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Note.
It has been recognised there are commonalities between the sections used by the discharge summaries, and we would look to simplify the design of this page in the future.Inpatient eDischarge
The Inpatient eDischarge Summary is a FHIR document, it's content is organised using a UK Core Composition resource instance, as the first resource within the payload FHIR Document Bundle.
Headings Used By Inpatient eDischarge
| The Inpatient eDischarge Composition SHALL contain clinical information content in line with the following cardinality and mandation requirements: | ||||
|---|---|---|---|---|
| Section Name | SNOMED Concept | Cardinality | Conformance | Associated Coded Profiles |
| Admission details | 886781000000108 | 0..1 | Required | 1 |
| Allergies and adverse reactions | 886921000000105 | 1..1 | Mandatory | 2 |
| Assessment scale | 887141000000103 | 0..1 | Optional | 0 |
| Clinical summary | 887181000000106 | 1..1 | Mandatory | 0 |
| Diagnoses | 887161000000102 | 1..1 | Mandatory | 2 |
| Discharge details | 886811000000106 | 0..1 | Required | 1 |
| Distribution list | 887261000000109 | 0..1 | Required | 4 |
| GP practice | 886711000000101 | 1..1 | Mandatory | 2 |
| Individual requirements | 1078911000000106 | 0..1 | Required | 0 |
| Information and advice given | 1052951000000105 | 0..1 | Required | 0 |
| Investigation results | 1082101000000102 | 0..1 | Optional | 0 |
| Legal information | 886961000000102 | 0..1 | Required | 0 |
| Medications and medical devices | 933361000000108 | 0..1 | Optional | 2 |
| Participation in research | 886751000000102 | 0..1 | Optional | 0 |
| Patient demographics | 886731000000109 | 1..1 | Mandatory | 1 |
| Patient and carer concerns, expectations and wishes | 1052941000000107 | 0..1 | Required | 0 |
| Person completing record | 887231000000104 | 1..1 | Mandatory | 0 |
| Plan and requested actions | 887201000000105 | 0..1 | Required | 0 |
| Procedures | 887171000000109 | 0..1 | Optional | 1 |
| Referrer details | 1052891000000108 | 0..1 | Required | 0 |
| Safety alerts | 886931000000107 | 0..1 | Required | 0 |
| Social context | 887051000000101 | 0..1 | Optional | 0 |
Outpatient Letter
The Outpatient Letter is a FHIR document, it's content is organised using a UK Core Composition resource instance, as the first resource within the payload FHIR Document Bundle.
Headings Used By Outpatient Letter
| The Outpatient Letter Composition SHALL contain clinical information content in line with the following cardinality and mandation requirements: | ||||
|---|---|---|---|---|
| Section Name | SNOMED Concept | Cardinality | Conformance | Associated Coded Profiles |
| Allergies and adverse reactions | 886921000000105 | 1..1 | Mandatory | 2 |
| Assessment scale | 887141000000103 | 0..1 | Optional | 0 |
| Attendance details | 1077881000000105 | 1..1 | Mandatory | 0 |
| Clinical review of systems | 1077901000000108 | 0..1 | Optional | 0 |
| Clinical review of systems | 887181000000106 | 1..1 | Mandatory | 0 |
| Diagnoses | 887161000000102 | 0..1 | Required | 2 |
| Distribution list | 887261000000109 | 0..1 | Required | 4 |
| Examination findings | 715851000000102 | 0..1 | Optional | 2 |
| Family history | 887111000000104 | 0..1 | Optional | 0 |
| GP practice | 886711000000101 | 1..1 | Mandatory | 2 |
| History | 717121000000105 | 0..1 | Required | 0 |
| Individual requirements | 1078911000000106 | 0..1 | Required | 0 |
| Information and advice given | 1052951000000105 | 0..1 | Required | 0 |
| Investigation results | 1082101000000102 | 0..1 | Optional | 0 |
| Legal information | 886961000000102 | 0..1 | Required | 0 |
| Medications and medical devices | 933361000000108 | 0..1 | Optional | 2 |
| Participation in research | 886751000000102 | 0..1 | Required | 0 |
| Patient and carer concerns, expectations and wishes | 1052941000000107 | 0..1 | Optional | 0 |
| Patient demographics | 886731000000109 | 1..1 | Mandatory | 1 |
| Person completing record | 887231000000104 | 1..1 | Mandatory | 0 |
| Plan and requested actions | 887201000000105 | 0..1 | Required | 0 |
| Problems and issues | 887151000000100 | 0..1 | Required | 2 |
| Procedures | 887171000000109 | 0..1 | Required | 2 |
| Referrer details | 1052891000000108 | 0..1 | Required | 0 |
| Relevant clinical risk factors | 886821000000100 | 0..1 | Optional | 0 |
| Safety alerts | 886931000000107 | 0..1 | Required | 0 |
| Social context | 887051000000101 | 0..1 | Optional | 0 |
Mental Health eDischarge
The Mental Health eDischarge is a FHIR document, it's content is organised using a UK Core Composition resource instance, as the first resource within the payload FHIR Document Bundle.
