Transfer of Care R4 Hackathon Implementation Guide

This guidance is under active development by NHS England and content may be added or updated on a regular basis.

Andy Example

Andy is a 56 yr old carpenter. He also has a history of an underactive thyroid gland and has to take levothyroxine every day. Getting him on the correct dose has been difficult, so he is on a slightly unusual dose.
He had a heart attack 2 weeks ago, and had a coronary stent inserted, since then he has needed to take daily Aspirin to prevent blood clotting and Atorvastatin to lower his cholesterol level. He has had problems in the past with alcohol misuse and on the advice of the local substance misuse service has been started on Acamprosate. Recently Andy started to feel more breathless at night. His GP diagnosed heart failure, and started him on Ramipril but after discussion with the cardiologist, he was admitted to hospital for further investigations. He is discharged again after 3 days, on unchanged medication, awaiting the result of the tests.

On admission

  • Aspirin 75mg dispersible tablets. One to be taken each morning. Take with or after food
  • Atorvastatin 10mg tablets once daily. Increase after 4 weeks to 2 tablets daily
  • Levothyroxine sodium 100microgram tablets one to be taken daily
  • Levothyroxine sodium 25microgram tablets one to be taken every other day
  • Ramipril 2.5mg capsules. One to be taken twice daily
  • Acamprosate calcium 333 mg gastro-resistant tablets. Two tablets – oral - three times daily

On discharge

  • Aspirin - oral 75mg - at 8am - Take with or after food - indefinitely
  • Atorvastatin - oral- 10mg - daily for 2 weeks then 20mg daily indefinitely
  • Levothyroxine sodium -oral - 100mcg/125 microgram on alternating days . Do not stop taking this medication except on your doctor’s advice
  • Ramipril - oral - 2.5mg - at 8am and 5pm
  • Acamprosate calcium gastro-resistant - oral 666 mg - at 8am 2pm 10pm

