An example to illustrate a composition containing a discharge summary

Table View

Composition.id[0]UKCore-Composition-Discharge-Example
Composition.text[0].status[0]additional
Composition.text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml">An example to illustrate a composition containing a discharge summary</div>
Composition.extension[0].url[0]https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType
Composition.extension[0].value[0].coding[0].system[0]http://snomed.info/sct
Composition.extension[0].value[0].coding[0].code[0]310000008
Composition.extension[0].value[0].coding[0].display[0]Accident and Emergency service
Composition.identifier[0].system[0]https://tools.ietf.org/html/rfc4122
Composition.identifier[0].value[0]2d361270-039f-4a48-827b-ef255ff8b6c4
Composition.status[0]final
Composition.type[0].coding[0].system[0]http://snomed.info/sct
Composition.type[0].coding[0].code[0]373942005
Composition.type[0].coding[0].display[0]Discharge summary
Composition.subject[0].reference[0]urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5
Composition.encounter[0].reference[0]urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9
Composition.date[0]2021-02-12T19:00:00+00:00
Composition.author[0].reference[0]urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb
Composition.title[0]Accident & Emergency Discharge summary
Composition.custodian[0].reference[0]urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc
Composition.section[0].title[0]Allergies and adverse reaction
Composition.section[0].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[0].code[0].coding[0].code[0]allergies-and-adverse-reaction
Composition.section[0].code[0].coding[0].display[0]Allergies and adverse reaction
Composition.section[0].text[0].status[0]additional
Composition.section[0].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Causative agent</th><td>Penicillin -class of antibiotic</td></tr><tr><th>Description of reaction</th><td>Eruption due to drug</td></tr><tr><th>Severity</th><td>Mild</td></tr><tr><th>Certainty</th><td>Certain</td></tr><tr><th>Comment</th><td>No swelling</td></tr></tbody></table></div>
Composition.section[0].entry[0].reference[0]urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b
Composition.section[1].title[0]Attendance details
Composition.section[1].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[1].code[0].coding[0].code[0]attendance-details
Composition.section[1].code[0].coding[0].display[0]Attendance details
Composition.section[1].text[0].status[0]additional
Composition.section[1].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Date and time of contact</th><td>12-Feb-2015 07:00</td></tr></tbody></table></div>
Composition.section[2].title[0]Clinical narrative
Composition.section[2].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[2].code[0].coding[0].code[0]clinical-narrative
Composition.section[2].code[0].coding[0].display[0]Clinical narrative
Composition.section[2].text[0].status[0]additional
Composition.section[2].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Clinical narrative</th></tr><tr><td><p>60 year old man complaining of chest pain lasting around 2 hours.</p><p>Examination unremarkable.</p><p>Inferior ischaemic changes on ECG.</p></td></tr></tbody></table><table><tbody><tr><td><pre>Full Blood Count TestValueUnitsReference Range White Cell Count11.1x10*9/L3.5 - 10.0 Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0 Haematocrit0.230L/L0.400 - 0.500 Mean Cell Volume90fL84 - 98 Mean Cell Hb33.0pg27.5 - 32.0 Mean Cell Hb Con34.0pg31.0 - 35.0 RDW12.0%&lt; 14.5 Platelet Count300x10*9/L150 - 400 Machine Differential TestValueUnitsReference Range Neutrophils7.0x10*9/L1.7 - 7.5 Lymphocytes3.5x10*9/L1.0 - 3.5 Monocytes0.3x10*9/L&lt; 0.6 Eosinophils0.4x10*9/L&lt; 0.4 Basophils0.1x10*9/L&lt; 0.1 LUCs0.2x10*9/L&lt; 0.4</pre></td></tr></tbody></table></div>
Composition.section[3].title[0]Contact for further information
Composition.section[3].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[3].code[0].coding[0].code[0]contact-for-further-information
Composition.section[3].code[0].coding[0].display[0]Contact for further information
Composition.section[3].text[0].status[0]additional
Composition.section[3].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Contact for further information</th><td>Dr Paul Rastall Tel: 0113 6323200</td></tr></tbody></table></div>
Composition.section[4].title[0]Diagnoses
Composition.section[4].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[4].code[0].coding[0].code[0]diagnoses
Composition.section[4].code[0].coding[0].display[0]Diagnoses
Composition.section[4].text[0].status[0]generated
Composition.section[4].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Acute ST segment elevation myocardial infarction</td></tr></tbody></table></div>
Composition.section[4].entry[0].reference[0]urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f
Composition.section[5].title[0]Discharge details
Composition.section[5].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[5].code[0].coding[0].code[0]discharge-details
Composition.section[5].code[0].coding[0].display[0]Discharge details
Composition.section[5].text[0].status[0]extensions
