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 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

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