Document-example-dischargesummary.xml

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

Raw XML

<feed xmlns="http://www.w3.org/2005/Atom">
  <title>Discharge Summary</title>
  <id>urn:uuid:500bee81-d973-4afe-b592-d39fe71e38</id>
  <updated>2013-05-28T22:12:21Z</updated>
  <author>
    <name>Dr Dave</name>
  </author>
  <category scheme="http://hl7.org/fhir/tag" term="http://hl7.org/fhir/tag/document"/>
  <entry>
    <title>Composition</title>
    <id>urn:guid:180f219f-97a8-486d-99d9-ed631fe4fc57</id>
    <updated>2013-05-28T22:12:21Z</updated>
    <content type="text/xml">
      <Composition xmlns="http://hl7.org/fhir">
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            <p>
              <b>Generated Narrative</b>
            </p>
            <p>
              <b>date</b>: 1-Feb 2013 12:30
            </p>
            <p>
              <b>type</b>: 
              <span title="Codes: {www.loinc.org 28655-9}">Discharge Summary from Responsible Clinician</span>
            </p>
            <p>
              <b>status</b>: final_
            </p>
            <p>
              <b>confidentiality</b>: 
              <span title="{www.nz.org 1234-5}">Normal</span>
            </p>
            <p>
              <b>author</b>: Doctor Dave
            </p>
          </div>
        </text>
        <date value="2013-02-01T12:30:02"/>
        <type>
          <coding>
            <system value="www.loinc.org"/>
            <code value="28655-9"/>
          </coding>
          <text value="Discharge Summary from Responsible Clinician"/>
        </type>
        <status value="final"/>
        <confidentiality>
          <system value="www.nz.org"/>
          <code value="1234-5"/>
          <display value="Normal"/>
        </confidentiality>
        <subject>
          <reference value="http://hl7connect.healthintersections.com.au/svc/fhir/Patient/d1"/>
          <display value="Eve Everywoman"/>
        </subject>
        <author>
          <reference value="http://hl7connect.healthintersections.com.au/svc/fhir/Practitioner/example"/>
          <display value="Doctor Dave"/>
        </author><!--    The Encounter resource. Points directly to an Encounter resource. Contains the dates
         of admission, specialtyu etc.    -->
        <section>
          <title value="Encounter Information"/>
          <content>
            <reference value="http://hl7connect.healthintersections.com.au/svc/fhir/Encounter/example"/>
          </content>
        </section>
        <section>
          <title value="Reason for admission"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="46241-6"/>
            </coding>
          </code>
          <content>
            <reference value="urn:guid:d0dd51d3-3ab2-4c84-b697-a630c3e40e7a"/>
          </content>
        </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"/>
            </coding>
          </code>
          <content>
            <reference value="urn:guid:673f8db5-0ffd-4395-9657-6da00420bbc1"/>
          </content>
        </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"/>
            </coding>
          </code>
          <content>
            <reference value="urn:guid:68f86194-e6e1-4f65-b64a-5314256f8d7b"/>
          </content>
        </section>
      </Composition>
    </content>
  </entry>
  <entry>
    <title>Written by Doctor Dave</title>
    <id>http://hl7connect.healthintersections.com.au/svc/fhir/Practitioner/example</id>
    <link href="http://hl7connect.healthintersections.com.au/svc/fhir/Practitioner/example/history/1" rel="self"/>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>68.151.217.168</name>
    </author>
    <published>2013-05-28T22:12:21Z</published>
    <content type="text/xml">
      <Practitioner xmlns="http://hl7.org/fhir">
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                        
            <h5>Doctor dave</h5>
                    
          </div>
        </text>
        <name>
          <text value="Doctor Dave"/>
        </name>
      </Practitioner>
    </content>
  </entry>
  <entry>
    <title>About Eve Everywoman</title>
    <id>http://hl7connect.healthintersections.com.au/svc/fhir/Patient/d1</id>
    <link href="http://hl7connect.healthintersections.com.au/svc/fhir/Patient/d1/history/10" rel="self"/>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>68.151.217.168</name>
    </author>
    <content type="text/xml">
      <Patient xmlns="http://hl7.org/fhir">
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                        
            <h5>Eve Everywoman</h5>
                    
