Please note:
- This version of the UK Core is for C&TA Sprint 7 Review.
- This version is not suitable 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
An example to illustrate a composition containing a discharge summary
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<Composition xmlns="http://hl7.org/fhir"> <id value="UKCore-Composition-Discharge-Example" /> <!-- Extension to carry details of the Correspondence Care Setting Type. --> <extension url="https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType"> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct" /> <code value="310000008" /> <display value="Accident and Emergency service" /> </coding> </valueCodeableConcept> </extension> <identifier> <system value="https://tools.ietf.org/html/rfc4122" /> <value value="2d361270-039f-4a48-827b-ef255ff8b6c4" /> </identifier> <!-- The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. --> <status value="final" /> <type> <!-- Discharge Summary document type --> <coding> <system value="http://snomed.info/sct" /> <code value="373942005" /> <display value="Discharge summary" /> </coding> </type> <!-- Reference to the patient subject of the Composition --> <subject> <reference value="urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5" /> </subject> <!-- Reference to the clinical encounter or type of care this documentation is associated with. --> <encounter> <reference value="urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9" /> </encounter> <!-- The composition editing time, when the composition was last logically changed by the author. --> <date value="2021-02-12T19:00:00+00:00" /> <!-- Identifies who is responsible for the information in the composition, not necessarily who typed it in --> <author> <reference value="urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb" /> </author> <title value="Accident & Emergency Discharge summary" /> <!-- Identifies the organisation responsible for ongoing maintenance of and access to the composition/document information. --> <custodian> <reference value="urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc" /> </custodian> <!-- Allergies and adverse reactions --> <section> <title value="Allergies and adverse reaction" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="allergies-and-adverse-reaction" /> <display value="Allergies and adverse reaction" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Causative agent</th><td>Penicillin -class of antibiotic</td></tr><tr><th>Description of reaction</th><td>Eruption due to drug</td></tr><tr><th>Severity</th><td>Mild</td></tr><tr><th>Certainty</th><td>Certain</td></tr><tr><th>Comment</th><td>No swelling</td></tr></tbody></table></div> </text> <!-- Reference to Allergies List as the source of information for this section --> <entry> <reference value="urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b" /> </entry> </section> <!-- Attendance details --> <section> <title value="Attendance details" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="attendance-details" /> <display value="Attendance details" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Date and time of contact</th><td>12-Feb-2015 07:00</td></tr></tbody></table></div> </text> </section> <!-- Clinical narrative --> <section> <title value="Clinical narrative" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="clinical-narrative" /> <display value="Clinical narrative" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Clinical narrative</th></tr><tr><td><p>60 year old man complaining of chest pain lasting around 2 hours.</p><p>Examination unremarkable.</p><p>Inferior ischaemic changes on ECG.</p></td></tr></tbody></table><table><tbody><tr><td><pre> Full Blood Count TestValueUnitsReference Range White Cell Count11.1x10*9/L3.5 - 10.0 Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0 Haematocrit0.230L/L0.400 - 0.500 Mean Cell Volume90fL84 - 98 Mean Cell Hb33.0pg27.5 - 32.0 Mean Cell Hb Con34.0pg31.0 - 35.0 RDW12.0%< 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 --> <section> <title value="Contact for further information" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="contact-for-further-information" /> <display value="Contact for further information" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Contact for further information</th><td>Dr Paul Rastall Tel: 0113 6323200</td></tr></tbody></table></div> </text> </section> <!-- Diagnoses --> <section> <title value="Diagnoses" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="diagnoses" /> <display value="Diagnoses" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Acute ST segment elevation myocardial infarction</td></tr></tbody></table></div> </text> <!-- Reference to information in the Condition list resource --> <entry> <reference value="urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" /> </entry> </section> <!-- Discharge details --> <section> <title value="Discharge details" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="discharge-details" /> <display value="Discharge details" /> </coding> </code> <text> <status value="extensions" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Discharge status</th><td>Streamed from emergency department to urgent care service following initial assessment</td></tr><tr><th>Date/time of discharge</th><td>12-Feb-2015 08:00</td></tr><tr><th>Discharge destination</th><td>NHS other Hospital Provider - Ward for general Patients or the younger physically disabled</td></tr></tbody></table></div> </text> <!-- Reference to the Encounter entry as the source of information for this section --> <entry> <reference value="urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9" /> </entry> </section> <!-- GP Practice --> <section> <title value="GP practice" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="general-practitioner-practice" /> <display value="General practitioner practice" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>GP name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>GP practice details</th><td><p>Name: MGP Medical Centre</p><p>Address:</p><p>Address Line: 1 MGP House, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 7PA</p></td></tr></tbody></table></div> </text> <!-- Reference to the Organisation entry as the source of information for this section --> <entry> <reference value="urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1" /> </entry> </section> <!