MyHealth@Eu Hospital Discharge Report
0.0.1 - qa-preview 150

MyHealth@Eu Hospital Discharge Report - Local Development build (v0.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Logical Model: HospitalStayEhn - Detailed Descriptions

Draft as of 2025-06-06

Definitions for the HospitalStay logical model.

Guidance on how to interpret the contents of this table can be foundhere

0. HospitalStay
Definition

Hospital Discharge Report - Hospital stay - A.2.6 eHN

ShortA.2.6 - Hospital stay (eHN)
Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. HospitalStay.diagnosticSummary
Definition

All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.

ShortA.2.6.1 - Diagnostic summary
Control1..*
TypeBase
4. HospitalStay.diagnosticSummary.problemDescription
Definition

Problem specification in narrative form

ShortA.2.6.1.1 - Problem description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
6. HospitalStay.diagnosticSummary.problemDetails
Definition

Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.

ShortA.2.6.1.2 - Problem details
Control0..*
TypeBase
8. HospitalStay.diagnosticSummary.onsetDate
Definition

Onset date of a problem/condition

ShortA.2.6.1.3 - Onset date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
10. HospitalStay.diagnosticSummary.category
Definition

Category of the problem allows flagging for conditions acquired during hospital stay.

ShortA.2.6.1.5 - Category
Control0..1
TypeCodeableConcept
12. HospitalStay.diagnosticSummary.treatmentClass
Definition

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital encounter. At least one problem should be marked as Treated. Other problems are recorded only if they are important for continuity of care (after discharge).

ShortA.2.6.1.6 - Treatment class
Control0..1
TypeCodeableConcept
14. HospitalStay.significantProcedures
Definition

Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other 'instrumental' interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.

ShortA.2.6.2 - Significant procedures
Control1..*
TypeBase
16. HospitalStay.significantProcedures.procedureCode
Definition

Procedure code

ShortA.2.6.2.1 - Procedure code
Control0..*
TypeCodeableConcept
18. HospitalStay.significantProcedures.description
Definition

Narrative description of the procedure

ShortA.2.6.2.2 - Procedure description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
20. HospitalStay.significantProcedures.date
Definition

Date and time when procedure was performed

ShortA.2.6.2.4 - Procedure date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
22. HospitalStay.significantProcedures.focalDevice
Definition

A reference to the device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

ShortA.2.6.2.8 - Focal device
Control0..*
TypeBase
24. HospitalStay.significantProcedures.focalDevice.type
Definition

Kind or Type of device

ShortA.2.6.2.8.1- Device Type
Control0..1
TypeCodeableConcept
26. HospitalStay.significantProcedures.focalDevice.name
Definition

The name of the device as given by the manufacturer

ShortA.2.6.2.8.2- Device Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
28. HospitalStay.significantProcedures.focalDevice.modelname
Definition

Model name of the device

ShortA.2.6.2.8.3- Model Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
30. HospitalStay.significantProcedures.focalDevice.identifier
Definition

Unique device identifier

ShortA.2.6.2.8.4- Device Identifier�
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
32. HospitalStay.significantProcedures.focalDevice.manufacturer
Definition

Name of device manufacturer

ShortA.2.6.2.8.5- Manufacturer�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
34. HospitalStay.medicalDevices
Definition

Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system

ShortA.2.6.3 - Medical devices and implants
Control1..*
TypeBase
36. HospitalStay.medicalDevices.description
Definition

Describes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

ShortA.2.6.3.1 - Device and implant description
Control1..1
TypeCodeableConcept
38. HospitalStay.medicalDevices.type
Definition

Kind or Type of device

ShortA.2.6.3.1.1- Device Type
Control0..1
TypeCodeableConcept
40. HospitalStay.medicalDevices.name
Definition

The name of the device as given by the manufacturer

ShortA.2.6.3.1.2- Device Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
42. HospitalStay.medicalDevices.modelname
Definition

Model name of the device

ShortA.2.6.3.1.3- Model Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
44. HospitalStay.medicalDevices.manufacturer
Definition

Name of device manufacturer

ShortA.2.6.3.1.4- Manufacturer�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
46. HospitalStay.medicalDevices.identifier
Definition

Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745

ShortA.2.6.3.2 - Device ID
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
48. HospitalStay.medicalDevices.implantDate
Definition

The date and time the device was implanted or when its use began.

