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 - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="clinical-document-composition-example1"/>
  <meta>
    <lastUpdated value="2024-05-07T13:28:17.000+00:00"/>
    <profile
             value="http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/clinical-document-composition"/>
  </meta>
  <text>
    <status value="additional"/>
    <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>
  </text>
  <extension
             url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version">
    <valueString value="1715088497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension">
    <extension url="type">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/>
          <code value="PRCP"/>
          <display value="primary information recipient"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension url="party">
      <valueReference>🔗 
        <reference value="Practitioner/example2"/>
      </valueReference>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension">
    <extension url="type">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/>
          <code value="ENT"/>
          <display value="data entry person"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension url="party">
      <valueReference>🔗 
        <reference value="Practitioner/example2"/>
      </valueReference>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension">
    <extension url="type">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/>
          <code value="INF"/>
          <display value="informant"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension url="party">
      <valueReference>🔗 
        <reference value="Practitioner/example2"/>
      </valueReference>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension">
    <extension url="type">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/>
          <code value="ESC"/>
          <display value="escort"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension url="party">
      <valueReference>🔗 
        <reference value="Practitioner/example2"/>
      </valueReference>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension">
    <valueReference>🔗 
      <reference value="ServiceRequest/service1"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension">
    <valueReference>🔗 
      <reference value="Consent/consent1"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="https://example.com/compId"/>
    <value value="1d6d6eb8-7d08-4ce1-94d4-19cdaa76ad6f"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="28655-9"/>
    </coding>
    <text value="Attending Discharge summary"/>
  </type>
  <subject>🔗 
    <reference value="Patient/d1"/>
    <display value="Eve Everiewoman"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/doc-example"/>
  </encounter>
  <date value="2024-05-07T13:28:17.000+00:00"/>
  <author>🔗 
    <reference value="Practitioner/example"/>
    <display value="Doctor Dave"/>
  </author>
  <title value="Discharge Summary"/>
  <confidentiality value="N"/>
  <attester>
    <mode value="legal"/>
    <time value="2024-05-07"/>
    <party>🔗 
      <reference value="Practitioner/example"/>
      <display value="Doctor Dave"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/custodianOrganization"/>
    <display value="Good Health Clinic"/>
  </custodian>
  <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="Observation/541a72a8-df75-4484-ac89-ac4923f03b81"/>
    </entry>
  </section>
  <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>
    <entry>🔗 
      <reference
                 value="MedicationRequest/124a6916-5d84-4b8c-b250-10cefb8e6e86"/>
    </entry>
    <entry>🔗 
      <reference
                 value="MedicationStatement/673f8db5-0ffd-4395-9657-6da00420bbc1"/>
    </entry>
  </section>
  <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="AllergyIntolerance/47600e0f-b6b5-4308-84b5-5dec157f7637"/>
    </entry>
  </section>
</Composition>