Headings Used By Mental Health eDischarge
| The Mental Health eDischarge Composition SHALL contain clinical information content in line with the following cardinality and mandation requirements: | ||||
|---|---|---|---|---|
| Section Name | SNOMED Concept | Cardinality | Conformance | Associated Coded Profiles |
| Admission details | 886781000000108 | 0..1 | Required | 1 |
| Allergies and adverse reactions | 886921000000105 | 1..1 | Mandatory | 2 |
| Assessment scale | 887141000000103 | 0..1 | Optional | 0 |
| Clinical summary | 887181000000106 | 1..1 | Mandatory | 0 |
| Diagnoses | 887161000000102 | 0..1 | Required | 2 |
| Discharge details | 886811000000106 | 0..1 | Required | 1 |
| Distribution list | 887261000000109 | 0..1 | Required | 4 |
| Family history | 887111000000104 | 0..1 | Optional | 1 |
| GP practice | 886711000000101 | 1..1 | Mandatory | 2 |
| Individual requirements | 1078911000000106 | 0..1 | Required | 0 |
| Information and advice given | 1052951000000105 | 0..1 | Required | 0 |
| Investigation results | 1082101000000102 | 0..1 | Optional | 0 |
| Legal information | 886961000000102 | 0..1 | Required | 0 |
| Medications and medical devices | 933361000000108 | 0..1 | Optional | 2 |
| Participation in research | 886751000000102 | 0..1 | Required | 0 |
| Patient demographics | 886731000000109 | 1..1 | Mandatory | 1 |
| Patient and carer concerns, expectations and wishes | 1052941000000107 | 0..1 | Optional | 0 |
| Person completing record | 887231000000104 | 1..1 | Mandatory | 0 |
| Plan and requested actions | 887201000000105 | 0..1 | Required | 0 |
| Procedures | 887171000000109 | 0..1 | Optional | 1 |
| Referrer details | 1052891000000108 | 0..1 | Required | 0 |
| Safety alerts | 886931000000107 | 0..1 | Required | 0 |
| Social context | 887051000000101 | 0..1 | Optional | 0 |
Emergency Care eDischarge
The Emergency Care eDischarge is a FHIR document, it's content is organised using a UK Core Composition resource instance, as the first resource within the payload FHIR Document Bundle.
| The Emergency Care eDischarge Composition SHALL contain clinical information content in line with the following cardinality and mandation requirements: | ||||
|---|---|---|---|---|
| Section Name | SNOMED Concept | Cardinality | Conformance | Associated Coded Profiles |
| Admission details | 886781000000108 | 0..1 | Required | 1 |
| Allergies and adverse reactions | 886921000000105 | 1..1 | Mandatory | 2 |
| Assessment scale | 887141000000103 | 0..1 | Optional | 0 |
| Clinical summary | 887181000000106 | 1..1 | Mandatory | 0 |
| Diagnoses | 887161000000102 | 0..1 | Required | 2 |
| Discharge details | 886811000000106 | 0..1 | Required | 1 |
| Distribution list | 887261000000109 | 0..1 | Required | 4 |
| Family history | 887111000000104 | 0..1 | Optional | 1 |
| GP practice | 886711000000101 | 1..1 | Mandatory | 2 |
| Individual requirements | 1078911000000106 | 0..1 | Required | 0 |
| Information and advice given | 1052951000000105 | 0..1 | Required | 0 |
| Investigation results | 1082101000000102 | 0..1 | Optional | 0 |
| Legal information | 886961000000102 | 0..1 | Required | 0 |
| Medications and medical devices | 933361000000108 | 0..1 | Optional | 2 |
| Participation in research | 886751000000102 | 0..1 | Required | 0 |
| Patient demographics | 886731000000109 | 1..1 | Mandatory | 1 |
| Patient and carer concerns,expectations and wishes | 1052941000000107 | 0..1 | Optional | 0 |
| Patient and carer concerns, expectations and wishes | 887231000000104 | 1..1 | Mandatory | 0 |
| Plan and requested actions | 887201000000105 | 0..1 | Required | 0 |
| Procedures | 887171000000109 | 0..1 | Optional | 1 |
| Referrer details | 1052891000000108 | 0..1 | Required | 0 |
| Safety alerts | 886931000000107 | 0..1 | Required | 0 |
| Social context | 887051000000101 | 0..1 | Optional | 0 |