The Inpatient Stay

The Inpatient stay is carried in the UKCore-Encounter profiled resource

Named Participants

Named Organisations

Example Instance of Scenario

{
    "resourceType": "Bundle",
    "id": "07b8ac93-bfab-4254-9b78-77cabc6a0cc0",
    "meta": {
        "lastUpdated": "2023-01-29T10:58:00+00:00",
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Bundle"
        ]
    },
    "identifier": {
        "system": "https://tools.ietf.org/html/rfc4122",
        "value": "3ece7415-8df6-4393-b413-f31caa5d585a"
    },
    "type": "document",
    "timestamp": "2023-01-29T10:58:21Z",
    "entry":  [
        {
            "fullUrl": "urn:uuid:4206d767-727c-4004-94f6-484999c40d01",
            "resource": {
                "resourceType": "Composition",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition"
                    ]
                },
                "extension":  [
                    {
                        "url": "https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType",
                        "valueCodeableConcept": {
                            "coding":  [
                                {
                                    "system": "http://snomed.info/sct",
                                    "code": "789718008",
                                    "display": "Cardiology service"
                                }
                            ]
                        }
                    }
                ],
                "status": "final",
                "type": {
                    "coding":  [
                        {
                            "system": "http://snomed.info/sct",
                            "code": "373942005",
                            "display": "Discharge summary"
                        }
                    ]
                },
                "subject": {
                    "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9"
                },
                "encounter": {
                    "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd"
                },
                "date": "2023-01-28T10:00:00+00:00",
                "author":  [
                    {
                        "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
                    }
                ],
                "title": "Cardiology Service Discharge Summary",
                "custodian": {
                    "reference": "urn:uuid:f21c2e2d-a3ef-4eb6-9b7a-737383f748ea"
                },
                "section":  [
                    {
                        "title": "Admission details",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "admission-details",
                                    "display": "Admission details"
                                }
                            ]
                        },
                        "text": {
                            "status": "extensions",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Reason for admission</th><td>Further investigations</td></tr></tbody></table></div>"
                        },
                        "entry":  [
                            {
                                "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd"
                            }
                        ]
                    },
                    {
                        "title": "Clinical summary",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "clinical-summary",
                                    "display": "Clinical summary"
                                }
                            ]
                        },
                        "text": {
                            "status": "additional",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Clinical Summary</th></tr><tr><td><p>56 yr old carpenter witha history of an underactive thyroid gland who has to take thyroxine every day.</p><p>Getting him on the correct dose has been difficult, so he is on a slightly unusual dose.</p><p>Had a heart attack 2 weeks ago, and had a coronary stent inserted, since when he has needed to take daily Aspirin to prevent blood clotting and Atorvastatin to lower his cholesterol level.</p><p>Has had problems in the past with alcohol misuse and on the advice of the local substance misuse service has been started on Acromposate.</p><p>Recently started to feel more breathless at night. GP diagnosed heart failure, and started Ramipril but after discussion with the cardiologist, admitted for further investigations.</p><p>Discharged again after 3 days, on unchanged medication, awaiting the result of the tests.</p></td></tr></tbody></table></div>"
                        }
                    },
                    {
                        "title": "Diagnoses",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "diagnoses",
                                    "display": "Diagnoses"
                                }
                            ]
                        },
                        "text": {
                            "status": "additional",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Underactive thyroid</td></tr><tr><th>Comment</th><td>Hypothyroidism (disorder) - 40930008</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Heart attack</td></tr><tr><th>Comment</th><td>Myocardial infarction (disorder) - 22298006</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Alcohol misuse</td></tr><tr><th>Comment</th><td>Alcohol abuse (disorder) - 15167005</td></tr></tbody></table></div>"
                        },
                        "entry":  [
                            {
                                "reference": "urn:uuid:e7fb78ed-db3a-4759-a370-0c0957f7f3bf"
                            }
                        ]
                    },
                    {
                        "title": "Discharge details",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "discharge-details",
                                    "display": "Discharge details"
                                }
                            ]
                        },
                        "text": {
                            "status": "additional",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Discharging consultant</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr><tr><th>Discharging specialty/department</th><td>Cardiology</td></tr><tr><th>Discharge location</th><td><p>Name: Cramer ward</p><p>Identifier: RR8CRAM</p></td></tr><tr><th>Date/time of discharge</th><td>29-Jan-2023 10:58</td></tr><tr><th>Discharge method</th><td>Patient discharged on clinical advice or with clinical consent</td></tr><tr><th>Discharge type</th><td>Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes Patients with no fixed abode.</td></tr></tbody></table></div>"
                        },
                        "entry":  [
                            {
                                "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd"