Composition.section[5].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Discharge status</th><td>Streamed from emergency department to urgent care service following initial assessment</td></tr><tr><th>Date/time of discharge</th><td>12-Feb-2015 08:00</td></tr><tr><th>Discharge destination</th><td>NHS other Hospital Provider - Ward for general Patients or the younger physically disabled</td></tr></tbody></table></div>
Composition.section[5].entry[0].reference[0]urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9
Composition.section[6].title[0]GP practice
Composition.section[6].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[6].code[0].coding[0].code[0]general-practitioner-practice
Composition.section[6].code[0].coding[0].display[0]General practitioner practice
Composition.section[6].text[0].status[0]additional
Composition.section[6].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>GP name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>GP practice details</th><td><p>Name: MGP Medical Centre</p><p>Address:</p><p>Address Line: 1 MGP House, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 7PA</p></td></tr></tbody></table></div>
Composition.section[6].entry[0].reference[0]urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1
Composition.section[7].title[0]Information and advice given
Composition.section[7].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[7].code[0].coding[0].code[0]information-and-advice-given
Composition.section[7].code[0].coding[0].display[0]Information and advice given
Composition.section[7].text[0].status[0]additional
Composition.section[7].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Information and advice given</th><td>Patient advised to be admitted to ward for further tests after ECG results showed inferior ischaemic changes.</td></tr></tbody></table></div>
Composition.section[8].title[0]Medications and medical devices
Composition.section[8].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[8].code[0].coding[0].code[0]medications-and-medical-devices
Composition.section[8].code[0].coding[0].display[0]Medications and medical devices
Composition.section[8].text[0].status[0]additional
Composition.section[8].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Medication name</th><td>Ramipril 2.5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>One 2.5mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Aspirin 75mg tablets (Sigma Pharmaceuticals Plc)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 75mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Simvastatin 40mg tablets (Brown &amp; Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>
Composition.section[8].entry[0].reference[0]urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca
Composition.section[9].title[0]Patient demographics
Composition.section[9].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[9].code[0].coding[0].code[0]patient-demographics
Composition.section[9].code[0].coding[0].display[0]Patient demographics
Composition.section[9].text[0].status[0]generated
Composition.section[9].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div>
Composition.section[9].entry[0].reference[0]urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5
Composition.section[10].title[0]Person completing record
Composition.section[10].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[10].code[0].coding[0].code[0]person-completing-record
Composition.section[10].code[0].coding[0].display[0]Person completing record
Composition.section[10].text[0].status[0]generated
Composition.section[10].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div>
Composition.section[10].entry[0].reference[0]urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb
Composition.section[11].title[0]Plan and requested actions
Composition.section[11].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[11].code[0].coding[0].code[0]plan-and-requested-actions
Composition.section[11].code[0].coding[0].display[0]Plan and requested actions
Composition.section[11].text[0].status[0]additional
Composition.section[11].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of his chest pain on 12 February 2015.</p><p>Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's University Hospital Accident and Emergency Department)</p><p>Status: Completed</p><p>Outcome: Patient expects to find out the more information about the reasons for his chest pain when tests are carried out after admission.</p></td></tr></tbody></table></div>
Composition.section[12].title[0]Presenting complaints or issues
Composition.section[12].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[12].code[0].coding[0].code[0]presenting-complaints-or-issues
Composition.section[12].code[0].coding[0].display[0]Presenting complaints or issues
Composition.section[12].text[0].status[0]generated
Composition.section[12].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Presenting complaints or issue</th><td>Chest pain</td></tr></tbody></table></div>
Composition.section[12].entry[0].reference[0]urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f
Composition.section[13].title[0]Procedures
Composition.section[13].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[13].code[0].coding[0].code[0]procedures
Composition.section[13].code[0].coding[0].display[0]Procedures
Composition.section[13].text[0].status[0]additional
