description: Clinical document used to represent the discharge summary record for ABDM HDE data set.
package_name: ndhm.in
derivation: constraint
name: DischargeSummaryRecord
type: Composition
elements:
  status: {mustSupport: true, index: 0}
  type:
    short: Kind of composition (SNOMED CT if possible)
    mustSupport: true
    index: 1
    elements:
      coding:
        index: 2
        elements:
          system:
            pattern: {type: uri, value: 'http://snomed.info/sct'}
            type: uri
            index: 3
          code:
            pattern: {type: code, value: '373942005'}
            type: code
            index: 4
          display:
            pattern: {type: string, value: Discharge summary}
            type: string
            index: 5
        required: [code, display, system]
      text: {mustSupport: true, index: 6}
    required: [coding]
  subject:
    type: Reference
    mustSupport: true
    refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient']
    index: 7
    elements:
      reference: {index: 8}
    required: [reference]
  encounter:
    type: Reference
    mustSupport: true
    refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter']
    index: 9
  author:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
    index: 10
  attester:
    mustSupport: true
    index: 11
    elements:
      party:
        type: Reference
        refers: ['http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
        index: 12
  custodian:
    type: Reference
    refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization']
    index: 13
  section:
    mustSupport: true
    index: 14
    slicing:
      rules: openAtEnd
      discriminator:
      - {path: code.coding.code, type: value}
      min: 1
      slices:
        CarePlan:
          match:
            code:
              coding: {code: '734163000'}
          schema:
            short: The section outlines the care plan developed for the patient, including treatment goals, planned interventions.
            index: 87
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 88
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 89
                      code:
                        pattern: {type: code, value: '734163000'}
                        type: code
                        index: 90
                      display:
                        pattern: {type: string, value: Care plan}
                        type: string
                        index: 91
                    required: [code, display, system]
                  text: {mustSupport: true, index: 92}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 93
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/CarePlan']
                index: 94
                elements:
                  reference: {index: 95}
                required: [reference]
        MedicalHistory:
          match:
            code:
              coding: {code: '1003642006'}
          schema:
            short: The section records the patient's past medical history, including previous illnesses, surgeries etc.
            index: 42
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 43
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 44
                      code:
                        pattern: {type: code, value: '1003642006'}
                        type: code
                        index: 45
                      display:
                        pattern: {type: string, value: Past medical history section}
                        type: string
                        index: 46
                    required: [code, display, system]
                  text: {mustSupport: true, index: 47}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 48
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure']
                index: 49
                elements:
                  reference: {index: 50}
                required: [reference]
        Procedures:
          match:
            code:
              coding: {code: '1003640003'}
          schema:
            short: The section records any surgical or medical procedures performed on the patient during their admission.
            index: 78
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 79
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 80
                      code:
                        pattern: {type: code, value: '1003640003'}
                        type: code
                        index: 81
                      display:
                        pattern: {type: string, value: History of past procedure section}
                        type: string
                        index: 82
                    required: [code, display, system]
                  text: {mustSupport: true, index: 83}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 84
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure']
                index: 85
                elements:
                  reference: {index: 86}
                required: [reference]
        DocumentReference:
          match:
            code:
              coding: {code: '373942005'}
          schema:
            short: The section contains references to documents related to the patient's discharge summary.
            index: 96
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 97
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 98
                      code:
                        pattern: {type: code, value: '373942005'}
                        type: code
                        index: 99
                      display:
                        pattern: {type: string, value: Discharge summary}
                        type: string
                        index: 100
                    required: [code, display, system]
                  text: {mustSupport: true, index: 101}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 102
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference']
                index: 103
                elements:
                  reference: {index: 104}
                required: [reference]
        Investigations:
          match:
            code:
              coding: {code: '721981007'}
          schema:
            short: The section includes information about diagnostic tests and investigations carried out during the patient's admission, such as lab tests, imaging studies, and other diagnostic procedures.
            index: 60
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 61
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 62
                      code:
                        pattern: {type: code, value: '721981007'}
                        type: code
                        index: 63
                      display:
                        pattern: {type: string, value: Diagnostic studies report}
                        type: string
                        index: 64
                    required: [code, display, system]
                  text: {mustSupport: true, index: 65}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 66
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportImaging', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportLab']
                index: 67
                elements:
                  reference: {index: 68}
                required: [reference]
        Allergies:
          match:
            code:
              coding: {code: '722446000'}
          schema:
            short: The section includes details about the patient's allergies and adverse reactions to medications, foods, or other substances.
            index: 33
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 34
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 35
                      code:
                        pattern: {type: code, value: '722446000'}
                        type: code
                        index: 36
                      display:
                        pattern: {type: string, value: Allergy record}
                        type: string
                        index: 37
                    required: [code, display, system]
                  text: {mustSupport: true, index: 38}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 39
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/AllergyIntolerance']
                index: 40
                elements:
                  reference: {index: 41}
                required: [reference]
        ChiefComplaints:
          match:
            code:
              coding: {code: '422843007'}
          schema:
            short: The section captures the primary reasons for the patient's admission, detailing the main symptoms or issues reported by the patient.
            index: 15
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 16
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 17
                      code:
                        pattern: {type: code, value: '422843007'}
                        type: code
                        index: 18
                      display:
                        pattern: {type: string, value: Chief complaint section}
                        type: string
                        index: 19
                    required: [code, display, system]
                  text: {mustSupport: true, index: 20}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 21
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition']
                index: 22
                elements:
                  reference: {index: 23}
                required: [reference]
        PhysicalExamination:
          match:
            code:
              coding: {code: '425044008'}
          schema:
            short: The section records the findings from the physical examination conducted by the healthcare provider, including vital signs and other physical assessments.
            index: 24
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 25
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 26
                      code:
                        pattern: {type: code, value: '425044008'}
                        type: code
                        index: 27
                      display:
                        pattern: {type: string, value: Physical exam section}
                        type: string
                        index: 28
                    required: [code, display, system]
                  text: {mustSupport: true, index: 29}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 30
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Observation']
                index: 31
                elements:
                  reference: {index: 32}
                required: [reference]
        Medications:
          match:
            code:
              coding: {code: '1003606003'}
          schema:
            short: The section lists the medications prescribed to the patient during their hospital stay, including dosage, frequency, and administration route.
            index: 69
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 70
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 71
                      code:
                        pattern: {type: code, value: '1003606003'}
                        type: code
                        index: 72
                      display:
                        pattern: {type: string, value: Medication history section}
                        type: string
                        index: 73
                    required: [code, display, system]
                  text: {mustSupport: true, index: 74}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 75
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest']
                index: 76
                elements:
                  reference: {index: 77}
                required: [reference]
        FamilyHistory:
          match:
            code:
              coding: {code: '422432008'}
          schema:
            short: The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
            index: 51
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 52
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 53
                      code:
                        pattern: {type: code, value: '422432008'}
                        type: code
                        index: 54
                      display:
                        pattern: {type: string, value: Family history section}
                        type: string
                        index: 55
                    required: [code, display, system]
                  text: {mustSupport: true, index: 56}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 57
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/FamilyMemberHistory']
                index: 58
                elements:
                  reference: {index: 59}
                required: [reference]
package_version: 6.5.0
class: profile
kind: resource
url: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DischargeSummaryRecord
base: http://hl7.org/fhir/StructureDefinition/Composition
version: 6.5.0
required: [encounter, section, subject]