                            },
                            {
                                "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
                            }
                        ]
                    },
                    {
                        "title": "Distribution list",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "distribution-list",
                                    "display": "Distribution list"
                                }
                            ]
                        },
                        "text": {
                            "status": "generated",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Mrs</p><p>Given Name: Angela</p><p>Family Name: Jones</p></td></tr><tr><th>Role</th><td>Community Nurse</td></tr><tr><th>Organisation name</th><td>Leeds Community Healthcare NHS Trust</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>Role</th><td>General Medical Practitioner</td></tr><tr><th>Organisation name</th><td>MGP Medical Centre</td></tr></tbody></table></div>"
                        },
                        "entry":  [
                            {
                                "reference": "urn:uuid:339b9af6-5f90-4067-b300-98176900d693"
                            },
                            {
                                "reference": "urn:uuid:a0b25b87-6278-4b18-9ae7-ce0ac36baab6"
                            }
                        ]
                    },
                    {
                        "title": "GP practice",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "general-practitioner-practice",
                                    "display": "GP 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:bd0b7423-6c10-40a0-b829-8e52afea92d3"
                            }
                        ]
                    },
                    {
                        "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><p>Patient seen by people and information given regarding discharge.</p></td></tr></tbody></table></div>"
                        }
                    },
                    {
                        "title": "Investigation results",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "investigation-results",
                                    "display": "Investigation results"
                                }
                            ]
                        },
                        "text": {
                            "status": "additional",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Investigation result</th></tr><tr><td><pre>Full Blood Count  TestValueUnitsReference RangeWhite Cell Count11.1x10*9/L3.5 - 10.0Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0Haematocrit0.2300.400 - 0.500Mean Cell Volume90fL84 - 98Mean Cell Hb33.0pg27.5 - 32.0Mean Cell Hb Con34.0pg31.0 - 35.0RDW12.0%&lt; 14.5Platelet Count300x10*9/L150 - 400Machine Differential  Test ValueUnits Reference RangeNeutrophils7.0x10*9/L1.7 - 7.5Lymphocytes3.5x10*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": "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": "extensions",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Aspirin 75mg dispersible tablets</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 with or after food - indefinitely</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Atorvastatin 10mg</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>Daily for 2 weeks  then  20mg daily indefinitely</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Levothyroxine sodium</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>100 microgram/125 microgram on alternating days . Do not stop taking this medication except on your doctors advice</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Ramipril - 2.5mg</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>At 8am and 5pm</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Acamprosate calcium gastro-resistant - oral 333 mg</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>At 8am 2pm 10pm</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>"
                        },
                        "entry":  [
                            {
                                "reference": "urn:uuid:f45f2d49-0808-4afb-b112-97ad7d9d0cd9"
                            }
                        ]
                    },
                    {
                        "title": "Patient demographics",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "patient-demographics",
                                    "display": "Patient demographics"
                                }
                            ]
                        },
                        "text": {
                            "status": "additional",
                            "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: Andy</p><p>Family Name: Andrews</p></td></tr><tr><th>Date of birth</th><td>1 January 1967</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>9449305072</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:2c0bca60-1873-46f7-a462-5733feaf32c9"
                            }
                        ]
                    },
                    {
                        "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": "additional",
                            "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><tr><th>Role</th><td>Consultant</td></tr><tr><th>Specialty</th><td>Cardiology</td></tr><tr><th>Professional identifier</th><td>GMC: 6122477</td></tr><tr><th>Date and time completed</th><td>29 Jan 2023 10:58</td></tr><tr><th>Contact details</th><td>Phone: 0113 6323200 (Work)</td></tr><tr><th>Organisation</th><td><p>Name: Leeds Teaching Hospitals NHS Trust,</p><p>Address Line: St James's University Hospital, Beckett Street</p><p>City: Leeds</p><p>Post Code: LS9 7TF</p></td></tr></tbody></table></div>"
                        },
                        "entry":  [
                            {
                                "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
                            }
                        ]
                    },
                    {
                        "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>Actions for healthcare professionals</th><td>\n                      GP please continue secondary preventative medication. \n                                 \n                      <p>Status: Requested</p><p>Doses will be uptitrated by Cardiac Rehab team.</p><p>Status: Requested</p></td></tr></tbody></table></div>"
                        }
                    },
                    {
                        "title": "Referrer details",
                        "code": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                                    "code": "referrer-details",
                                    "display": "Referrer details"
                                }