Composition.section[13].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Procedure name</th><td>Electrocardiographic monitoring</td></tr><tr><th>Comment</th><td>ECGs showed inferior ischaemic changes.</td></tr></tbody></table></div>
Composition.section[13].entry[0].reference[0]urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1
Composition.section[14].title[0]Referrer details
Composition.section[14].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[14].code[0].coding[0].code[0]referrer-details
Composition.section[14].code[0].coding[0].display[0]Referrer details
Composition.section[14].text[0].status[0]additional
Composition.section[14].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Referrer details</th><td>Self-referral to accident and emergency department</td></tr></tbody></table></div>
Composition.section[15].title[0]Senior reviewing clinician
Composition.section[15].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[15].code[0].coding[0].code[0]senior-reviewing-clinician
Composition.section[15].code[0].coding[0].display[0]Senior reviewing clinician
Composition.section[15].text[0].status[0]generated
Composition.section[15].text[0].div[0]<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Mr</p><p>Family Name: Abacus</p></td></tr></tbody></table></div>
Composition.section[15].entry[0].reference[0]urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9

Tree View

Composition

XML View

<Composition xmlns="http://hl7.org/fhir">
<id value="UKCore-Composition-Discharge-Example" />
<text>
<status value="additional" />
--- We have skipped the narrative for better readability of the resource ---
</text>
<!-- Extension to carry details of the Correspondence Care Setting Type. -->
<extension url="https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType">
<valueCodeableConcept>
<coding>
<system value="http://snomed.info/sct" />
<code value="310000008" />
<display value="Accident and Emergency service" />
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="2d361270-039f-4a48-827b-ef255ff8b6c4" />
</identifier>
<!-- The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. -->
<status value="final" />
<type>
<!-- Discharge Summary document type -->
<coding>
<system value="http://snomed.info/sct" />
<code value="373942005" />
<display value="Discharge summary" />
</coding>
</type>
<!-- Reference to the patient subject of the Composition -->
<subject>
<reference value="urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5" />
</subject>
<!-- Reference to the clinical encounter or type of care this documentation is associated with. -->
<encounter>
<reference value="urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9" />
</encounter>
<!-- The composition editing time, when the composition was last logically changed by the author. -->
<date value="2021-02-12T19:00:00+00:00" />
<!-- Identifies who is responsible for the information in the composition, not necessarily who typed it in -->
<author>
<reference value="urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb" />
</author>
<title value="Accident & Emergency Discharge summary" />
<!-- Identifies the organisation responsible for ongoing maintenance of and access to the composition/document information. -->
<custodian>
<reference value="urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc" />
</custodian>
<!-- Allergies and adverse reactions -->
<section>
<title value="Allergies and adverse reaction" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="allergies-and-adverse-reaction" />
<display value="Allergies and adverse reaction" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Causative agent</th><td>Penicillin -class of antibiotic</td></tr><tr><th>Description of reaction</th><td>Eruption due to drug</td></tr><tr><th>Severity</th><td>Mild</td></tr><tr><th>Certainty</th><td>Certain</td></tr><tr><th>Comment</th><td>No swelling</td></tr></tbody></table></div>
</text>
<!-- Reference to Allergies List as the source of information for this section -->
<entry>
<reference value="urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b" />
</entry>
</section>
<!-- Attendance details -->
<section>
<title value="Attendance details" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="attendance-details" />
<display value="Attendance details" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Date and time of contact</th><td>12-Feb-2015 07:00</td></tr></tbody></table></div>
</text>
</section>
<!-- Clinical narrative -->
<section>
<title value="Clinical narrative" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="clinical-narrative" />
<display value="Clinical narrative" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Clinical narrative</th></tr><tr><td><p>60 year old man complaining of chest pain lasting around 2 hours.</p><p>Examination unremarkable.</p><p>Inferior ischaemic changes on ECG.</p></td></tr></tbody></table><table><tbody><tr><td><pre>Full Blood Count TestValueUnitsReference Range White Cell Count11.1x10*9/L3.5 - 10.0 Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0 Haematocrit0.230L/L0.400 - 0.500 Mean Cell Volume90fL84 - 98 Mean Cell Hb33.0pg27.5 - 32.0 Mean Cell Hb Con34.0pg31.0 - 35.0 RDW12.0%&lt; 14.5 Platelet Count300x10*9/L150 - 400 Machine Differential TestValueUnitsReference Range Neutrophils7.0x10*9/L1.7 - 7.5 Lymphocytes3.5x10*9/L1.0 - 3.5 Monocytes0.3x10*9/L&lt; 0.6 Eosinophils0.4x10*9/L&lt; 0.4 Basophils0.1x10*9/L&lt; 0.1 LUCs0.2x10*9/L&lt; 0.4</pre></td></tr></tbody></table></div>
