MyHealth@Eu Hospital Discharge Report - Local Development build (v9.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

HDR Models Overview

MyHealth@EU logical models (MyHealth@EU Hospital Discharge Report Content) refine the EHDS logical information models provided by the Xt-EHR project. These models use obligations on the logical models to highlight the elements identified by the MyHealth@EU Functional Requirements. Three types of obligations are defined based on the MyHealth@EU requirements:

• Mandatory: the data element must be provided
• Required: the data element must be provided, although exceptional justifications can be provided
• Optional: the data element can be completely omitted

These obligations are implemented using the following rule sets:

• ObligationMandatory - SHALL:handle for mandatory elements
• ObligationRequired - SHOULD:handle for required elements
• ObligationOptional - MAY:able-to-populate for optional elements

Information Models

Hospital Discharge Report

The hospital discharge report is structured using the MyHealthEuHdrDischargeReport model which is divided into a document header, a structured body with multiple clinical sections, and optional attachments.

The body of the report covers the following clinical sections:

• Alerts – allergies, intolerances and medical alerts relevant to the hospital stay
• Encounter information – details of the inpatient encounter including admission and discharge
• Admission evaluation – objective findings and functional status at admission (if relevant)
• Patient history – past problems, devices, and procedures relevant to the current episode
• Course of encounter – diagnostic summary, significant procedures, devices, pharmacotherapy, and test results during hospitalisation
• Discharge details – objective findings and functional status at discharge
• Medication summary – medication recommended after discharge
• Care plan – care plan and other recommendations after discharge

Encounter

The encounter is described using the MyHealthEuHdrEncounter model, capturing admission and discharge details, service provider, reason for admission, and locations visited during the stay.

Clinical Content Models

Clinical content within the report body is described by the following models:

• MyHealthEuHdrCondition – problems, diagnoses, and conditions
• MyHealthEuHdrObservation – clinical observations including vital signs and anthropometric measurements
• MyHealthEuHdrProcedure – significant procedures performed during hospitalisation
• MyHealthEuHdrDeviceUse – medical devices and implants
• MyHealthEuHdrMedicationUse – medication use during and after hospitalisation
• MyHealthEuHdrCarePlan – care plan after discharge
• MyHealthEuHdrAllergyIntolerance – allergies and intolerances
• MyHealthEuHdrAlert – medical alerts

Detail MyHealth@EU information models for Hospital Discharge Report

• MyHealth@EU HDR Discharge Report
• MyHealth@EU HDR Encounter
• MyHealth@EU HDR Condition
• MyHealth@EU HDR Observation
• MyHealth@EU HDR Procedure
• MyHealth@EU HDR Device Use
• MyHealth@EU HDR Medication Use
• MyHealth@EU HDR Care Plan
• MyHealth@EU HDR Allergy Intolerance
• MyHealth@EU HDR Alert

Core Models Used

The MyHealth@EU HDR models utilize the following core models:

• ​MyHealth@EU Patient
• ​MyHealth@EU Organisation
• ​MyHealth@EU Health Professional
• ​MyHealth@EU Device
• ​MyHealth@EU Body Structure
• ​MyHealth@EU Medication

Supporting Information

• MyHealth@EU Hospital Discharge Report Content
• eHealth Network Guideline on Hospital Discharge Reports
• EHDS Logical Information Models