ShortA.2.6.3.3 - Implant date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. HospitalStay.medicalDevices.endDate
Definition

Date and time when the device was explanted from the patient or the external device was no longer in use; likewise when the device is planned to be explanted

ShortA.2.6.3.4 - End date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
52. HospitalStay.medicalDevices.expectedendDate
Definition

Date when the device is planned to be explanted.

ShortExpected end date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
54. HospitalStay.pharmacotherapy
Definition

Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.Medicinal products, the administration of which was started during hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.

ShortA.2.6.5 - Pharmacotherapy
Control1..*
TypeBase
56. HospitalStay.pharmacotherapy.productCode
Definition

Product code

ShortA.2.6.5.2 - Code
Control0..1
TypeCodeableConcept
58. HospitalStay.pharmacotherapy.productName
Definition

Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)

ShortA.2.6.5.4 - Brand name
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
60. HospitalStay.pharmacotherapy.period
Definition

The time interval when the patient was, or was not, given the medication.

ShortA.2.6.5.10 - Period of treatment
Control0..1
TypePeriod
62. HospitalStay.significantResults
Definition

Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.

ShortA.2.6.6 - Significant Observation Results
Control1..*
TypeBase
64. HospitalStay.significantResults.date
Definition

Date and time of the observation

ShortA.2.6.6.1 - Date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
66. HospitalStay.significantResults.description
Definition

Narrative representation of the observation result and findings.

ShortA.2.6.6.3 - Result description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
68. HospitalStay.significantResults.details
Definition

Observation details include code that identifies observation, specification of the observed body structure or specimen, date and time of the specimen collection, observation method or protocol used and other aspects of the observation.

ShortA.2.6.6.4 - Observation details
Control1..1
TypeBase
70. HospitalStay.significantResults.details.code
Definition

Code representing the observation using the agreed code systems

ShortA.2.6.6.4.1 -Observation code�
Control0..1
TypeCodeableConcept
72. HospitalStay.significantResults.details.method
Definition

Observation method (measurement principle) to obtain the result.

ShortA.2.6.6.4.2-Observation method
Control0..1
TypeCodeableConcept
74. HospitalStay.significantResults.details.specimen
Definition

Identifies specimen this observation refers to

ShortA.2.6.6.4.3-Specimen
Control0..1
TypeReference
76. HospitalStay.significantResults.details.resultinterpretationcode
Definition

Codes identifying interpretations of observations

ShortA.2.6.6.4.4-Result interpretation code
Control0..*
TypeCodeableConcept
78. HospitalStay.significantResults.details.standardreferencerange
Definition

Provides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

ShortA.2.6.6.4.5-Standard reference range�
Control0..*
TypeBase
80. HospitalStay.significantResults.result
Definition

Result of the observation including numeric and coded results of the measurement, details about how the tests were done to get the result values, information about reference ranges and result interpretation. Content of the observation result will vary according to the type of the observation.

ShortA.2.6.6.5 - Observation result
Control1..1
TypeBase
82. HospitalStay.significantResults.textualresult
Definition

Narrative text result

ShortA.2.6.6.5.1 -Textual Result
Control0..1
TypeNarrative
84. HospitalStay.significantResults.numericresult
Definition

A numeric value or interval (open or closed) of the result, Result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

ShortA.2.6.6.5.2-Numeric Result
Control0..1
TypeQuantity
86. HospitalStay.significantResults.codedresult
Definition

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

ShortA.2.6.6.5.3-Coded Result
Control0..1
TypeCodeableConcept
88. HospitalStay.synthesis
Definition

This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

ShortA.2.6.7 - Synthesis
Control0..1
TypeBase
90. HospitalStay.synthesis.description
Definition

Summary description of the reason and course of hospitalisation for a specific problem.