</text>
</section>
<!-- Contact for further information -->
<section>
<title value="Contact for further information" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="contact-for-further-information" />
<display value="Contact for further information" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Contact for further information</th><td>Dr Paul Rastall Tel: 0113 6323200</td></tr></tbody></table></div>
</text>
</section>
<!-- Diagnoses -->
<section>
<title value="Diagnoses" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="diagnoses" />
<display value="Diagnoses" />
</coding>
</code>
<text>
<status value="generated" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Acute ST segment elevation myocardial infarction</td></tr></tbody></table></div>
</text>
<!-- Reference to information in the Condition list resource -->
<entry>
<reference value="urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" />
</entry>
</section>
<!-- Discharge details -->
<section>
<title value="Discharge details" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="discharge-details" />
<display value="Discharge details" />
</coding>
</code>
<text>
<status value="extensions" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Discharge status</th><td>Streamed from emergency department to urgent care service following initial assessment</td></tr><tr><th>Date/time of discharge</th><td>12-Feb-2015 08:00</td></tr><tr><th>Discharge destination</th><td>NHS other Hospital Provider - Ward for general Patients or the younger physically disabled</td></tr></tbody></table></div>
</text>
<!-- Reference to the Encounter entry as the source of information for this section -->
<entry>
<reference value="urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9" />
</entry>
</section>
<!-- GP Practice -->
<section>
<title value="GP practice" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="general-practitioner-practice" />
<display value="General practitioner practice" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>GP name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>GP practice details</th><td><p>Name: MGP Medical Centre</p><p>Address:</p><p>Address Line: 1 MGP House, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 7PA</p></td></tr></tbody></table></div>
</text>
<!-- Reference to the Organisation entry as the source of information for this section -->
<entry>
<reference value="urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1" />
</entry>
</section>
<!-- Information and advice given -->
<section>
<title value="Information and advice given" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="information-and-advice-given" />
<display value="Information and advice given" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Information and advice given</th><td>Patient advised to be admitted to ward for further tests after ECG results showed inferior ischaemic changes.</td></tr></tbody></table></div>
</text>
</section>
<!-- Medications and medical devices -->
<section>
<title value="Medications and medical devices" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="medications-and-medical-devices" />
<display value="Medications and medical devices" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Medication name</th><td>Ramipril 2.5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>One 2.5mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Aspirin 75mg tablets (Sigma Pharmaceuticals Plc)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 75mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Simvastatin 40mg tablets (Brown &amp; Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>
</text>
<!-- Reference to medication list -->
<entry>
<reference value="urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca" />
</entry>
</section>
<!-- Patient demographics -->
<section>
<title value="Patient demographics" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="patient-demographics" />
<display value="Patient demographics" />
</coding>
</code>
<text>
<status value="generated" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div>
</text>
<!-- reference to further information carried in the patient resource -->
<entry>
<reference value="urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5" />
</entry>
</section>
<!-- Person completing record -->
<section>
<title value="Person completing record" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="person-completing-record" />
<display value="Person completing record" />
</coding>
</code>
<text>
<status value="generated" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div>
</text>
<!-- Reference to the practitioner entry as the source of information for this section -->
<entry>
<reference value="urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb" />
</entry>
</section>
<!-- Plan and requested actions -->
<section>
<title value="Plan and requested actions" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="plan-and-requested-actions" />
