FHIR Clinical Documents
1.1.0 - STU 1.1 International flag

This page is part of the FHIR Clinical Documents (v1.1.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Discharge Summary

Page standards status: Informative

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://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 -------------------------------------------------------------------

<http://hl7.org/fhir/Composition/clinical-document-composition-example1> a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "clinical-document-composition-example1"] ;
  fhir:Resource.meta [
     fhir:Meta.lastUpdated [ fhir:value "2024-05-07T13:28:17.000+00:00"^^xsd:dateTime ] ;
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/clinical-document-composition" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/clinical-document-composition>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "additional" ] ;
     fhir:Narrative.div "<div xml:lang=\"en\" xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en\"><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:DomainResource.extension [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version" ] ;
     fhir:Extension.valueString [ fhir:value "1715088497" ]
  ], [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "type" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ParticipationType" ] ;
           fhir:Coding.code [ fhir:value "PRCP" ] ;
           fhir:Coding.display [ fhir:value "primary information recipient" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "party" ] ;
       fhir:Extension.valueReference [
         fhir:link <http://hl7.org/fhir/Practitioner/Doctor2> ;
         fhir:Reference.reference [ fhir:value "Practitioner/Doctor2" ]
       ]
     ] ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension" ]
  ], [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "type" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ParticipationType" ] ;
           fhir:Coding.code [ fhir:value "ENT" ] ;
           fhir:Coding.display [ fhir:value "data entry person" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "party" ] ;
       fhir:Extension.valueReference [
         fhir:link <http://hl7.org/fhir/Practitioner/Doctor2> ;
         fhir:Reference.reference [ fhir:value "Practitioner/Doctor2" ]
       ]
     ] ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension" ]
  ], [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "type" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ParticipationType" ] ;
           fhir:Coding.code [ fhir:value "INF" ] ;
           fhir:Coding.display [ fhir:value "informant" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "party" ] ;
       fhir:Extension.valueReference [
         fhir:link <http://hl7.org/fhir/Practitioner/Doctor2> ;
         fhir:Reference.reference [ fhir:value "Practitioner/Doctor2" ]
       ]
     ] ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension" ]
  ], [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "type" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ParticipationType" ] ;
           fhir:Coding.code [ fhir:value "ESC" ] ;
           fhir:Coding.display [ fhir:value "escort" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "party" ] ;
       fhir:Extension.valueReference [
         fhir:link <http://hl7.org/fhir/Practitioner/Doctor2> ;
         fhir:Reference.reference [ fhir:value "Practitioner/Doctor2" ]
       ]
     ] ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension" ]
  ], [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/event-basedOn" ] ;
     fhir:Extension.valueReference [
       fhir:link <http://hl7.org/fhir/ServiceRequest/service1> ;
       fhir:Reference.reference [ fhir:value "ServiceRequest/service1" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension" ] ;
     fhir:Extension.valueReference [
       fhir:link <http://hl7.org/fhir/Consent/consent1> ;
       fhir:Reference.reference [ fhir:value "Consent/consent1" ]
     ]
  ] ;
  fhir:Composition.identifier [
     fhir:Identifier.system [ fhir:value "https://example.com/compId" ] ;
     fhir:Identifier.value [ fhir:value "1d6d6eb8-7d08-4ce1-94d4-19cdaa76ad6f" ]
  ] ;
  fhir:Composition.status [ fhir:value "final"] ;
  fhir:Composition.type [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a loinc:28655-9 ;
       fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
       fhir:Coding.code [ fhir:value "28655-9" ]
     ] ;
     fhir:CodeableConcept.text [ fhir:value "Attending Discharge summary" ]
  ] ;
  fhir:Composition.category [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a loinc:107903-7 ;
       fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
       fhir:Coding.code [ fhir:value "107903-7" ] ;
       fhir:Coding.display [ fhir:value "Clinical note" ]
     ]
  ] ;
  fhir:Composition.subject [
     fhir:link <http://hl7.org/fhir/Patient/patient-example> ;
     fhir:Reference.reference [ fhir:value "Patient/patient-example" ] ;
     fhir:Reference.display [ fhir:value "Eve Everiewoman" ]
  ] ;
  fhir:Composition.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/encounter-example> ;
     fhir:Reference.reference [ fhir:value "Encounter/encounter-example" ]
  ] ;
  fhir:Composition.date [ fhir:value "2024-05-07T13:28:17.000+00:00"^^xsd:dateTime] ;
  fhir:Composition.author [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Practitioner/Doctor1> ;
     fhir:Reference.reference [ fhir:value "Practitioner/Doctor1" ] ;
     fhir:Reference.display [ fhir:value "Doctor Dave" ]
  ] ;
  fhir:Composition.title [ fhir:value "Discharge Summary"] ;
  fhir:Composition.confidentiality [ fhir:value "N"] ;
  fhir:Composition.attester [
     fhir:index -1 ;
     fhir:Composition.attester.mode [ fhir:value "legal" ] ;
     fhir:Composition.attester.time [ fhir:value "2024-05-07"^^xsd:date ] ;
     fhir:Composition.attester.party [
       fhir:link <http://hl7.org/fhir/Practitioner/Doctor1> ;
       fhir:Reference.reference [ fhir:value "Practitioner/Doctor1" ] ;
       fhir:Reference.display [ fhir:value "Doctor Dave" ]
     ]
  ] ;
  fhir:Composition.custodian [
     fhir:link <http://hl7.org/fhir/Organization/custodianOrganization> ;
     fhir:Reference.reference [ fhir:value "Organization/custodianOrganization" ] ;
     fhir:Reference.display [ fhir:value "Good Health Clinic" ]
  ] ;
  fhir:Composition.section [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Reason for admission" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:29299-5 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "29299-5" ] ;
         fhir:Coding.display [ fhir:value "Reason for visit Narrative" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "additional" ] ;
       fhir:Narrative.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:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Observation/Observation-541a72a8-df75-4484-ac89-ac4923f03b81> ;
       fhir:Reference.reference [ fhir:value "Observation/Observation-541a72a8-df75-4484-ac89-ac4923f03b81" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Medications on Discharge" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:10183-2 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "10183-2" ] ;
         fhir:Coding.display [ fhir:value "Hospital discharge medications Narrative" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "additional" ] ;
       fhir:Narrative.div "<div xml:lang=\"en\" xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en\"><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:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/MedicationRequest/MedRequest-124a6916-5d84-4b8c-b250-10cefb8e6e86> ;
       fhir:Reference.reference [ fhir:value "MedicationRequest/MedRequest-124a6916-5d84-4b8c-b250-10cefb8e6e86" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/MedicationStatement/MedStatement-673f8db5-0ffd-4395-9657-6da00420bbc1> ;
       fhir:Reference.reference [ fhir:value "MedicationStatement/MedStatement-673f8db5-0ffd-4395-9657-6da00420bbc1" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Known allergies" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:48765-2 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "48765-2" ] ;
         fhir:Coding.display [ fhir:value "Allergies and adverse reactions Document" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "additional" ] ;
       fhir:Narrative.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:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/AllergyIntolerance/AllergyIntolerance-47600e0f-b6b5-4308-84b5-5dec157f7637> ;
       fhir:Reference.reference [ fhir:value "AllergyIntolerance/AllergyIntolerance-47600e0f-b6b5-4308-84b5-5dec157f7637" ]
     ]
  ] .

