Document-example-dischargesummary.xml

Example of a discharge summary (id = "father")

Raw XML

<Bundle xmlns="http://hl7.org/fhir">
  <id value="father"/>
  <meta>
    <lastUpdated value="2013-05-28T22:12:21Z"/>
    <tag>
      <system value="http://hl7.org/fhir/tag"/>
      <code value="document"/>
    </tag>
  </meta>
  <type value="document"/>
  <base value="http://fhir.healthintersections.com.au/open"/><!--    The Composition resource    -->
  <entry>
    <base value="urn:uuid:"/>
    <resource>
      <Composition>
        <id value="180f219f-97a8-486d-99d9-ed631fe4fc57"/>
        <meta>
          <lastUpdated value="2013-05-28T22:12:21Z"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <date value="2013-02-01T12:30:02Z"/>
        <type>
          <coding>
            <system value="http://loinc.org"/>
            <code value="28655-9"/>
          </coding>
          <text value="Discharge Summary from Responsible Clinician"/>
        </type>
        <status value="final"/>
        <confidentiality value="N"/>
        <subject>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Eve Everywoman"/>
        </subject>
        <author>
          <reference value="Practitioner/example"/>
          <display value="Doctor Dave"/>
        </author><!--    The Encounter resource. Points directly to an Encounter resource. Contains the dates
         of admission, specialtyu etc.    -->
        <encounter>
          <reference value="http://fhir.healthintersections.com.au/open/Encounter/doc-example"/>
        </encounter>
        <section>
          <title value="Reason for admission"/>
          <content>
            <reference value="urn:uuid:d0dd51d3-3ab2-4c84-b697-a630c3e40e7a"/>
          </content>
        </section><!--    Points to the list that groups the medications on discharge    -->
        <section>
          <title value="Medications on Discharge"/>
          <content>
            <reference value="urn:uuid:673f8db5-0ffd-4395-9657-6da00420bbc1"/>
          </content>
        </section><!--    Points to the list that groups the allergies    -->
        <section>
          <title value="Known allergies"/>
          <content>
            <reference value="urn:uuid:68f86194-e6e1-4f65-b64a-5314256f8d7b"/>
          </content>
        </section>
      </Composition>
    </resource>
  </entry><!--    The Practitioner Resource. In this document they are the author of the document
    (There is a reference from the document resource). Note that, strictly, it doesn't
   need to be within the document as the
    recipient knows where to go and get it if they need it - assuming it is available
   on-line of course.   -->
  <entry>
    <resource>
      <Practitioner>
        <id value="example"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <identifier>
          <system value="http://www.acme.org/practitioners"/>
          <value value="23"/>
        </identifier>
        <name>
          <family value="Careful"/>
          <given value="Adam"/>
          <prefix value="Dr"/>
        </name>
        <practitionerRole>
          <managingOrganization>
            <reference value="Organization/1"/>
          </managingOrganization><!--      Referring Practitioner for the first 3 months of 2012      -->
          <role>
            <coding>
              <system value="http://hl7.org/fhir/v2/0286"/>
              <code value="RP"/>
            </coding>
          </role>
          <period>
            <start value="2012-01-01"/>
            <end value="2012-03-31"/>
          </period>
        </practitionerRole>
      </Practitioner>
    </resource>
  </entry><!--    The Patient who is the subject of the document. Same coments as practitioner.    -->
  <entry>
    <resource>
      <Patient>
        <id value="d1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <name>
          <text value="Eve Everywoman"/>
          <family value="Everywoman1"/>
          <given value="Eve"/>
        </name>
        <telecom>
          <system value="phone"/>
          <value value="555-555-2003"/>
          <use value="work"/>
        </telecom>
        <gender value="female"/>
        <birthDate value="1955-01-06"/>
        <address>
          <use value="home"/>
          <line value="2222 Home Street"/>
        </address>
        <active value="true"/>
      </Patient>
    </resource>
  </entry><!--    The encounter that is being documented.   -->
  <entry>
    <resource>
      <Encounter>
        <id value="doc-example"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <identifier>
          <value value="S100"/>
        </identifier>
        <status value="finished"/>
        <class value="inpatient"/>
        <type>
          <text value="Orthopedic Admission"/>
        </type>
        <patient>
          <reference value="Patient/d1"/>
        </patient>
        <period>
          <start value="2013-01-20T12:30:02Z"/>
          <end value="2013-02-01T12:30:02Z"/>
        </period>
        <hospitalization>
          <dischargeDisposition>
            <text value="Discharged to care of GP"/>
          </dischargeDisposition>
        </hospitalization>
      </Encounter>
    </resource>
  </entry><!--    The Reason for admission.   -->
  <entry>
    <base value="urn:uuid:"/>
    <resource>
      <List>
        <id value="d0dd51d3-3ab2-4c84-b697-a630c3e40e7a"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="8646-2"/>
            <display value="Hospital admission diagnosis"/>
          </coding>
        </code>
        <subject>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Peter Patient"/>
        </subject>
        <status value="current"/>
        <mode value="working"/><!--    This is an entry that refers to an Observation resource in this document.    -->
        <entry>
          <item>
            <reference value="urn:uuid:541a72a8-df75-4484-ac89-ac4923f03b81"/>
          </item>
        </entry>
      </List>
    </resource>
  </entry>
  <entry>
    <base value="urn:uuid:"/>
    <resource>
      <Observation>
        <id value="541a72a8-df75-4484-ac89-ac4923f03b81"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="46241-6"/>
          </coding>
          <text value="Reason for admission"/>
        </code>
        <valueString value="Acute Asthmatic attack. Was wheezing for days prior to admission."/>
        <status value="final"/>
        <reliability value="ok"/>
      </Observation>
    </resource>
  </entry><!--    The list of medications on discharge   -->
  <entry>
    <base value="urn:uuid:"/>
    <resource>
      <List>
        <id value="673f8db5-0ffd-4395-9657-6da00420bbc1"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="10183-2"/>
            <display value="Hospital discharge medications"/>
          </coding>
        </code>
        <subject>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Peter Patient"/>
        </subject>