ShortA.2.6.7.1 - Problem synthesis
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. HospitalStay
Definition

Hospital Discharge Report - Hospital stay - A.2.6 eHN

ShortA.2.6 - Hospital stay (eHN)
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. HospitalStay.diagnosticSummary
Definition

All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.

ShortA.2.6.1 - Diagnostic summary
Control1..*
TypeBase
4. HospitalStay.diagnosticSummary.problemDescription
Definition

Problem specification in narrative form

ShortA.2.6.1.1 - Problem description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
6. HospitalStay.diagnosticSummary.problemDetails
Definition

Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.

ShortA.2.6.1.2 - Problem details
Control0..*
TypeBase
8. HospitalStay.diagnosticSummary.onsetDate
Definition

Onset date of a problem/condition

ShortA.2.6.1.3 - Onset date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
10. HospitalStay.diagnosticSummary.category
Definition

Category of the problem allows flagging for conditions acquired during hospital stay.

ShortA.2.6.1.5 - Category
Control0..1
TypeCodeableConcept
12. HospitalStay.diagnosticSummary.treatmentClass
Definition

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital encounter. At least one problem should be marked as Treated. Other problems are recorded only if they are important for continuity of care (after discharge).

ShortA.2.6.1.6 - Treatment class
Control0..1
TypeCodeableConcept
14. HospitalStay.significantProcedures
Definition

Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other 'instrumental' interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.

ShortA.2.6.2 - Significant procedures
Control1..*
TypeBase
16. HospitalStay.significantProcedures.procedureCode
Definition

Procedure code

ShortA.2.6.2.1 - Procedure code
Control0..*
TypeCodeableConcept
18. HospitalStay.significantProcedures.description
Definition

Narrative description of the procedure

ShortA.2.6.2.2 - Procedure description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
20. HospitalStay.significantProcedures.date
Definition

Date and time when procedure was performed

ShortA.2.6.2.4 - Procedure date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
22. HospitalStay.significantProcedures.focalDevice
Definition

A reference to the device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

ShortA.2.6.2.8 - Focal device
Control0..*
TypeBase
24. HospitalStay.significantProcedures.focalDevice.type
Definition

Kind or Type of device

ShortA.2.6.2.8.1- Device Type
Control0..1
TypeCodeableConcept
26. HospitalStay.significantProcedures.focalDevice.name
Definition

The name of the device as given by the manufacturer

ShortA.2.6.2.8.2- Device Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
28. HospitalStay.significantProcedures.focalDevice.modelname
Definition

Model name of the device

ShortA.2.6.2.8.3- Model Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
30. HospitalStay.significantProcedures.focalDevice.identifier
Definition

Unique device identifier

ShortA.2.6.2.8.4- Device Identifier�
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
32. HospitalStay.significantProcedures.focalDevice.manufacturer
Definition

Name of device manufacturer

ShortA.2.6.2.8.5- Manufacturer�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
34. HospitalStay.medicalDevices
Definition

Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system

ShortA.2.6.3 - Medical devices and implants
Control1..*
TypeBase
36. HospitalStay.medicalDevices.description
Definition

Describes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

ShortA.2.6.3.1 - Device and implant description
Control1..1
TypeCodeableConcept
38. HospitalStay.medicalDevices.type
Definition

Kind or Type of device

ShortA.2.6.3.1.1- Device Type
Control0..1
TypeCodeableConcept
40. HospitalStay.medicalDevices.name
Definition

The name of the device as given by the manufacturer

ShortA.2.6.3.1.2- Device Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
42. HospitalStay.medicalDevices.modelname
Definition

Model name of the device

ShortA.2.6.3.1.3- Model Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
44. HospitalStay.medicalDevices.manufacturer
Definition

Name of device manufacturer

ShortA.2.6.3.1.4- Manufacturer�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
46. HospitalStay.medicalDevices.identifier
Definition

Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745

ShortA.2.6.3.2 - Device ID
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
48. HospitalStay.medicalDevices.implantDate
Definition

The date and time the device was implanted or when its use began.