<http://hl7.org/fhir/Practitioner/Doctor2> a fhir:Practitioner .

<http://hl7.org/fhir/ServiceRequest/service1> a fhir:ServiceRequest .

<http://hl7.org/fhir/Consent/consent1> a fhir:Consent .

<http://hl7.org/fhir/Patient/patient-example> a fhir:Patient .

<http://hl7.org/fhir/Encounter/encounter-example> a fhir:Encounter .

<http://hl7.org/fhir/Practitioner/Doctor1> a fhir:Practitioner .

<http://hl7.org/fhir/Organization/custodianOrganization> a fhir:Organization .

<http://hl7.org/fhir/Observation/Observation-541a72a8-df75-4484-ac89-ac4923f03b81> a fhir:Observation .

<http://hl7.org/fhir/MedicationRequest/MedRequest-124a6916-5d84-4b8c-b250-10cefb8e6e86> a fhir:MedicationRequest .

<http://hl7.org/fhir/MedicationStatement/MedStatement-673f8db5-0ffd-4395-9657-6da00420bbc1> a fhir:MedicationStatement .

<http://hl7.org/fhir/AllergyIntolerance/AllergyIntolerance-47600e0f-b6b5-4308-84b5-5dec157f7637> a fhir:AllergyIntolerance .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/Composition/clinical-document-composition-example1.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/Composition/clinical-document-composition-example1.ttl> .