DSTU2 Ballot Source

This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Document-example-dischargesummary

This is the narrative for the resource. See also the XML or JSON format.

Generated Narrative with Details

date: Feb 1, 2013 11:30:02 PM

type: Discharge Summary from Responsible Clinician (Details : {LOINC code '28655-9' = 'Physician attending Discharge summary)

status: FINAL

confidentiality: N

author: Doctor Dave. Generated Summary: 23; Adam Careful

encounter: http://fhir.healthintersections.com.au/open/Encounter/doc-example

Dr Adam Careful is a Referring Practitioner for Acme Hospital from 1-Jan 2012 to 31-Mar 2012

Generated Narrative with Details

text:

identifier: 23

name: Adam Careful

PractitionerRoles

IdExtensionModifierExtensionManagingOrganizationRoleSpecialtyPeriodLocationHealthcareService
Generated Summary: Gastro; name: Gastroenterology; ph: +1 555 234 3523(MOBILE), gastro@acme.org(WORK)Referring Provider (Details : {http://hl7.org/fhir/v2/0286 code 'RP' = 'Referring Provider) Jan 1, 2012 --> Mar 31, 2012

Eve Everywoman

Generated Narrative with Details

text:

name: Eve Everywoman

telecom: ph: 555-555-2003(WORK)

gender: FEMALE

birthDate: Jan 6, 1955

address: 2222 Home Street (HOME)

active: true

Admitted to Orthopedics Service, Middlemore Hospital between Jan 20 and Feb ist 2013

Generated Narrative with Details

text:

identifier: S100

status: FINISHED

class: INPATIENT

type: Orthopedic Admission (Details )

patient: Patient/d1

period: Jan 20, 2013 11:30:02 PM --> Feb 1, 2013 11:30:02 PM

Hospitalizations

IdExtensionModifierExtensionPreAdmissionIdentifierOriginAdmitSourceDietPreferenceSpecialCourtesySpecialArrangementDestinationDischargeDispositionDischargeDiagnosisReAdmission
Discharged to care of GP (Details )
Details
Acute Asthmatic attack. Was wheezing for days prior to admission.

Generated Narrative with Details

text:

code: Hospital admission diagnosis (Details : {LOINC code '8646-2' = 'Hospital admission diagnosis', given as 'Hospital admission diagnosis'})

subject: Peter Patient

status: CURRENT

mode: WORKING

Entries

IdExtensionModifierExtensionFlagDeletedDateItem
urn:uuid:541a72a8-df75-4484-ac89-ac4923f03b81
Acute Asthmatic attack. Was wheezing for days prior to admission.

Generated Narrative with Details

text:

code: Reason for admission (Details : {LOINC code '46241-6' = 'Hospital admission diagnosis Narrative - Reported)

value: Acute Asthmatic attack. Was wheezing for days prior to admission.

status: FINAL

reliability: OK

Medication Last Change Last ChangeReason
Theophylline 200mg BD after meals continued
Ventolin Inhaler stopped Getting side effect of tremor

Generated Narrative with Details

text:

code: Hospital discharge medications (Details : {LOINC code '10183-2' = 'Hospital discharge medications Narrative', given as 'Hospital discharge medications'})

subject: Peter Patient

status: CURRENT

mode: WORKING

entry

flag: started (Details : {http://www.ithealthboard.health.nz/fhir/ValueSet/medicationStatus code 'started' = 'started)

item: urn:uuid:124a6916-5d84-4b8c-b250-10cefb8e6e86

entry

flag: stopped (Details : {http://www.ithealthboard.health.nz/fhir/ValueSet/medicationStatus code 'stopped' = 'stopped)

deleted: true

item: use of Ventolin Inhaler was discontinued

Theophylline 200mg twice a day

Generated Narrative with Details

text:

contained:

patient: Peter Patient

prescriber: Peter Practitioner. Generated Summary: 23; Adam Careful

reason: Management of Asthma (Details )

medication: Theophylline 200mg BD. Generated Summary: name: Theophylline 200mg; Theophylline (product) (Details : {SNOMED CT code '66493003' = 'Theophylline (product))

DosageInstructions

IdExtensionModifierExtensionTextAdditionalInstructionsScheduled[x]AsNeeded[x]SiteRouteMethodDose[x]RateMaxDosePerPeriod
Take with Food (Details )Do 2 per 1days oral administration of treatment (Details : {SNOMED CT code '394899003' = 'Treatment administered orally', given as 'oral administration of treatment'}) 1 tablet (Details: http://unitsofmeasure.org code tbl = 'tbl')
Allergen Reaction
Doxycycline Hives

Generated Narrative with Details

text:

code: Allergies and adverse reactions Document (Details : {LOINC code '48765-2' = 'Allergies and adverse reactions Document', given as 'Allergies and adverse reactions Document'})

subject: Peter Patient

status: CURRENT

mode: WORKING

Entries

IdExtensionModifierExtensionFlagDeletedDateItem
urn:uuid:47600e0f-b6b5-4308-84b5-5dec157f7637
Sensitivity to Doxycycline : Hives

Generated Narrative with Details

text:

recordedDate: Sep 17, 2012

patient: Eve Everywoman

substance: Doxycycline (Details )

status: CONFIRMED

criticality: HIGH

type: IMMUNE

Events

IdExtensionModifierExtensionSubstanceCertaintyManifestationDescriptionOnsetDurationSeverityExposureRouteComment
Hives (Details : {http://example.org/system code 'xxx' = 'xxx', given as 'Hives'})

 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.