<display value="Plan and requested actions" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of his chest pain on 12 February 2015.</p><p>Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's University Hospital Accident and Emergency Department)</p><p>Status: Completed</p><p>Outcome: Patient expects to find out the more information about the reasons for his chest pain when tests are carried out after admission.</p></td></tr></tbody></table></div>
</text>
</section>
<!-- Presenting complaints or issues -->
<section>
<title value="Presenting complaints or issues" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="presenting-complaints-or-issues" />
<display value="Presenting complaints or issues" />
</coding>
</code>
<text>
<status value="generated" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Presenting complaints or issue</th><td>Chest pain</td></tr></tbody></table></div>
</text>
<!-- Reference to information in the Condition list resource -->
<entry>
<reference value="urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" />
</entry>
</section>
<!-- Procedures -->
<section>
<title value="Procedures" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="procedures" />
<display value="Procedures" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Procedure name</th><td>Electrocardiographic monitoring</td></tr><tr><th>Comment</th><td>ECGs showed inferior ischaemic changes.</td></tr></tbody></table></div>
</text>
<!-- reference to further information carried in the procedure list resource -->
<entry>
<reference value="urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1" />
</entry>
</section>
<!-- Referrer details -->
<section>
<title value="Referrer details" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="referrer-details" />
<display value="Referrer details" />
</coding>
</code>
<text>
<status value="additional" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Referrer details</th><td>Self-referral to accident and emergency department</td></tr></tbody></table></div>
</text>
</section>
<!-- Senior reviewing clinician -->
<section>
<title value="Senior reviewing clinician" />
<code>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
<code value="senior-reviewing-clinician" />
<display value="Senior reviewing clinician" />
</coding>
</code>
<text>
<status value="generated" />
<div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Mr</p><p>Family Name: Abacus</p></td></tr></tbody></table></div>
</text>
<!-- reference to further information carried in the practitioner resource -->
<entry>
<reference value="urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9" />
</entry>
</section>
</Composition>

JSON View

{
"resourceType": "Composition",
"id": "UKCore-Composition-Discharge-Example",
"text": {
"status": "additional",
--- We have skipped the narrative for better readability of the resource ---
},
"extension": [
{
"url": "https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType",
"valueCodeableConcept": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "310000008",
"display": "Accident and Emergency service"
}
]
}
}
],
"identifier": {
"system": "https://tools.ietf.org/html/rfc4122",
"value": "2d361270-039f-4a48-827b-ef255ff8b6c4"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "373942005",
"display": "Discharge summary"
}
]
},
"subject": {
"reference": "urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5"
},
"encounter": {
"reference": "urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9"
},
"date": "2021-02-12T19:00:00+00:00",
"author": [
{
"reference": "urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb"
}
],
"title": "Accident & Emergency Discharge summary",
"custodian": {
"reference": "urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc"
},
"section": [
{
"title": "Allergies and adverse reaction",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "allergies-and-adverse-reaction",
"display": "Allergies and adverse reaction"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Causative agent</th><td>Penicillin -class of antibiotic</td></tr><tr><th>Description of reaction</th><td>Eruption due to drug</td></tr><tr><th>Severity</th><td>Mild</td></tr><tr><th>Certainty</th><td>Certain</td></tr><tr><th>Comment</th><td>No swelling</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b"
}
]
},
{
"title": "Attendance details",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "attendance-details",
"display": "Attendance details"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Date and time of contact</th><td>12-Feb-2015 07:00</td></tr></tbody></table></div>"
}
},
{
"title": "Clinical narrative",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "clinical-narrative",
"display": "Clinical narrative"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Clinical narrative</th></tr><tr><td><p>60 year old man complaining of chest pain lasting around 2 hours.</p><p>Examination unremarkable.</p><p>Inferior ischaemic changes on ECG.</p></td></tr></tbody></table><table><tbody><tr><td><pre>Full Blood Count TestValueUnitsReference Range White Cell Count11.1x10*9/L3.5 - 10.0 Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0 Haematocrit0.230L/L0.400 - 0.500 Mean Cell Volume90fL84 - 98 Mean Cell Hb33.0pg27.5 - 32.0 Mean Cell Hb Con34.0pg31.0 - 35.0 RDW12.0%&lt; 14.5 Platelet Count300x10*9/L150 - 400 Machine Differential TestValueUnitsReference Range Neutrophils7.0x10*9/L1.7 - 7.5 Lymphocytes3.5x10*9/L1.0 - 3.5 Monocytes0.3x10*9/L&lt; 0.6 Eosinophils0.4x10*9/L&lt; 0.4 Basophils0.1x10*9/L&lt; 0.1 LUCs0.2x10*9/L&lt; 0.4</pre></td></tr></tbody></table></div>"