                            ]
                        },
                        "text": {
                            "status": "generated",
                            "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Referrer details</th><td><p>Name:</p><p>Prefix: Dr.</p><p>Given name: Amanda</p><p>Family name: Smith</p><p>Role: Specialist Registrar</p><p>Tel: 0113 6323222 (work)</p><p>Organisation</p><p>Name: St. James's University Hospital Accident and Emergency Department</p><p>Address Line: St James's University Hospital, Beckett Street</p><p>City: Leeds</p><p>Post Code: LS9 7TF</p></td></tr></tbody></table></div>"
                        },
                        "entry":  [
                            {
                                "reference": "urn:uuid:32a15090-f3dc-4955-9954-ebd884ee9f4a"
                            },
                            {
                                "reference": "urn:uuid:08c0277b-f10a-4a18-97ff-4f26a107d902"
                            }
                        ]
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd",
            "resource": {
                "resourceType": "Encounter",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Encounter"
                    ]
                },
                "extension":  [
                    {
                        "url": "https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-AdmissionMethod",
                        "valueCodeableConcept": {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-AdmissionMethodEngland",
                                    "code": "21",
                                    "display": "Accident and emergency or dental casualty department of the Health Care Provider"
                                }
                            ]
                        }
                    }
                ],
                "status": "finished",
                "class": {
                    "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
                    "code": "IMP",
                    "display": "inpatient encounter"
                },
                "type":  [
                    {
                        "coding":  [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "185212007",
                                "display": "Seen in hospital ward"
                            }
                        ]
                    }
                ],
                "subject": {
                    "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9"
                },
                "participant":  [
                    {
                        "type":  [
                            {
                                "coding":  [
                                    {
                                        "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                                        "code": "DIS",
                                        "display": "discharger"
                                    }
                                ]
                            }
                        ],
                        "individual": {
                            "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
                        }
                    }
                ],
                "period": {
                    "start": "2023-01-12T09:00:00+00:00",
                    "end": "2023-01-16T11:20:00+00:00"
                },
                "reasonCode":  [
                    {
                        "coding":  [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "425419005",
                                "display": "ECG: inferior ischaemia"
                            }
                        ]
                    }
                ],
                "hospitalization": {
                    "admitSource": {
                        "coding":  [
                            {
                                "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-SourceOfAdmissionEngland",
                                "code": "51",
                                "display": "NHS other Hospital Provider - Ward for general Patients or the younger physically disabled or A and E department"
                            }
                        ]
                    },
                    "dischargeDisposition": {
                        "coding":  [
                            {
                                "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-DischargeDestinationEngland",
                                "code": "19",
                                "display": "Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes Patients with no fixed abode."
                            }
                        ]
                    }
                },
                "location":  [
                    {
                        "location": {
                            "reference": "urn:uuid:ee191f90-2655-4488-b735-a347ed65a448"
                        },
                        "period": {
                            "end": "2015-02-16T15:00:00+00:00"
                        }
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:f45f2d49-0808-4afb-b112-97ad7d9d0cd9",
            "resource": {
                "resourceType": "List",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-List"
                    ]
                },
                "status": "current",
                "mode": "snapshot",
                "code": {
                    "coding":  [
                        {
                            "system": "http://snomed.info/sct",
                            "code": "1102411000000102",
                            "display": "Active medications"
                        }
                    ]
                },
                "subject": {
                    "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9"
                },
                "encounter": {
                    "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd"
                },
                "source": {
                    "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
                },
                "entry":  [
                    {
                        "item": {
                            "reference": "urn:uuid:64428106-7427-489f-aef2-945c23ffc8e3"
                        }
                    },
                    {
                        "item": {
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                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Practitioner"
                    ]
                },
                "name":  [
                    {
                        "family": "Smith",
                        "given":  [
                            "Amanda"
                        ],
                        "prefix":  [
                            "Dr"
                        ]
                    }
                ],