          </div>
        </text>
        <identifier>
          <system value="nhi"/>
        </identifier>
        <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>
          <coding>
            <system value="http://hl7.org/fhir/v3/AdministrativeGender"/>
            <code value="F"/>
            <display value="Female"/>
          </coding>
        </gender>
        <birthDate value="1955-01-06"/>
        <address>
          <use value="home"/>
          <line value="2222 Home Street"/>
        </address>
        <active value="true"/>
      </Patient>
    </content>
    <summary type="xhtml">
      <div xmlns="http://www.w3.org/1999/xhtml">
                
        <h5>Eve Everywoman</h5>
            
      </div>
    </summary>
  </entry>
  <entry>
    <title>Admission to Middlemore </title>
    <id>http://hl7connect.healthintersections.com.au/svc/fhir/Encounter/example</id>
    <link href="http://hl7connect.healthintersections.com.au/svc/fhir/Encounter/example/history/1" rel="self"/>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>68.151.217.168</name>
    </author>
    <content type="text/xml">
      <Encounter xmlns="http://hl7.org/fhir">
        <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>
        <subject>
          <reference value="http://hl7connect.healthintersections.com.au/svc/fhir/Patient/d1"/>
        </subject>
        <hospitalization>
          <period>
            <start value="2013-01-20T12:30:02"/>
            <end value="2013-02-01T12:30:02"/>
          </period>
          <dischargeDisposition>
            <text value="Discharged to care of GP"/>
          </dischargeDisposition>
        </hospitalization>
      </Encounter>
    </content>
  </entry>
  <entry>
    <title>Admission Reason</title>
    <id>urn:guid:d0dd51d3-3ab2-4c84-b697-a630c3e40e7a</id>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>Dr Dave</name>
    </author>
    <content type="text/xml">
      <Observation xmlns="http://hl7.org/fhir">
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"> Acute Asthmatic attack. Was wheezing
                        for days prior to admission. </div>
        </text>
        <name>
          <coding>
            <system value="http://loinc.org"/>
            <code value="46241-6"/>
          </coding>
          <text value="Reason for admission"/>
        </name>
        <valueString value="Acute Asthmatic attack. Was wheezing for days prior to admission."/>
        <status value="final"/>
        <reliability value="ok"/>
      </Observation>
    </content>
  </entry>
  <entry>
    <title>List of Medications</title>
    <id>urn:guid:673f8db5-0ffd-4395-9657-6da00420bbc1</id>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>Dr Dave</name>
    </author>
    <content type="text/xml">
      <List xmlns="http://hl7.org/fhir">
        <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>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="10183-2"/>
            <display value="Hospital discharge medications"/>
          </coding>
        </code>
        <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:guid: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="http://hl7connect.healthintersections.com.au/svc/fhir/MedicationPrescription/1"/>
            <display value="use of Ventolin Inhaler was discontinued"/>
          </item>
        </entry>
      </List>
    </content>
  </entry>
  <entry>
    <title>Medication #1</title>
    <id>urn:guid:124a6916-5d84-4b8c-b250-10cefb8e6e86</id>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>Dr Dave</name>
    </author>
    <content type="text/xml">
      <MedicationPrescription xmlns="http://hl7.org/fhir"><!--    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>
        <contained><!--    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...    -->
          <Medication id="med1">
            <name value="Theophylline 200mg"/>
            <code>
              <coding>
                <system value="http:/snomed.org"/>
                <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://hl7connect.healthintersections.com.au/svc/fhir/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="Medication/example"/>
          <display value="Theophylline 200mg BD"/>
        </medication>
        <dosageInstruction>
          <additionalInstructions>
            <text value="Take with Food"/>
          </additionalInstructions><!--    twice a day    -->
          <timingSchedule>
            <repeat>
              <frequency value="2"/>
              <duration value="1"/>
              <units value="d"/>
            </repeat>
          </timingSchedule><!--    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>
    </content>
  </entry>
  <entry>
    <title>List of Allergies</title>
    <id>urn:guid:68f86194-e6e1-4f65-b64a-5314256f8d7b</id>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>Dr Dave</name>
    </author>
    <content type="text/xml">
      <List xmlns="http://hl7.org/fhir">
        <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>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="48765-2"/>
            <display value="Allergies and adverse reactions Document"/>
          </coding>
        </code>
        <mode value="working"/><!--    This is an entry that refers to an allergy resource in this document.    -->
        <entry>
          <item>
            <reference value="urn:guid:47600e0f-b6b5-4308-84b5-5dec157f7637"/>
          </item>
        </entry>
      </List>
    </content>
  </entry>
  <entry>
    <title>Allergy to Doxycycline</title>
    <id>urn:guid:47600e0f-b6b5-4308-84b5-5dec157f7637</id>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>Dr Dave</name>
    </author>
    <content type="text/xml">
      <AllergyIntolerance xmlns="http://hl7.org/fhir">
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">Sensitivity to Doxycycline :
                        Hives</div>
        </text>
        <criticality value="fatal"/>
        <sensitivityType value="allergy"/>
        <recordedDate value="2012-09-17"/>
        <status value="confirmed"/>
        <subject>
          <reference value="http://hl7connect.healthintersections.com.au/svc/fhir/Patient/d1"/>
          <display value="Eve Everywoman"/>
        </subject>
        <substance>
          <reference value="urn:guid:4c2d16c0-b102-486c-aa7c-b266ce98709f"/>
          <display value="Doxycycline"/>
        </substance>
        <reaction>
          <reference value="urn:guid:25be7cdf-7055-40fa-80ac-defd531180dd"/>
          <display value="Hives"/>
        </reaction>
      </AllergyIntolerance>
    </content>
  </entry>
  <entry>
    <title>Adverse Reaction</title>
    <id>urn:guid:25be7cdf-7055-40fa-80ac-defd531180dd</id>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>Dr Dave</name>
    </author>
    <content type="text/xml">
      <AdverseReaction xmlns="http://hl7.org/fhir">
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            <p>
              <b>Generated Narrative</b>
            </p>
            <p>
              <b>subject</b>: Eve Everywoman
            </p>
            <p>
              <b>didNotOccurFlag</b>: false
            </p>
            <h3>Symptoms</h3>
            <table class="grid">
              <tr>
                <td>
                  <b>Code</b>
                </td>
                <td>
                  <b>Severity</b>
                </td>
              </tr>
              <tr>
                <td>
                  <span title="Codes: {sys xxx}">Hives</span>
                </td>
                <td> </td>
              </tr>
            </table>
          </div>
        </text>
        <subject>
          <reference value="http://hl7connect.healthintersections.com.au/svc/fhir/Patient/d1"/>
          <display value="Eve Everywoman"/>
        </subject>
        <didNotOccurFlag value="false"/>
        <symptom>
          <code>
            <coding>
              <system value="sys"/>
              <code value="xxx"/>
              <display value="Hives"/>
            </coding>
            <text value="Hives"/>
          </code>
        </symptom>
      </AdverseReaction>
    </content>
  </entry>
  <entry>
    <title>Substance</title>
    <id>urn:guid:4c2d16c0-b102-486c-aa7c-b266ce98709f</id>
    <updated>2013-05-05T16:13:03Z</updated>
    <author>
      <name>Dr Dave</name>
    </author>
    <content type="text/xml">
      <Substance xmlns="http://hl7.org/fhir">
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">Doxycycline</div>
        </text>
        <type>
          <coding>
            <system value="codesys"/>
            <code value="123445"/>
            <display value="Doxycycline"/>
          </coding>
        </type>
      </Substance>
    </content>
  </entry>
</feed>