-- Information and advice given --> <section> <title value="Information and advice given" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="information-and-advice-given" /> <display value="Information and advice given" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Information and advice given</th><td>Patient advised to be admitted to ward for further tests after ECG results showed inferior ischaemic changes.</td></tr></tbody></table></div> </text> </section> <!-- Medications and medical devices --> <section> <title value="Medications and medical devices" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="medications-and-medical-devices" /> <display value="Medications and medical devices" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Medication name</th><td>Ramipril 2.5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>One 2.5mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Aspirin 75mg tablets (Sigma Pharmaceuticals Plc)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 75mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Simvastatin 40mg tablets (Brown & Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div> </text> <!-- Reference to medication list --> <entry> <reference value="urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca" /> </entry> </section> <!-- Patient demographics --> <section> <title value="Patient demographics" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="patient-demographics" /> <display value="Patient demographics" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div> </text> <!-- reference to further information carried in the patient resource --> <entry> <reference value="urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5" /> </entry> </section> <!-- Person completing record --> <section> <title value="Person completing record" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="person-completing-record" /> <display value="Person completing record" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div> </text> <!-- Reference to the practitioner entry as the source of information for this section --> <entry> <reference value="urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb" /> </entry> </section> <!-- Plan and requested actions --> <section> <title value="Plan and requested actions" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="plan-and-requested-actions" /> <display value="Plan and requested actions" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of his chest pain on 12 February 2015.</p><p>Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's University Hospital Accident and Emergency Department)</p><p>Status: Completed</p><p>Outcome: Patient expects to find out the more information about the reasons for his chest pain when tests are carried out after admission.</p></td></tr></tbody></table></div> </text> </section> <!-- Presenting complaints or issues --> <section> <title value="Presenting complaints or issues" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="presenting-complaints-or-issues" /> <display value="Presenting complaints or issues" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Presenting complaints or issue</th><td>Chest pain</td></tr></tbody></table></div> </text> <!-- Reference to information in the Condition list resource --> <entry> <reference value="urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" /> </entry> </section> <!-- Procedures --> <section> <title value="Procedures" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="procedures" /> <display value="Procedures" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Procedure name</th><td>Electrocardiographic monitoring</td></tr><tr><th>Comment</th><td>ECGs showed inferior ischaemic changes.</td></tr></tbody></table></div> </text> <!-- reference to further information carried in the procedure list resource --> <entry> <reference value="urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1" /> </entry> </section> <!-- Referrer details --> <section> <title value="Referrer details" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="referrer-details" /> <display value="Referrer details" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Referrer details</th><td>Self-referral to accident and emergency department</td></tr></tbody></table></div> </text> </section> <!-- Senior reviewing clinician --> <section> <title value="Senior reviewing clinician" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="senior-reviewing-clinician" /> <display value="Senior reviewing clinician" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Mr</p><p>Family Name: Abacus</p></td></tr></tbody></table></div> </text> <!-- reference to further information carried in the practitioner resource --> <entry> <reference value="urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9" /> </entry> </section> </Composition>
JSON View
{ "resourceType": "Composition", "id": "UKCore-Composition-Discharge-Example", "extension": [ { "url": "https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "310000008", "display": "Accident and Emergency service" } ] } } ], "identifier": { "system": "https://tools.ietf.org/html/rfc4122", "value": "2d361270-039f-4a48-827b-ef255ff8b6c4" }, "status": "final", "type": { "coding": [ { "system": "http://snomed.info/sct", "code": "373942005", "display": "Discharge summary" } ] }, "subject": { "reference": "urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5" }, "encounter": { "reference": "urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9" }, "date": "2021-02-12T19:00:00+00:00", "author": [ { "reference": "urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb" } ], "title": "Accident & Emergency Discharge summary", "custodian": { "reference": "urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc" }, "section": [ { "title": "Allergies and adverse reaction", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "allergies-and-adverse-reaction", "display": "Allergies and adverse reaction" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Causative agent</th><td>Penicillin -class of antibiotic</td></tr><tr><th>Description of reaction</th><td>Eruption due to drug</td></tr><tr><th>Severity</th><td>Mild</td></tr><tr><th>Certainty</th><td>Certain</td></tr><tr><th>Comment</th><td>No swelling</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b" } ] }, { "title": "Attendance details", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "attendance-details", "display": "Attendance details" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Date and time of contact</th><td>12-Feb-2015 07:00</td></tr></tbody></table></div>" } }, { "title": "Clinical narrative", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "clinical-narrative", "display": "Clinical narrative" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Clinical narrative</th></tr><tr><td><p>60 year old man complaining of chest pain lasting around 2 hours.