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) - XML Representation

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    <Composition xmlns="http://hl7.org/fhir">
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        <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>
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          <display value="Hospital Discharge summary"/>
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      <date value="2025-04-29T13:30:00+01:00"/>
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      <title value="Hospital Discharge Report"/>
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      <section>
        <title value="Admission evaluation"/>
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            <display value="Hospital Admission evaluation note"/>
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          <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>
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      <section>
        <title value="Family History"/>
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          <div xmlns="http://www.w3.org/1999/xhtml">Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).</div>
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      <section>
        <title value="Vital signs note"/>
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          <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>
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        <title value="Tobacco use"/>
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          <div xmlns="http://www.w3.org/1999/xhtml">The patient smokes &quot;a few&quot; cigarettes per day.</div>
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        <title value="Hospital course note"/>
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          <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>
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        <title value="Significant Observation Results"/>
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          <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>
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        <title value="Significant procedures"/>
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          <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>
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      <section>
        <title value="Medications"/>
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            <display value="Medication administration.brief"/>
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          <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>
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        <title value="Follow-up"/>
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          <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>
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      <section>
        <title value="Diagnosis at Discharge"/>
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            <display value="Hospital discharge diagnosis note"/>
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          <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>
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      <section>
        <title value="Hospital Discharge Instructions"/>
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          <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>
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