ShortA.2.6.3.3 - Implant date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. HospitalStay.medicalDevices.endDate
Definition

Date and time when the device was explanted from the patient or the external device was no longer in use; likewise when the device is planned to be explanted

ShortA.2.6.3.4 - End date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
52. HospitalStay.medicalDevices.expectedendDate
Definition

Date when the device is planned to be explanted.

ShortExpected end date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
54. HospitalStay.pharmacotherapy
Definition

Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.Medicinal products, the administration of which was started during hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.

ShortA.2.6.5 - Pharmacotherapy
Control1..*
TypeBase
56. HospitalStay.pharmacotherapy.productCode
Definition

Product code

ShortA.2.6.5.2 - Code
Control0..1
TypeCodeableConcept
58. HospitalStay.pharmacotherapy.productName
Definition

Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)

ShortA.2.6.5.4 - Brand name
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
60. HospitalStay.pharmacotherapy.period
Definition

The time interval when the patient was, or was not, given the medication.

ShortA.2.6.5.10 - Period of treatment
Control0..1
TypePeriod
62. HospitalStay.significantResults
Definition

Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.

ShortA.2.6.6 - Significant Observation Results
Control1..*
TypeBase
64. HospitalStay.significantResults.date
Definition

Date and time of the observation

ShortA.2.6.6.1 - Date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
66. HospitalStay.significantResults.description
Definition

Narrative representation of the observation result and findings.

ShortA.2.6.6.3 - Result description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
68. HospitalStay.significantResults.details
Definition

Observation details include code that identifies observation, specification of the observed body structure or specimen, date and time of the specimen collection, observation method or protocol used and other aspects of the observation.

ShortA.2.6.6.4 - Observation details
Control1..1
TypeBase
70. HospitalStay.significantResults.details.code
Definition

Code representing the observation using the agreed code systems

ShortA.2.6.6.4.1 -Observation code�
Control0..1
TypeCodeableConcept
72. HospitalStay.significantResults.details.method
Definition

Observation method (measurement principle) to obtain the result.

ShortA.2.6.6.4.2-Observation method
Control0..1
TypeCodeableConcept
74. HospitalStay.significantResults.details.specimen
Definition

Identifies specimen this observation refers to

ShortA.2.6.6.4.3-Specimen
Control0..1
TypeReference
76. HospitalStay.significantResults.details.resultinterpretationcode
Definition

Codes identifying interpretations of observations

ShortA.2.6.6.4.4-Result interpretation code
Control0..*
TypeCodeableConcept
78. HospitalStay.significantResults.details.standardreferencerange
Definition

Provides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

ShortA.2.6.6.4.5-Standard reference range�
Control0..*
TypeBase
80. HospitalStay.significantResults.result
Definition

Result of the observation including numeric and coded results of the measurement, details about how the tests were done to get the result values, information about reference ranges and result interpretation. Content of the observation result will vary according to the type of the observation.

ShortA.2.6.6.5 - Observation result
Control1..1
TypeBase
82. HospitalStay.significantResults.textualresult
Definition

Narrative text result

ShortA.2.6.6.5.1 -Textual Result
Control0..1
TypeNarrative
84. HospitalStay.significantResults.numericresult
Definition

A numeric value or interval (open or closed) of the result, Result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

ShortA.2.6.6.5.2-Numeric Result
Control0..1
TypeQuantity
86. HospitalStay.significantResults.codedresult
Definition

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

ShortA.2.6.6.5.3-Coded Result
Control0..1
TypeCodeableConcept
88. HospitalStay.synthesis
Definition

This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

ShortA.2.6.7 - Synthesis
Control0..1
TypeBase
90. HospitalStay.synthesis.description
Definition

Summary description of the reason and course of hospitalisation for a specific problem.

ShortA.2.6.7.1 - Problem synthesis
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. HospitalStay
Definition

Hospital Discharge Report - Hospital stay - A.2.6 eHN

ShortA.2.6 - Hospital stay (eHN)
Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. HospitalStay.diagnosticSummary
Definition

All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.