</p><p>Examination unremarkable.</p><p>Inferior ischaemic changes on ECG.</p></td></tr></tbody></table><table><tbody><tr><td><pre>\nFull Blood Count \n\nTestValueUnitsReference Range\nWhite Cell Count11.1x10*9/L3.5 - 10.0\nRed Cell Count5.0x10*12/L4.25 - 5.75 \nHaemoglobin150g/L13.0 - 17.0\nHaematocrit0.230L/L0.400 - 0.500\nMean Cell Volume90fL84 - 98\nMean Cell Hb33.0pg27.5 - 32.0\nMean Cell Hb Con34.0pg31.0 - 35.0\nRDW12.0%< 14.5\nPlatelet Count300x10*9/L150 - 400\n\nMachine Differential \n\nTestValueUnitsReference Range\nNeutrophils7.0x10*9/L1.7 - 7.5\nLymphocytes3.5x10*9/L1.0 - 3.5\nMonocytes0.3x10*9/L< 0.6\nEosinophils0.4x10*9/L< 0.4\nBasophils0.1x10*9/L< 0.1\nLUCs0.2x10*9/L< 0.4\n </pre></td></tr></tbody></table></div>" } }, { "title": "Contact for further information", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "contact-for-further-information", "display": "Contact for further information" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Contact for further information</th><td>Dr Paul Rastall Tel: 0113 6323200</td></tr></tbody></table></div>" } }, { "title": "Diagnoses", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "diagnoses", "display": "Diagnoses" } ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Acute ST segment elevation myocardial infarction</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" } ] }, { "title": "Discharge details", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "discharge-details", "display": "Discharge details" } ] }, "text": { "status": "extensions", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Discharge status</th><td>Streamed from emergency department to urgent care service following initial assessment</td></tr><tr><th>Date/time of discharge</th><td>12-Feb-2015 08:00</td></tr><tr><th>Discharge destination</th><td>NHS other Hospital Provider - Ward for general Patients or the younger physically disabled</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9" } ] }, { "title": "GP practice", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "general-practitioner-practice", "display": "General practitioner practice" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>GP name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>GP practice details</th><td><p>Name: MGP Medical Centre</p><p>Address:</p><p>Address Line: 1 MGP House, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 7PA</p></td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1" } ] }, { "title": "Information and advice given", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "information-and-advice-given", "display": "Information and advice given" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Information and advice given</th><td>Patient advised to be admitted to ward for further tests after ECG results \nshowed inferior ischaemic changes.</td></tr></tbody></table></div>" } }, { "title": "Medications and medical devices", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "medications-and-medical-devices", "display": "Medications and medical devices" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Ramipril 2.5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>One 2.5mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Aspirin 75mg tablets (Sigma Pharmaceuticals Plc)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 75mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Simvastatin 40mg tablets (Brown & Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca" } ] }, { "title": "Patient demographics", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "patient-demographics", "display": "Patient demographics" } ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5" } ] }, { "title": "Person completing record", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "person-completing-record", "display": "Person completing record" } ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb" } ] }, { "title": "Plan and requested actions", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "plan-and-requested-actions", "display": "Plan and requested actions" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of \nhis chest pain on 12 February 2015.</p><p>Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's \nUniversity 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 \nchest pain when tests are carried out after admission.</p></td></tr></tbody></table></div>" } }, { "title": "Presenting complaints or issues", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "presenting-complaints-or-issues", "display": "Presenting complaints or issues" } ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Presenting complaints or issue</th><td>Chest pain</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" } ] }, { "title": "Procedures", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "procedures", "display": "Procedures" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Procedure name</th><td>Electrocardiographic monitoring</td></tr><tr><th>Comment</th><td>ECGs showed inferior ischaemic changes.</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1" } ] }, { "title": "Referrer details", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "referrer-details", "display": "Referrer details" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Referrer details</th><td>Self-referral to accident and emergency department</td></tr></tbody></table></div>" } }, { "title": "Senior reviewing clinician", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "senior-reviewing-clinician", "display": "Senior reviewing clinician" } ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Mr</p><p>Family Name: Abacus</p></td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9" } ] } ] }