}
},
{
"title": "Contact for further information",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "contact-for-further-information",
"display": "Contact for further information"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Contact for further information</th><td>Dr Paul Rastall Tel: 0113 6323200</td></tr></tbody></table></div>"
}
},
{
"title": "Diagnoses",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "diagnoses",
"display": "Diagnoses"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Acute ST segment elevation myocardial infarction</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f"
}
]
},
{
"title": "Discharge details",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "discharge-details",
"display": "Discharge details"
}
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Discharge status</th><td>Streamed from emergency department to urgent care service following initial assessment</td></tr><tr><th>Date/time of discharge</th><td>12-Feb-2015 08:00</td></tr><tr><th>Discharge destination</th><td>NHS other Hospital Provider - Ward for general Patients or the younger physically disabled</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9"
}
]
},
{
"title": "GP practice",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "general-practitioner-practice",
"display": "General practitioner practice"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>GP name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>GP practice details</th><td><p>Name: MGP Medical Centre</p><p>Address:</p><p>Address Line: 1 MGP House, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 7PA</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1"
}
]
},
{
"title": "Information and advice given",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "information-and-advice-given",
"display": "Information and advice given"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Information and advice given</th><td>Patient advised to be admitted to ward for further tests after ECG results showed inferior ischaemic changes.</td></tr></tbody></table></div>"
}
},
{
"title": "Medications and medical devices",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "medications-and-medical-devices",
"display": "Medications and medical devices"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Ramipril 2.5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>One 2.5mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Aspirin 75mg tablets (Sigma Pharmaceuticals Plc)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 75mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Simvastatin 40mg tablets (Brown &amp; Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca"
}
]
},
{
"title": "Patient demographics",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "patient-demographics",
"display": "Patient demographics"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5"
}
]
},
{
"title": "Person completing record",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "person-completing-record",
"display": "Person completing record"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb"
}
]
},
{
"title": "Plan and requested actions",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "plan-and-requested-actions",
"display": "Plan and requested actions"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of his chest pain on 12 February 2015.</p><p>Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's University Hospital Accident and Emergency Department)</p><p>Status: Completed</p><p>Outcome: Patient expects to find out the more information about the reasons for his chest pain when tests are carried out after admission.</p></td></tr></tbody></table></div>"
}
},
{
"title": "Presenting complaints or issues",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "presenting-complaints-or-issues",
"display": "Presenting complaints or issues"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Presenting complaints or issue</th><td>Chest pain</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f"
}
]
},
{
"title": "Procedures",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "procedures",
"display": "Procedures"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Procedure name</th><td>Electrocardiographic monitoring</td></tr><tr><th>Comment</th><td>ECGs showed inferior ischaemic changes.</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1"
}
]
},
{
"title": "Referrer details",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "referrer-details",
"display": "Referrer details"
}
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Referrer details</th><td>Self-referral to accident and emergency department</td></tr></tbody></table></div>"
}
},
{
"title": "Senior reviewing clinician",
"code": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
"code": "senior-reviewing-clinician",
"display": "Senior reviewing clinician"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Mr</p><p>Family Name: Abacus</p></td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9"
}
]
}
]
}
back to top