ShortA.2.6.1 - Diagnostic summary
Control1..*
TypeBase
4. HospitalStay.diagnosticSummary.problemDescription
Definition

Problem specification in narrative form

ShortA.2.6.1.1 - Problem description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
6. HospitalStay.diagnosticSummary.problemDetails
Definition

Problem details include code that identifies problem, specification of the body structure, laterality, and other aspects of the problem.

ShortA.2.6.1.2 - Problem details
Control0..*
TypeBase
8. HospitalStay.diagnosticSummary.onsetDate
Definition

Onset date of a problem/condition

ShortA.2.6.1.3 - Onset date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
10. HospitalStay.diagnosticSummary.category
Definition

Category of the problem allows flagging for conditions acquired during hospital stay.

ShortA.2.6.1.5 - Category
Control0..1
TypeCodeableConcept
12. HospitalStay.diagnosticSummary.treatmentClass
Definition

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital encounter. At least one problem should be marked as Treated. Other problems are recorded only if they are important for continuity of care (after discharge).

ShortA.2.6.1.6 - Treatment class
Control0..1
TypeCodeableConcept
14. HospitalStay.significantProcedures
Definition

Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other 'instrumental' interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others. This section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.

ShortA.2.6.2 - Significant procedures
Control1..*
TypeBase
16. HospitalStay.significantProcedures.procedureCode
Definition

Procedure code

ShortA.2.6.2.1 - Procedure code
Control0..*
TypeCodeableConcept
18. HospitalStay.significantProcedures.description
Definition

Narrative description of the procedure

ShortA.2.6.2.2 - Procedure description
Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
20. HospitalStay.significantProcedures.date
Definition

Date and time when procedure was performed

ShortA.2.6.2.4 - Procedure date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
22. HospitalStay.significantProcedures.focalDevice
Definition

A reference to the device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

ShortA.2.6.2.8 - Focal device
Control0..*
TypeBase
24. HospitalStay.significantProcedures.focalDevice.type
Definition

Kind or Type of device

ShortA.2.6.2.8.1- Device Type
Control0..1
TypeCodeableConcept
26. HospitalStay.significantProcedures.focalDevice.name
Definition

The name of the device as given by the manufacturer

ShortA.2.6.2.8.2- Device Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
28. HospitalStay.significantProcedures.focalDevice.modelname
Definition

Model name of the device

ShortA.2.6.2.8.3- Model Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
30. HospitalStay.significantProcedures.focalDevice.identifier
Definition

Unique device identifier

ShortA.2.6.2.8.4- Device Identifier�
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
32. HospitalStay.significantProcedures.focalDevice.manufacturer
Definition

Name of device manufacturer

ShortA.2.6.2.8.5- Manufacturer�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
34. HospitalStay.medicalDevices
Definition

Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system

ShortA.2.6.3 - Medical devices and implants
Control1..*
TypeBase
36. HospitalStay.medicalDevices.description
Definition

Describes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

ShortA.2.6.3.1 - Device and implant description
Control1..1
TypeCodeableConcept
38. HospitalStay.medicalDevices.type
Definition

Kind or Type of device

ShortA.2.6.3.1.1- Device Type
Control0..1
TypeCodeableConcept
40. HospitalStay.medicalDevices.name
Definition

The name of the device as given by the manufacturer

ShortA.2.6.3.1.2- Device Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
42. HospitalStay.medicalDevices.modelname
Definition

Model name of the device

ShortA.2.6.3.1.3- Model Name�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
44. HospitalStay.medicalDevices.manufacturer
Definition

Name of device manufacturer

ShortA.2.6.3.1.4- Manufacturer�
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
46. HospitalStay.medicalDevices.identifier
Definition

Normalised identifier of the device instance such as UDI according to REGULATION (EU) 2017/745

ShortA.2.6.3.2 - Device ID
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
48. HospitalStay.medicalDevices.implantDate
Definition

The date and time the device was implanted or when its use began.