        <status value="current"/>
        <mode value="working"/><!--    This is an entry that refers to a MedicationPrescription resource in this document.
                It is a new medication (as indicated by the flag)   -->
        <entry>
          <flag>
            <coding><!--    The flag refers to the valueset containing permissable codes for changes
                            to medication status that occurred during this encounter.
               Possible values are started,
                            continued, stopped, changed   -->
              <system value="http://www.ithealthboard.health.nz/fhir/ValueSet/medicationStatus"/>
              <code value="started"/>
            </coding>
          </flag>
          <item>
            <reference value="urn:uuid:124a6916-5d84-4b8c-b250-10cefb8e6e86"/>
          </item>
        </entry><!--    This is an entry that refers to a medicationPrescription that is available on an external
         server.
                In practice, you may still want an entry in the document as well, but
         it's not necessary. The medication
                was stopped on this admission. Note that the deleted element is also true.
         Because the resource is
                no longer active, we assume that it was deleted on the server, so following
         the link would result
                in an http status code of 410 (Though you can always use the history to
         get previous versions)   -->
        <entry>
          <flag>
            <coding>
              <system value="http://www.ithealthboard.health.nz/fhir/ValueSet/medicationStatus"/>
              <code value="stopped"/>
            </coding>
          </flag>
          <deleted value="true"/>
          <item>
            <reference value="MedicationPrescription/1"/>
            <display value="use of Ventolin Inhaler was discontinued"/>
          </item>
        </entry>
      </List>
    </resource>
  </entry><!--    The first medication in the medications list    -->
  <entry>
    <base value="urn:uuid:"/>
    <resource>
      <MedicationPrescription>
        <id value="124a6916-5d84-4b8c-b250-10cefb8e6e86"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta><!--    The Human readible version of the script    -->
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <contained>
          <Medication><!--    This text section can be exctly the same as CDA    --><!--    The medication. This is currently modelled as a contained resource within the prescription,
             but could also be a separate
                    resource either within the document bundle, or a reference to the
             medication on a server. The latter
                    (i.e. where the medication terminology is hosted on a publically available
             server and simply referenced from the
                MedicationPrescription resource is particularly attractive...    -->
            <id value="med1"/>
            <name value="Theophylline 200mg"/>
            <code>
              <coding>
                <system value="http://snomed.info/sct"/>
                <code value="66493003"/>
              </coding>
            </code>
          </Medication>
        </contained><!--    The patient details will generally be in the Document resource in the Document bundle,
         but could just as easily
        point to a patient resource on a server   -->
        <patient>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Peter Patient"/>
        </patient><!--    The prescriber details could also be within the bundle, but has the same options as
         patient   -->
        <prescriber>
          <reference value="Practitioner/example"/>
          <display value="Peter Practitioner"/>
        </prescriber>
        <reasonCodeableConcept>
          <text value="Management of Asthma"/>
        </reasonCodeableConcept><!--    a reference to the medication being prescribed. As described earlier, this could be
         contained (as is the example here), separately
        within the document bundle or simply a reference to a remote server. See comment
         in the contained resource   -->
        <medication>
          <reference value="#med1"/>
          <display value="Theophylline 200mg BD"/>
        </medication>
        <dosageInstruction>
          <additionalInstructions>
            <text value="Take with Food"/>
          </additionalInstructions><!--    twice a day    -->
          <scheduledTiming>
            <repeat>
              <frequency value="2"/>
              <period value="1"/>
              <periodUnits value="d"/>
            </repeat>
          </scheduledTiming><!--    Orally    -->
          <route>
            <coding>
              <system value="http://snomed.info/sct"/>
              <code value="394899003"/>
              <display value="oral administration of treatment"/>
            </coding>
          </route>
          <doseQuantity>
            <value value="1"/>
            <units value="tablet"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="tbl"/>
          </doseQuantity>
        </dosageInstruction>
      </MedicationPrescription>
    </resource>
  </entry><!--    The list of known allergies   -->
  <entry>
    <base value="urn:uuid:"/>
    <resource>
      <List>
        <id value="68f86194-e6e1-4f65-b64a-5314256f8d7b"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="48765-2"/>
            <display value="Allergies and adverse reactions Document"/>
          </coding>
        </code>
        <subject>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Peter Patient"/>
        </subject>
        <status value="current"/>
        <mode value="working"/><!--    This is an entry that refers to an allergy resource in this document.    -->
        <entry>
          <item>
            <reference value="urn:uuid:47600e0f-b6b5-4308-84b5-5dec157f7637"/>
          </item>
        </entry>
      </List>
    </resource>
  </entry><!--    The Allergy.   -->
  <entry>
    <base value="urn:uuid:"/>
    <resource>
      <AllergyIntolerance>
        <id value="47600e0f-b6b5-4308-84b5-5dec157f7637"/>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
        </text>
        <recordedDate value="2012-09-17"/>
        <patient>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Eve Everywoman"/>
        </patient>
        <substance>
          <text value="Doxycycline"/>
        </substance>
        <status value="confirmed"/>
        <criticality value="high"/>
        <type value="immune"/>
        <event>
          <manifestation>
            <coding>
              <system value="http://example.org/system"/>
              <code value="xxx"/>
              <display value="Hives"/>
            </coding>
            <text value="Hives"/>
          </manifestation>
        </event>
      </AllergyIntolerance>
    </resource>
  </entry>
</Bundle>