Please note:
- This version of the UK Core is a development copy.
- This contains BREAKING CHANGES as a result of the C&TA Sprint 7 Review, and STU2 Sequence ballot reconciliation.
- This version is not yet reviewed for implementation. Other versions are available on the UK Core Version History Guide
- Please follow the guidance on the Contact Us page if you need any assistance.
- A summary of changes is available on the STU3 Sequence Change Log
UKCore-Composition-Discharge-Example
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%< 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< 0.6 Eosinophils0.4x10*9/L< 0.4 Basophils0.1x10*9/L< 0.1 LUCs0.2x10*9/L< 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 & 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 |
| id : UKCore-Composition-Discharge-Example |
| text |
| status : additional |
| extension |
| url : https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType |
| value |
| 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 |
| entry |
| reference : urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b |
| section |
| title : Attendance details |
| code |
| coding |
| system : https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings |
| code : attendance-details |
| display : Attendance details |
| text |
| status : additional |
| section |
| title : Clinical narrative |
| code |
| coding |
| system : https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings |
| code : clinical-narrative |
| display : Clinical narrative |
| text |
| status : additional |
| section |
| 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 |
| section |
| title : Diagnoses |
| code |
| coding |
| system : https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings |
| code : diagnoses |
| display : Diagnoses |
| text |
| status : generated |
| entry |
| reference : urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f |
| section |
| title : Discharge details |
| code |
| coding |
| system : https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings |
| code : discharge-details |
| display : Discharge details |
| text |
| status : extensions |
| entry |
| reference : urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9 |
| section |
| 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 |
| entry |
| reference : urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1 |
| section |
| 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 |
| section |
| 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 |
| entry |
| reference : urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca |
| section |
| title : Patient demographics |
| code |
| coding |
| system : https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings |
| code : patient-demographics |
| display : Patient demographics |
| text |
| status : generated |
| entry |
| reference : urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5 |
| section |
| 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 |
| entry |
| reference : urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb |
| section |
| 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 |
| section |
| 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 |
| entry |
| reference : urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f |
| section |
| title : Procedures |
| code |
| coding |
| system : https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings |
| code : procedures |
| display : Procedures |
| text |
| status : additional |
| entry |
| reference : urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1 |
| section |
| title : Referrer details |
| code |
| coding |
| system : https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings |
| code : referrer-details |
| display : Referrer details |
| text |
| status : additional |
| section |
| 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 |
| entry |
| reference : urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9 |
XML View
--- We have skipped the narrative for better readability of the resource ---
</text>
<!-- Extension to carry details of the Correspondence Care Setting Type. -->
</coding>
</valueCodeableConcept>
</extension>
</identifier>
<!-- The workflow/clinical status of this composition.
The status is a marker for the clinical standing of the document. -->
<!-- Discharge Summary document type -->
</coding>
</type>
<!-- Reference to the patient subject of the Composition -->
</subject>
<!-- Reference to the clinical encounter or type of care this documentation is associated with. -->
</encounter>
<!-- The composition editing time, when the composition was last logically changed by the author. -->
<!-- Identifies who is responsible for the information in the composition,
not necessarily who typed it in -->
</author>
<!-- Identifies the organisation responsible for ongoing maintenance of and
access to the composition/document information. -->
</custodian>
<!-- Allergies and adverse reactions -->
</coding>
</code>
<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>
</section>
<!-- Attendance details -->
</coding>
</code>
<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 -->
</coding>
</code>
<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%< 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< 0.6 Eosinophils0.4x10*9/L< 0.4 Basophils0.1x10*9/L< 0.1 LUCs0.2x10*9/L< 0.4</pre></td></tr></tbody></table></div>
</text>
</section>
<!-- Contact for further information -->
</coding>
</code>
<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 -->
</coding>
</code>
<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>
</section>
<!-- Discharge details -->
</coding>
</code>
<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>
</section>
<!-- GP Practice -->
</coding>
</code>
<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>
</section>
<!-- Information and advice given -->
</coding>
</code>
<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 -->
</coding>
</code>
<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 & 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>
</section>
<!-- Patient demographics -->
</coding>
</code>
<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>
</section>
<!-- Person completing record -->
</coding>
</code>
<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>
</section>
<!-- Plan and requested actions -->
</coding>
</code>
<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 -->
</coding>
</code>
<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>
</section>
<!-- Procedures -->
</coding>
</code>
<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>
</section>
<!-- Referrer details -->
</coding>
</code>
<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 -->
</coding>
</code>
<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>
</section>
</Composition>
JSON View
{
--- We have skipped the narrative for better readability of the resource ---
},
{
{
}
]
}
}
],
},
]
},
},
},
],
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
}
},
{
{
}
]
},
"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%< 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< 0.6 Eosinophils0.4x10*9/L< 0.4 Basophils0.1x10*9/L< 0.1 LUCs0.2x10*9/L< 0.4</pre></td></tr></tbody></table></div>"
}
},
{
{
}
]
},
"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>"
}
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
}
},
{
{
}
]
},
"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 & 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>"
},
]
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
}
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
},
]
},
{
{
}
]
},
"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>"
}
},
{
{
}
]
},
"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>"
},
]
}
]
}