all children optional

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> effective: 2025-04-10

> > component

> > code: Systolic blood pressure

> > value: 150 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

> > component

> > code: Diastolic blood pressure

> > value: 90 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 19 - fullUrl = urn:uuid:67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6

Resource Observation:

> status: Final

> category: Social History

> code: History of Tobacco use

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> effective: 2025-04-01

> value: Current smoker

> note:

> > Patient smokes a few cigarettes a day

Entry 20 - fullUrl = urn:uuid:bda0b497-c9f2-47ca-8339-da1d379cb2f4

Resource MedicationAdministration:

> Profile: MedicationAdministration (HDR)

> status: In Progress

> subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier)

> ### Dosages

> - | Text | Route | Dose
> * | 500 mg, twice a day | Oral route | 500 mg