                "telecom":  [
                    {
                        "system": "phone",
                        "value": "0113 6323222",
                        "use": "work"
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:918539fd-3140-4306-b814-064f26cc8750",
            "resource": {
                "resourceType": "PractitionerRole",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-PractitionerRole"
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                },
                "practitioner": {
                    "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
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                "organization": {
                    "reference": "urn:uuid:f21c2e2d-a3ef-4eb6-9b7a-737383f748ea"
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                "code":  [
                    {
                        "coding":  [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "768839008",
                                "display": "Consultant"
                            }
                        ]
                    }
                ],
                "specialty":  [
                    {
                        "coding":  [
                            {
                                "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-PracticeSettingCode",
                                "code": "320",
                                "display": "Cardiology"
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        {
            "fullUrl": "urn:uuid:6dcd8f6c-4fa1-4146-b979-b02b26e1580c",
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                "practitioner": {
                    "reference": "urn:uuid:339b9af6-5f90-4067-b300-98176900d693"
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                "organization": {
                    "reference": "urn:uuid:4ba94ff2-8ebc-4afa-ba0c-0bbd4813154e"
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                "code":  [
                    {
                        "coding":  [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "224540001",
                                "display": "Community nurse"
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        {
            "fullUrl": "urn:uuid:c483bd7c-f6be-4259-90ca-21e278a841c5",
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                "practitioner": {
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                "organization": {
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                "code":  [
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                        "coding":  [
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                                "code": "62247001",
                                "display": "General practitioner"
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            "fullUrl": "urn:uuid:54784874-a655-43b0-a360-b385f55d4210",
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                "practitioner": {
                    "reference": "urn:uuid:32a15090-f3dc-4955-9954-ebd884ee9f4a"
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                "organization": {
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                "code":  [
                    {
                        "coding":  [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "302211009",
                                "display": "Specialist registrar"
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        {
            "fullUrl": "urn:uuid:bd0b7423-6c10-40a0-b829-8e52afea92d3",
            "resource": {
                "resourceType": "Organization",
                "meta": {
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                },
                "identifier":  [
                    {
                        "system": "https://fhir.nhs.uk/Id/ods-organization-code",
                        "value": "GP123456"
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                ],
                "name": "MGP Medical Centre",
                "address":  [
                    {
                        "line":  [
                            "1 MGP House, Overtown"
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                        "city": "Leeds",
                        "postalCode": "LS21 7PA"
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                "resourceType": "Organization",
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                },
                "identifier":  [
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                        "system": "https://fhir.nhs.uk/Id/ods-organization-code",
                        "value": "RR8"
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                ],
                "name": "Leeds Teaching Hospitals NHS Trust",
                "address":  [
                    {
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                            "St James's University Hospital, Beckett Street"
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                        "city": "Leeds",
                        "postalCode": "LS9 7TF"
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                "identifier":  [
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                        "system": "https://fhir.nhs.uk/Id/ods-organization-code",
                        "value": "RY6"
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                "name": "Leeds Community Healthcare NHS Trust"
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        {
            "fullUrl": "urn:uuid:08c0277b-f10a-4a18-97ff-4f26a107d902",
            "resource": {
                "resourceType": "Organization",
                "meta": {
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                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Organization"
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                },
                "name": "St. James's University Hospital Accident and Emergency Department",
                "address":  [
                    {
                        "line":  [
                            "St James's University Hospital, Beckett Street"
                        ],
                        "city": "Leeds",
                        "postalCode": "LS9 7TF"
                    }
                ]
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        },
        {
            "fullUrl": "urn:uuid:ee191f90-2655-4488-b735-a347ed65a448",
            "resource": {
                "resourceType": "Location",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Location"
                    ]
                },
                "identifier":  [
                    {
                        "system": "https://fhir.nhs.uk/Id/local-location-identifier",
                        "value": "RR8CRAM"
