Document-example-dischargesummary.xml

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

<Bundle xmlns="http://hl7.org/fhir">
  <id value="father"/>
  <meta>
    <lastUpdated value="2013-05-28T22:12:21Z"/>
  </meta>
  <type value="document"/>
<!--      The Composition resource      -->
  <entry>
    <fullUrl value="http://fhir.healthintersections.com.au/open/Composition/180f219f-97a8-486d-99d9-ed631fe4fc57"/>
    <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"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 180f219f-97a8-486d-99d9-ed631fe4fc57</p><p><b>meta</b>: </p><p><b>date</b>: 01/02/2013 11:30:02 PM</p><p><b>type</b>: Discharge Summary from Responsible Clinician <span>(Details : {LOINC code '28655-9' = 'Physician attending Discharge summary)</span></p><p><b>title</b>: Discharge Summary</p><p><b>status</b>: final</p><p><b>confidentiality</b>: N</p><p><b>author</b>: <a>Doctor Dave</a></p><p><b>encounter</b>: <a>http://fhir.healthintersections.com.au/open/Encounter/doc-example</a></p></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>
        <title value="Discharge Summary"/>
        <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"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="29299-5"/>
              <display value="Reason for visit Narrative"/>
            </coding>
          </code>
          <text>
            <status value="additional"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
              
              <table>
                
                <thead>
                  
                  <tr>
                    
                    <td>Details</td>
                    
                    <td/>
                  
                  </tr>
                
                </thead>
                
                <tbody>
                  
                  <tr>
                    
                    <td>Acute Asthmatic attack. Was wheezing for days prior to admission.</td>
                    
                    <td/>
                  
                  </tr>
                
                </tbody>
              
              </table>
            
            </div>
          </text>
          <entry>
            <reference value="urn:uuid:541a72a8-df75-4484-ac89-ac4923f03b81"/>
          </entry>
        </section>
      <!--      Points to the list that groups the medications on discharge      -->
        <section>
          <title value="Medications on Discharge"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="10183-2"/>
              <display value="Hospital discharge medications Narrative"/>
            </coding>
          </code>
          <text>
            <status value="additional"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
              
              <table>
                
                <thead>
                  
                  <tr>
                    
                    <td>Medication</td>
                    
                    <td>Last Change</td>
                    
                    <td>Last ChangeReason</td>
                  
                  </tr>
                
                </thead>
                
                <tbody>
                  
                  <tr>
                    
                    <td>Theophylline 200mg BD after meals</td>
                    
                    <td>continued</td>
                  
                  </tr>
                  
                  <tr>
                    
                    <td>Ventolin Inhaler</td>
                    
                    <td>stopped</td>
                    
                    <td>Getting side effect of tremor</td>
                  
                  </tr>
                
                </tbody>
              
              </table>
            
            </div>
          </text>
          <mode value="working"/>
          <!--      This is an entry that refers to a MedicationOrder resource in this document.
                It is a new medication (as indicated by the flag)     -->
          <entry>
            <reference value="urn:uuid:124a6916-5d84-4b8c-b250-10cefb8e6e86"/>
          </entry>
          <entry>
            <reference value="urn:uuid:673f8db5-0ffd-4395-9657-6da00420bbc1"/>
          </entry>
        </section>
      <!--      Points to the list that groups the allergies      -->
        <section>
          <title value="Known allergies"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="48765-2"/>
              <display value="Allergies and adverse reactions Document"/>
            </coding>
          </code>
          <text>
            <status value="additional"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
              
              <table>
                
                <thead>
                  
                  <tr>
                    
                    <td>Allergen</td>
                    
                    <td>Reaction</td>
                  
                  </tr>
                
                </thead>
                
                <tbody>
                  
                  <tr>
                    
                    <td>Doxycycline</td>
                    
                    <td>Hives</td>
                  
                  </tr>
                
                </tbody>
              
              </table>
            
            </div>
          </text>
          <entry>
            <reference value="urn:uuid:47600e0f-b6b5-4308-84b5-5dec157f7637"/>
          </entry>
        </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>
    <fullUrl value="http://fhir.healthintersections.com.au/open/Practitioner/example"/>
    <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">
            
            <p>Dr Adam Careful is a Referring Practitioner for Acme Hospital from 1-Jan 2012 to 31-Mar
              2012</p>
          
          </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>
          <organization>
            <reference value="Organization/1"/>
          </organization>
        <!--        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>
    <fullUrl value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
    <resource>
      <Patient>
        <id value="d1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            
            <h1>Eve Everywoman</h1>
          
