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

## : Composition: HDR (1) - JSON Representation

Raw json | Download

    {
      "resourceType" : "Composition",
      "id" : "b9dc409d-ec81-4556-9fac-4dc3f731c199",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr"
        ]
      },
      "text" : {
        "status" : "generated",
        "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><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\">Encounter: status = finished; class = inpatient encounter (ActCode#IMP); serviceType = Diabetes mellitus screening (procedure); period = 2025-04-01 08:45:00+0000 --&gt; 2025-04-10 11:00:00+0000; reasonCode = Prediabetes (finding)</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\">PractitionerRole</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\">Organization Casa di cura Villa S. Giuliana</a></p></div>"
      },
      "status" : "final",
      "type" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "34105-7",
            "display" : "Hospital Discharge summary"
          }
        ]
      },
      "subject" : {
        "reference" : "urn:uuid:b01a2623-e219-41d2-8e78-1fa1439751d0"
      },
      "encounter" : {
        "reference" : "urn:uuid:7c9a2bf1-507f-4d43-b06e-d78e9670379d"
      },
      "date" : "2025-04-29T13:30:00+01:00",
      "author" : [
        {
          "reference" : "urn:uuid:74403dd8-bb1b-45f9-bb69-e843dfaf45e9"
        }
      ],
      "title" : "Hospital Discharge Report",
      "custodian" : {
        "reference" : "urn:uuid:a61a91f8-b8f2-4947-9a64-5165ea380a38"
      },
      "section" : [
        {
          "title" : "Admission evaluation",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "67851-6"
              },
              {
                "system" : "http://loinc.org",
                "code" : "67852-4",
                "display" : "Hospital Admission evaluation note"
              }
            ]
          },
          "text" : {
            "status" : "additional",
            "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>"
          }
        },
        {
          "title" : "Family History",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "10157-6",
                "display" : "History of family member diseases note"
              }
            ]
          },
          "text" : {
            "status" : "additional",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).</div>"
          },
          "entry" : [
            {
              "reference" : "urn:uuid:635c22e7-d7f1-45ad-9b4d-d4fe35239085"
            },
            {
              "reference" : "urn:uuid:3fbdfbe1-9d70-47ec-ac05-3e30b063365a"
            }
          ]
        },
        {
          "title" : "Vital signs note",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "8716-3",
                "display" : "Vital signs note"
              }
            ]
          },
          "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>"
          },
          "entry" : [
            {
              "reference" : "urn:uuid:f0113857-b9b7-429b-8893-b645a38ae20a"
            },
            {
              "reference" : "urn:uuid:065c918f-730a-47f8-938a-7ad54618037b"
            },
            {
              "reference" : "urn:uuid:81783ae4-c36d-424f-8cea-fe7d3407a36b"
            },
            {
              "reference" : "urn:uuid:a19e48e1-2271-4cdb-9c76-b0626c7a5363"
            },
            {
              "reference" : "urn:uuid:fd7f7580-5788-45dd-88ec-dca615d69c7d"
            }
          ]
        },
        {
          "title" : "Tobacco use",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "11367-0",
                "display" : "History of Tobacco use"
              }
            ]
          },
          "text" : {
            "status" : "additional",
            "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">The patient smokes &quot;a few&quot; cigarettes per day.</div>"
          },
          "entry" : [
            {
              "reference" : "urn:uuid:67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6"
            }
          ]
        },
        {
          "title" : "Hospital course note",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "8648-8",
                "display" : "Hospital course note"
              }
            ]
          },
          "text" : {
            "status" : "additional",
            "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>"
          }
        },
        {
          "title" : "Significant Observation Results",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "30954-2",
                "display" : "Relevant diagnostic tests/laboratory data note"
              }
            ]
          },
          "text" : {
            "status" : "additional",
            "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>&lt; 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>"
          }
        },
        {
          "title" : "Significant procedures",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "10185-7",
                "display" : "Hospital discharge procedure note"
              }
            ]
          },
          "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>"
          },
          "entry" : [
            {
              "reference" : "urn:uuid:92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0"
            },
            {
              "reference" : "urn:uuid:a74a3dca-92fa-4b71-8e70-89a07ac74bc3"
            },
            {
              "reference" : "urn:uuid:53a8c3c3-5d1b-4950-87bc-fddae2ebc079"
            }
          ]
        },
        {
          "title" : "Medications",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "87232-5",
                "display" : "Medication administration.brief"
              }
            ]
          },
          "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>"
          },
          "entry" : [
            {
              "reference" : "urn:uuid:bda0b497-c9f2-47ca-8339-da1d379cb2f4"
            }
          ]
        },
        {
          "title" : "Follow-up",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "18776-5",
                "display" : "Plan of care note"
              }
            ]
          },
          "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>"
          },
          "entry" : [
            {
              "reference" : "urn:uuid:b84038f8-9541-4c5b-93b0-a7f1b8e55bd3"
            }
          ]
        },
        {
          "title" : "Diagnosis at Discharge",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "11535-2",
                "display" : "Hospital discharge diagnosis note"
              }
            ]
          },
          "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>"
          },
          "entry" : [
            {
              "reference" : "urn:uuid:a5bf69e4-24db-48a8-9eda-71516dcaf1d9"
            }
          ]
        },
        {
          "title" : "Hospital Discharge Instructions",
          "code" : {
            "coding" : [
              {
                "system" : "http://loinc.org",
                "code" : "8653-8",
                "display" : "Hospital Discharge Instructions"
              }
            ]
          },
          "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>"
          }
        }
      ]
    }