                    }
                ],
                "name": "Cramer Ward",
                "managingOrganization": {
                    "reference": "urn:uuid:f21c2e2d-a3ef-4eb6-9b7a-737383f748ea"
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}
<Bundle xmlns="http://hl7.org/fhir">
    <id value="07b8ac93-bfab-4254-9b78-77cabc6a0cc0" />
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        <lastUpdated value="2023-01-29T10:58:00+00:00" />
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        <value value="3ece7415-8df6-4393-b413-f31caa5d585a" />
    </identifier>
    <type value="document" />
    <timestamp value="2023-01-29T10:58:21Z" />
    <entry>
        <fullUrl value="urn:uuid:4206d767-727c-4004-94f6-484999c40d01" />
        <resource>
            <Composition>
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" />
                </meta>
                <extension url="https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType">
                    <valueCodeableConcept>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="789718008" />
                            <display value="Cardiology service" />
                        </coding>
                    </valueCodeableConcept>
                </extension>
                <status value="final" />
                <type>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="373942005" />
                        <display value="Discharge summary" />
                    </coding>
                </type>
                <subject>
                    <reference value="urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" />
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                <encounter>
                    <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" />
                </encounter>
                <date value="2023-01-28T10:00:00+00:00" />
                <author>
                    <reference value="urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" />
                </author>
                <title value="Cardiology Service Discharge Summary" />
                <custodian>
                    <reference value="urn:uuid:f21c2e2d-a3ef-4eb6-9b7a-737383f748ea" />
                </custodian>
                <section>
                    <title value="Admission details" />
                    <code>
                        <coding>
                            <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                            <code value="admission-details" />
                            <display value="Admission details" />
                        </coding>
                    </code>
                    <text>
                        <status value="extensions" />
                        <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Reason for admission</th><td>Further investigations</td></tr></tbody></table></div>
                    </text>
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                        <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" />
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                <section>
                    <title value="Clinical summary" />
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                        <coding>
                            <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                            <code value="clinical-summary" />
                            <display value="Clinical summary" />
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                    </code>
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                        <status value="additional" />
                        <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Clinical Summary</th></tr><tr><td><p>56 yr old carpenter witha history of an underactive thyroid gland who has to take thyroxine every day.</p><p>Getting him on the correct dose has been difficult, so he is on a slightly unusual dose.</p><p>Had a heart attack 2 weeks ago, and had a coronary stent inserted, since when he has needed to take daily Aspirin to prevent blood clotting and Atorvastatin to lower his cholesterol level.</p><p>Has had problems in the past with alcohol misuse and on the advice of the local substance misuse service has been started on Acromposate.</p><p>Recently started to feel more breathless at night. GP diagnosed heart failure, and started Ramipril but after discussion with the cardiologist, admitted for further investigations.</p><p>Discharged again after 3 days, on unchanged medication, awaiting the result of the tests.</p></td></tr></tbody></table></div>
                    </text>
                </section>
                <section>
                    <title value="Diagnoses" />
                    <code>
                        <coding>
                            <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                            <code value="diagnoses" />
                            <display value="Diagnoses" />
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                        <status value="additional" />
                        <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Underactive thyroid</td></tr><tr><th>Comment</th><td>Hypothyroidism (disorder) - 40930008</td></tr></tbody></table><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Heart attack</td></tr><tr><th>Comment</th><td>Myocardial infarction (disorder) - 22298006</td></tr></tbody></table><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Alcohol misuse</td></tr><tr><th>Comment</th><td>Alcohol abuse (disorder) - 15167005</td></tr></tbody></table></div>
                    </text>
                    <entry>
                        <reference value="urn:uuid:e7fb78ed-db3a-4759-a370-0c0957f7f3bf" />
                    </entry>
                </section>
                <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="additional" />
                        <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Discharging consultant</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr><tr><th>Discharging specialty/department</th><td>Cardiology</td></tr><tr><th>Discharge location</th><td><p>Name: Cramer ward</p><p>Identifier: RR8CRAM</p></td></tr><tr><th>Date/time of discharge</th><td>29-Jan-2023 10:58</td></tr><tr><th>Discharge method</th><td>Patient discharged on clinical advice or with clinical consent</td></tr><tr><th>Discharge type</th><td>Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes Patients with no fixed abode.</td></tr></tbody></table></div>
                    </text>
                    <entry>
                        <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" />
                    </entry>
                    <entry>
                        <reference value="urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" />
                    </entry>
                </section>
