description: A generic, flexible model for any kind of discharge report. Different types of encounters may require adding relevant sections and elements, or omitting irrelevant ones, depending on their data needs. package_name: xtehr.eu.ehds.models derivation: specialization name: EHDSDischargeReport type: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDischargeReport elements: header: elements: author: short: The author of the report. choices: [] index: 1 status: {index: 2} documentType: {short: Type of the document (e.g. '34105-7 Hospital discharge summary), index: 3} documentTitle: {short: 'Title of the document, possibly autogenerated from the structured fields (e.g. ''Hospital discharge report. Jane Green. 07.10.2025-10.10.2025'')', index: 4} period: {short: Time of service that is being documented (typically the same as the time/period of encounter), index: 5} intendedRecipient: short: Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility. choices: ['intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient', 'intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson', 'intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional', 'intendedRecipientHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation'] array: true index: 7 intendedRecipientHttp://www: elements: xt-ehr: elements: eu/fhir/models/StructureDefinition/EHDSPatient: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient', short: 'Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.', choiceOf: intendedRecipient, array: true, index: 8} eu/fhir/models/StructureDefinition/EHDSRelatedPerson: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSRelatedPerson', short: 'Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.', choiceOf: intendedRecipient, array: true, index: 9} eu/fhir/models/StructureDefinition/EHDSHealthProfessional: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional', short: 'Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.', choiceOf: intendedRecipient, array: true, index: 10} eu/fhir/models/StructureDefinition/EHDSOrganisation: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation', short: 'Intended recipient(s) of the information, i.e. a person or organisation that should be notified or be aware of the content. This element is used to indicate explicit communication intent and does not represent routine storage or passive availability of information (e.g. in portals). Listing an intended recipient does not create an assignment or responsibility.', choiceOf: intendedRecipient, array: true, index: 11} body: type: Base short: Structured body of the discharge report document index: 12 elements: encounterInformation: type: Base short: 'Section: Encounter information.' index: 16 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section.', index: 17} encounter: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSEncounter', short: Encounter information, index: 18} note: {type: string, short: Free text notes by the health professional, index: 19} admissionEvaluation: type: Base short: 'Section: Admission evaluation. Admission evaluation section should be reported only if it is relevant to ensure continuity of care.' index: 20 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section.', index: 21} objectiveFindings: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', short: 'Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination', array: true, index: 22} functionalStatus: short: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being choices: ['functionalStatusHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', 'functionalStatusHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation'] array: true index: 24 functionalStatusHttp://www: elements: xt-ehr: elements: eu/fhir/models/StructureDefinition/EHDSCondition: {short: 'An individual''s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', array: true, choiceOf: functionalStatus, index: 25} eu/fhir/models/StructureDefinition/EHDSObservation: {short: 'An individual''s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', array: true, choiceOf: functionalStatus, index: 26} note: {type: string, short: Free text notes by the evaluation performer, index: 27} medicationSummary: type: Base short: Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued. index: 53 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section.', index: 54} medicationUse: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationUse', short: Details about medication and dosage, array: true, index: 55} note: {type: string, short: Free text notes by the health professional, index: 56} courseOfEncounter: type: Base short: Course of inpatient or outpatient encounter. index: 34 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section.', index: 35} diagnosticSummary: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', short: 'Problems that were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the encounter. At least one treated problem should be marked. Other problems are recorded only if they are important for continuity of care (after discharge).', array: true, index: 36} procedures: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure', short: 'Procedures performed during encounter which are significant for continuity of care, e.g. surgeries and other instrumental interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. Diagnostic procedures are typically captured as observation results and not repeated here.', array: true, index: 37} medicalDevicesAndImplants: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse', short: 'Medical devices (including implants) whose use was started, stopped, or otherwise modified during the encounter.', array: true, index: 38} pharmacotherapy: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationUse', short: Significant medication treatments during encounter. The content of this section may be repeated in the medication summary for full overview of patient's medications., array: true, index: 39} testResults: short: Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived. choices: ['testResultsHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', 'testResultsHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation'] array: true index: 41 testResultsHttp://www: elements: xt-ehr: elements: eu/fhir/models/StructureDefinition/EHDSObservation: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', short: 'Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.', choiceOf: testResults, array: true, index: 42} eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSLaboratoryObservation', short: 'Significant medical test results of functional, diagnostic (including laboratory), and imaging examinations performed during encounter. This may include orders for which the results have not yet arrived.', choiceOf: testResults, array: true, index: 43} note: {type: string, short: Free text notes by the health professional, index: 44} alerts: type: Base short: 'Section: Alerts.' index: 13 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section.', index: 14} medicalAlert: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert', short: 'Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.', array: true, index: 15} patientHistory: type: Base short: 'Section: Patient health history (anamnesis) containing only information that is highly relevant for this specific episode of care. The model is designed with the expectation that patient summary is available.' index: 28 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section. In case the section includes structured information, it should also be included in generatedNarrative.', index: 29} pastProblems: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', short: 'A list of conditions of a patient that the patient suffered in the past or still suffers. Unlike diagnostic summary, medical history is not only a list of problems, but could contain broader description of the condition and its progress, details about treatment including medication and patient response to treatment. Past problem section (unlike the same section of the patient summary) should include only conditions that are important for continuity of care. This section, if provided, complements the diagnostic summary section of the discharge report.', array: true, index: 30} devicesAndImplants: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse', short: Devices and implants in patient anamnesis., array: true, index: 31} procedures: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure', short: Procedures in patient anamnesis., array: true, index: 32} note: {type: string, short: Free text notes by the health professional, index: 33} carePlan: type: Base short: Care plan and other recommendations after discharge. index: 57 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section.', index: 58} carePlan: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan', short: Structured care plan after discharge. Multiple care plans could be provided., array: true, index: 59} otherRecommendations: {type: string, short: 'Other recommendations (advice) after discharge. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.', index: 60} dischargeDetails: type: Base short: Discharge details index: 45 elements: generatedNarrative: {type: string, short: 'Narrative, potentially formatted, content of the whole section.', index: 46} objectiveFindings: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', short: 'Objective findings, such as anthropometric measurements, vital signs, or objective anatomical findings of physical examination', array: true, index: 47} functionalStatus: short: An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being choices: ['functionalStatusHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', 'functionalStatusHttp://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation'] array: true index: 49 functionalStatusHttp://www: elements: xt-ehr: elements: eu/fhir/models/StructureDefinition/EHDSCondition: {short: 'An individual''s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition', array: true, choiceOf: functionalStatus, index: 50} eu/fhir/models/StructureDefinition/EHDSObservation: {short: 'An individual''s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being', type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation', array: true, choiceOf: functionalStatus, index: 51} note: {type: string, short: Free text notes by the health professional, index: 52} synthesis: {type: string, short: 'Clinical synthesis (e.g. description of reasons and course of encounter) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.', index: 61} required: [encounterInformation, courseOfEncounter] attachments: {type: 'http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment', short: Report attachments. Implementations may define what kind of attachments are allowed and may ignore unexpected attachments for security reasons., array: true, index: 62} package_version: 1.0.0 class: logical kind: logical url: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDischargeReport base: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDocument version: 1.0.0