          </div>
        </text>
        <active value="true"/>
        <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>
      </Patient>
    </resource>
  </entry>
<!--      The encounter that is being documented.     -->
  <entry>
    <fullUrl value="http://fhir.healthintersections.com.au/open/Encounter/doc-example"/>
    <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"> Admitted to Orthopedics Service,
                        Middlemore Hospital between Jan 20 and Feb ist 2013 </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>
  <entry>
    <fullUrl value="urn:uuid:541a72a8-df75-4484-ac89-ac4923f03b81"/>
    <resource>
      <Observation>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"> Acute Asthmatic attack. Was wheezing
                        for days prior to admission. </div>
        </text>
        <status value="final"/>
        <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."/>
      </Observation>
    </resource>
  </entry>
<!--      The first medication in the medications list      -->
  <entry>
    <fullUrl value="urn:uuid:124a6916-5d84-4b8c-b250-10cefb8e6e86"/>
    <resource>
      <MedicationOrder>
        <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">
            
            <p>Theophylline 200mg twice a day</p>
          
          </div>
        </text>
      <!--      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     -->
      <medicationCodeableConcept>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="66493003"/>
          </coding>
          <text value="Theophylline 200mg"/>
        </medicationCodeableConcept>
     <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>
        <reasonCode>
          <text value="Management of Asthma"/>
        </reasonCode>
      <!--      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     -->
             <dosageInstruction>
          <additionalInstructions>
            <text value="Take with Food"/>
          </additionalInstructions>
        <!--      twice a day      -->
          <timing>
            <repeat>
              <frequency value="2"/>
              <period value="1"/>
              <periodUnit value="d"/>
            </repeat>
          </timing>
        <!--      Orally      -->
          <route>
            <coding>
              <system value="http://snomed.info/sct"/>
              <code value="394899003"/>
              <display value="oral administration of treatment"/>
            </coding>
          </route>
          <doseQuantity>
            <value value="1"/>
            <unit value="tablet"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="tbl"/>
          </doseQuantity>
        </dosageInstruction>
      </MedicationOrder>
    </resource>
  </entry>
<!--      The second medication in the medications list      -->
  <entry>
    <fullUrl value="urn:uuid:673f8db5-0ffd-4395-9657-6da00420bbc1"/>
    <resource>
      <MedicationStatement>
      <!--      The Human readible version of the medication statement     -->
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            
            <p>Ventolin inhaler discontinued</p>
          
          </div>
        </text>
      <!--      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     -->
    <status value="completed"/>
  <!--      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     -->
        <medicationCodeableConcept>
          <text value="Ventolin Inhaler"/>
        </medicationCodeableConcept>
  <patient>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Peter Patient"/>
        </patient>
        <dateAsserted value="2013-05-05T16:13:03Z"/>
        <wasNotTaken value="true"/>
        <reasonNotTaken>
          <text value="Management of Asthma"/>
        </reasonNotTaken>
       </MedicationStatement>
    </resource>
  </entry>
<!--      The Allergy.     -->
  <entry>
    <fullUrl value="urn:uuid:47600e0f-b6b5-4308-84b5-5dec157f7637"/>
    <resource>
      <AllergyIntolerance>
        <meta>
          <lastUpdated value="2013-05-05T16:13:03Z"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">Sensitivity to Doxycycline :
                        Hives</div>
        </text>
        <status value="confirmed"/>
        <type value="allergy"/>
        <criticality value="high"/>
        <substance>
          <text value="Doxycycline"/>
        </substance>
        <patient>
          <reference value="http://fhir.healthintersections.com.au/open/Patient/d1"/>
          <display value="Eve Everywoman"/>
        </patient>
        <recordedDate value="2012-09-17"/>
        <reaction>
          <manifestation>
            <coding>
              <system value="http://example.org/system"/>
              <code value="xxx"/>
              <display value="Hives"/>
            </coding>
            <text value="Hives"/>
          </manifestation>
        </reaction>
      </AllergyIntolerance>
    </resource>
  </entry>
  <signature>
    <type>
      <system value="http://hl7.org/fhir/valueset-signature-type"/>
      <code value="1.2.840.10065.1.12.1.1"/>
      <display value="Author's Signature"/>
    </type>
    <when value="2015-08-31T07:42:33+10:00"/>
    <whoReference>
      <reference value="Device/software"/>
    </whoReference>
    <!--    a real document would typically have an digital signature, but 
      the publishing tools are not yet setup to produce a valid digital 
      signature. For now, an image of a signature    -->
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