                <section>
                    <title value="Distribution list" />
                    <code>
                        <coding>
                            <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                            <code value="distribution-list" />
                            <display value="Distribution list" />
                        </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: Mrs</p><p>Given Name: Angela</p><p>Family Name: Jones</p></td></tr><tr><th>Role</th><td>Community Nurse</td></tr><tr><th>Organisation name</th><td>Leeds Community Healthcare NHS Trust</td></tr></tbody></table><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>Role</th><td>General Medical Practitioner</td></tr><tr><th>Organisation name</th><td>MGP Medical Centre</td></tr></tbody></table></div>
                    </text>
                    <entry>
                        <reference value="urn:uuid:339b9af6-5f90-4067-b300-98176900d693" />
                    </entry>
                    <entry>
                        <reference value="urn:uuid:a0b25b87-6278-4b18-9ae7-ce0ac36baab6" />
                    </entry>
                </section>
                <section>
                    <title value="GP practice" />
                    <code>
                        <coding>
                            <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                            <code value="general-practitioner-practice" />
                            <display value="GP 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>
                    <entry>
                        <reference value="urn:uuid:bd0b7423-6c10-40a0-b829-8e52afea92d3" />
                    </entry>
                </section>
                <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><p>Patient seen by people and information given regarding discharge.</p></td></tr></tbody></table></div>
                    </text>
                </section>
                <section>
                    <title value="Investigation results" />
                    <code>
                        <coding>
                            <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                            <code value="investigation-results" />
                            <display value="Investigation results" />
                        </coding>
                    </code>
                    <text>
                        <status value="additional" />
                        <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Investigation result</th></tr><tr><td><pre>Full Blood Count  TestValueUnitsReference RangeWhite Cell Count11.1x10*9/L3.5 - 10.0Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0Haematocrit0.2300.400 - 0.500Mean Cell Volume90fL84 - 98Mean Cell Hb33.0pg27.5 - 32.0Mean Cell Hb Con34.0pg31.0 - 35.0RDW12.0%&lt; 14.5Platelet Count300x10*9/L150 - 400Machine Differential  Test ValueUnits Reference RangeNeutrophils7.0x10*9/L1.7 - 7.5Lymphocytes3.5x10*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>
                <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="extensions" />
                        <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Medication name</th><td>Aspirin 75mg dispersible tablets</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 with or after food - indefinitely</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Atorvastatin 10mg</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>Daily for 2 weeks  then  20mg daily indefinitely</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Levothyroxine sodium</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>100 microgram/125 microgram on alternating days . Do not stop taking this medication except on your doctors advice</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Ramipril - 2.5mg</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>At 8am and 5pm</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Acamprosate calcium gastro-resistant - oral 333 mg</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>At 8am 2pm 10pm</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>
                    </text>
                    <entry>
                        <reference value="urn:uuid:f45f2d49-0808-4afb-b112-97ad7d9d0cd9" />
                    </entry>
                </section>
                <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="additional" />
                        <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: Andy</p><p>Family Name: Andrews</p></td></tr><tr><th>Date of birth</th><td>1 January 1967</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>9449305072</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>
                    <entry>
                        <reference value="urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" />
                    </entry>
                </section>
                <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="additional" />
                        <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><tr><th>Role</th><td>Consultant</td></tr><tr><th>Specialty</th><td>Cardiology</td></tr><tr><th>Professional identifier</th><td>GMC: 6122477</td></tr><tr><th>Date and time completed</th><td>29 Jan 2023 10:58</td></tr><tr><th>Contact details</th><td>Phone: 0113 6323200 (Work)</td></tr><tr><th>Organisation</th><td><p>Name: Leeds Teaching Hospitals NHS Trust,</p><p>Address Line: St James's University Hospital, Beckett Street</p><p>City: Leeds</p><p>Post Code: LS9 7TF</p></td></tr></tbody></table></div>
                    </text>
                    <entry>
                        <reference value="urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" />
                    </entry>
                </section>
                <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>Actions for healthcare professionals</th><td>
                      GP please continue secondary preventative medication. 
                                 
                      <p>Status: Requested</p><p>Doses will be uptitrated by Cardiac Rehab team.</p><p>Status: Requested</p></td></tr></tbody></table></div>
                    </text>
                </section>
                <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>
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                        <code value="encounter-diagnosis" />
                        <display value="Encounter Diagnosis" />
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                        <code value="15167005" />
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                    <value value="033345750517" />
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                    <value value="0113 6323222" />
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</Bundle>
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