ShortA.2.6.3.3 - Implant date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. HospitalStay.medicalDevices.endDate
Definition

Date and time when the device was explanted from the patient or the external device was no longer in use; likewise when the device is planned to be explanted

ShortA.2.6.3.4 - End date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
52. HospitalStay.medicalDevices.expectedendDate
Definition

Date when the device is planned to be explanted.

ShortExpected end date
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
54. HospitalStay.pharmacotherapy
Definition

Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.Medicinal products, the administration of which was started during hospitalisation, but is also recommended after discharge, will be listed in the summary table in the recommendation section.

ShortA.2.6.5 - Pharmacotherapy
Control1..*
TypeBase
56. HospitalStay.pharmacotherapy.productCode
Definition

Product code

ShortA.2.6.5.2 - Code
Control0..1
TypeCodeableConcept
58. HospitalStay.pharmacotherapy.productName
Definition

Brand name if biological medicinal product or when justified by the health professional (ref. Commission Directive 2012/52/EU)

ShortA.2.6.5.4 - Brand name
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
60. HospitalStay.pharmacotherapy.period
Definition

The time interval when the patient was, or was not, given the medication.

ShortA.2.6.5.10 - Period of treatment
Control0..1
TypePeriod
62. HospitalStay.significantResults
Definition

Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.

ShortA.2.6.6 - Significant Observation Results
Control1..*
TypeBase
64. HospitalStay.significantResults.date
Definition

Date and time of the observation

ShortA.2.6.6.1 - Date
Control1..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
66. HospitalStay.significantResults.description
Definition

Narrative representation of the observation result and findings.

ShortA.2.6.6.3 - Result description
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
68. HospitalStay.significantResults.details
Definition

Observation details include code that identifies observation, specification of the observed body structure or specimen, date and time of the specimen collection, observation method or protocol used and other aspects of the observation.

ShortA.2.6.6.4 - Observation details
Control1..1
TypeBase
70. HospitalStay.significantResults.details.code
Definition

Code representing the observation using the agreed code systems

ShortA.2.6.6.4.1 -Observation code�
Control0..1
TypeCodeableConcept
72. HospitalStay.significantResults.details.method
Definition

Observation method (measurement principle) to obtain the result.

ShortA.2.6.6.4.2-Observation method
Control0..1
TypeCodeableConcept
74. HospitalStay.significantResults.details.specimen
Definition

Identifies specimen this observation refers to

ShortA.2.6.6.4.3-Specimen
Control0..1
TypeReference
76. HospitalStay.significantResults.details.resultinterpretationcode
Definition

Codes identifying interpretations of observations

ShortA.2.6.6.4.4-Result interpretation code
Control0..*
TypeCodeableConcept
78. HospitalStay.significantResults.details.standardreferencerange
Definition

Provides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

ShortA.2.6.6.4.5-Standard reference range�
Control0..*
TypeBase
80. HospitalStay.significantResults.result
Definition

Result of the observation including numeric and coded results of the measurement, details about how the tests were done to get the result values, information about reference ranges and result interpretation. Content of the observation result will vary according to the type of the observation.

ShortA.2.6.6.5 - Observation result
Control1..1
TypeBase
82. HospitalStay.significantResults.textualresult
Definition

Narrative text result

ShortA.2.6.6.5.1 -Textual Result
Control0..1
TypeNarrative
84. HospitalStay.significantResults.numericresult
Definition

A numeric value or interval (open or closed) of the result, Result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

ShortA.2.6.6.5.2-Numeric Result
Control0..1
TypeQuantity
86. HospitalStay.significantResults.codedresult
Definition

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

ShortA.2.6.6.5.3-Coded Result
Control0..1
TypeCodeableConcept
88. HospitalStay.synthesis
Definition

This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions, Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.

ShortA.2.6.7 - Synthesis
Control0..1
TypeBase
90. HospitalStay.synthesis.description
Definition

Summary description of the reason and course of hospitalisation for a specific problem.

ShortA.2.6.7.1 - Problem synthesis
Control1..*
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension