UK Core Implementation Guide 0.3.0 STU1

An example to illustrate a composition containing a discharge summary

Table View

Composition.id[0]UKCore-Composition-Discharge-Example
Composition.extension[0].url[0]https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-CareSettingType
Composition.extension[0].valueCodeableConcept[0].coding[0].system[0]http://snomed.info/sct
Composition.extension[0].valueCodeableConcept[0].coding[0].code[0]310000008
Composition.extension[0].valueCodeableConcept[0].coding[0].display[0]Accident and Emergency service
Composition.identifier[0].system[0]https://tools.ietf.org/html/rfc4122
Composition.identifier[0].value[0]2d361270-039f-4a48-827b-ef255ff8b6c4
Composition.status[0]final
Composition.type[0].coding[0].system[0]http://snomed.info/sct
Composition.type[0].coding[0].code[0]373942005
Composition.type[0].coding[0].display[0]Discharge summary
Composition.subject[0].reference[0]urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5
Composition.encounter[0].reference[0]urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9
Composition.date[0]2021-02-12T19:00:00+00:00
Composition.author[0].reference[0]urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb
Composition.title[0]Accident & Emergency Discharge summary
Composition.custodian[0].reference[0]urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc
Composition.section[0].title[0]Allergies and adverse reaction
Composition.section[0].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[0].code[0].coding[0].code[0]allergies-and-adverse-reaction
Composition.section[0].code[0].coding[0].display[0]Allergies and adverse reaction
Composition.section[0].text[0].status[0]additional
Composition.section[0].text[0].div[0]
Causative agentPenicillin -class of antibiotic
Description of reactionEruption due to drug
SeverityMild
CertaintyCertain
CommentNo swelling
Composition.section[0].entry[0].reference[0]urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b
Composition.section[1].title[0]Attendance details
Composition.section[1].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[1].code[0].coding[0].code[0]attendance-details
Composition.section[1].code[0].coding[0].display[0]Attendance details
Composition.section[1].text[0].status[0]additional
Composition.section[1].text[0].div[0]
Date and time of contact12-Feb-2015 07:00
Composition.section[2].title[0]Clinical narrative
Composition.section[2].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[2].code[0].coding[0].code[0]clinical-narrative
Composition.section[2].code[0].coding[0].display[0]Clinical narrative
Composition.section[2].text[0].status[0]additional
Composition.section[2].text[0].div[0]
Clinical narrative

60 year old man complaining of chest pain lasting around 2 hours.

Examination unremarkable.

Inferior ischaemic changes on ECG.

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
                                
Composition.section[3].title[0]Contact for further information
Composition.section[3].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[3].code[0].coding[0].code[0]contact-for-further-information
Composition.section[3].code[0].coding[0].display[0]Contact for further information
Composition.section[3].text[0].status[0]additional
Composition.section[3].text[0].div[0]
Contact for further informationDr Paul Rastall Tel: 0113 6323200
Composition.section[4].title[0]Diagnoses
Composition.section[4].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[4].code[0].coding[0].code[0]diagnoses
Composition.section[4].code[0].coding[0].display[0]Diagnoses
Composition.section[4].text[0].status[0]generated
Composition.section[4].text[0].div[0]
Diagnosis nameAcute ST segment elevation myocardial infarction
Composition.section[4].entry[0].reference[0]urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f
Composition.section[5].title[0]Discharge details
Composition.section[5].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[5].code[0].coding[0].code[0]discharge-details
Composition.section[5].code[0].coding[0].display[0]Discharge details
Composition.section[5].text[0].status[0]extensions
Composition.section[5].text[0].div[0]
Discharge statusStreamed from emergency department to urgent care service following initial assessment
Date/time of discharge12-Feb-2015 08:00
Discharge destinationNHS other Hospital Provider - Ward for general Patients or the younger physically disabled
Composition.section[5].entry[0].reference[0]urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9
Composition.section[6].title[0]GP practice
Composition.section[6].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[6].code[0].coding[0].code[0]general-practitioner-practice
Composition.section[6].code[0].coding[0].display[0]General practitioner practice
Composition.section[6].text[0].status[0]additional
Composition.section[6].text[0].div[0]
GP name

Prefix: Dr

Given Name: John

Family Name: Lorenzo

GP practice details

Name: MGP Medical Centre

Address:

Address Line: 1 MGP House, Overtown

City: Leeds

Post Code: LS21 7PA

Composition.section[6].entry[0].reference[0]urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1
Composition.section[7].title[0]Information and advice given
Composition.section[7].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[7].code[0].coding[0].code[0]information-and-advice-given
Composition.section[7].code[0].coding[0].display[0]Information and advice given
Composition.section[7].text[0].status[0]additional
Composition.section[7].text[0].div[0]
Information and advice givenPatient advised to be admitted to ward for further tests after ECG results showed inferior ischaemic changes.
Composition.section[8].title[0]Medications and medical devices
Composition.section[8].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[8].code[0].coding[0].code[0]medications-and-medical-devices
Composition.section[8].code[0].coding[0].display[0]Medications and medical devices
Composition.section[8].text[0].status[0]additional
Composition.section[8].text[0].div[0]
Medication nameRamipril 2.5mg tablets (A A H Pharmaceuticals Ltd)
FormTablet
RouteOral
Dose directions descriptionOne 2.5mg tablet once a day.
StatusContinued
Medication nameAspirin 75mg tablets (Sigma Pharmaceuticals Plc)
FormTablet
RouteOral
Dose directions descriptionTake one 75mg tablet once a day.
StatusContinued
Medication nameSimvastatin 40mg tablets (Brown & Burk UK Ltd)
FormTablet
RouteOral
Dose directions descriptionTake one 40mg tablet once a day.
StatusContinued
Medication nameBisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)
FormTablet
RouteOral
Dose directions descriptionTake one 5mg tablet daily.
Comment/recommendationRecommend Uptitrate according to BP and HR
StatusContinued
Composition.section[8].entry[0].reference[0]urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca
Composition.section[9].title[0]Patient demographics
Composition.section[9].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[9].code[0].coding[0].code[0]patient-demographics
Composition.section[9].code[0].coding[0].display[0]Patient demographics
Composition.section[9].text[0].status[0]generated
Composition.section[9].text[0].div[0]
Patient name

Prefix: Mr

Given Name: Richard

Family Name: Smith

Date of birth1 January 1957
GenderMale
NHS number1352465790
Patient address

Address Line: 21, