FHIR Clinical Documents
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This page is part of the FHIR Clinical Documents (v1.0.0-ballot: STU1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. . For a full list of available versions, see the Directory of published versions

: Discharge Summary - JSON Representation

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{
  "resourceType" : "Composition",
  "id" : "clinical-document-composition-example1",
  "meta" : {
    "lastUpdated" : "2024-05-07T13:28:17.000+00:00",
    "profile" : [
      🔗 "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/clinical-document-composition"
    ]
  },
  "text" : {
    "status" : "additional",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Discharge Summary</b></p><p><b>CC</b>: Dr. BettaB Careful</p><p><b>status</b>: final</p><p><b>patient</b>: Eve Everiewoman</p><p><b>author</b>: Doctor Dave / Good Health Clinic</p><p><b>encounter</b>: Inpatient encounter, 2024-05-03 - 2024-05-07</p><p><b>confidentiality</b>: N</p><p><b>Contained sections</b>:</p><ul><li>Reason for admission</li><li>Medications on Discharge</li><li>Known allergies</li></ul></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version",
      "valueString" : "1715088497"
    },
    {
      "extension" : [
        {
          "url" : "type",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                "code" : "PRCP",
                "display" : "primary information recipient"
              }
            ]
          }
        },
        {
          "url" : "party",
          "valueReference" : {
            🔗 "reference" : "Practitioner/example2"
          }
        }
      ],
      "url" : "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
    },
    {
      "extension" : [
        {
          "url" : "type",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                "code" : "ENT",
                "display" : "data entry person"
              }
            ]
          }
        },
        {
          "url" : "party",
          "valueReference" : {
            🔗 "reference" : "Practitioner/example2"
          }
        }
      ],
      "url" : "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension"
    },
    {
      "extension" : [
        {
          "url" : "type",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                "code" : "INF",
                "display" : "informant"
              }
            ]
          }
        },
        {
          "url" : "party",
          "valueReference" : {
            🔗 "reference" : "Practitioner/example2"
          }
        }
      ],
      "url" : "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension"
    },
    {
      "extension" : [
        {
          "url" : "type",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                "code" : "ESC",
                "display" : "escort"
              }
            ]
          }
        },
        {
          "url" : "party",
          "valueReference" : {
            🔗 "reference" : "Practitioner/example2"
          }
        }
      ],
      "url" : "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension"
    },
    {
      "url" : "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension",
      "valueReference" : {
        🔗 "reference" : "ServiceRequest/service1"
      }
    },
    {
      "url" : "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension",
      "valueReference" : {
        🔗 "reference" : "Consent/consent1"
      }
    }
  ],
  "identifier" : {
    "system" : "https://example.com/compId",
    "value" : "1d6d6eb8-7d08-4ce1-94d4-19cdaa76ad6f"
  },
  "status" : "final",
  "type" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "28655-9"
      }
    ],
    "text" : "Attending Discharge summary"
  },
  "subject" : {
    🔗 "reference" : "Patient/d1",
    "display" : "Eve Everiewoman"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/doc-example"
  },
  "date" : "2024-05-07T13:28:17.000+00:00",
  "author" : [
    {
      🔗 "reference" : "Practitioner/example",
      "display" : "Doctor Dave"
    }
  ],
  "title" : "Discharge Summary",
  "confidentiality" : "N",
  "attester" : [
    {
      "mode" : "legal",
      "time" : "2024-05-07",
      "party" : {
        🔗 "reference" : "Practitioner/example",
        "display" : "Doctor Dave"
      }
    }
  ],
  "custodian" : {
    🔗 "reference" : "Organization/custodianOrganization",
    "display" : "Good Health Clinic"
  },
  "section" : [
    {
      "title" : "Reason for admission",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "29299-5",
            "display" : "Reason for visit Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<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>"
      },
      "entry" : [
        {
          🔗 "reference" : "Observation/541a72a8-df75-4484-ac89-ac4923f03b81"
        }
      ]
    },
    {
      "title" : "Medications on Discharge",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10183-2",
            "display" : "Hospital discharge medications Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<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>"
      },
      "entry" : [
        {
          🔗 "reference" : "MedicationRequest/124a6916-5d84-4b8c-b250-10cefb8e6e86"
        },
        {
          🔗 "reference" : "MedicationStatement/673f8db5-0ffd-4395-9657-6da00420bbc1"
        }
      ]
    },
    {
      "title" : "Known allergies",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "48765-2",
            "display" : "Allergies and adverse reactions Document"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<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>"
      },
      "entry" : [
        {
          🔗 "reference" : "AllergyIntolerance/47600e0f-b6b5-4308-84b5-5dec157f7637"
        }
      ]
    }
  ]
}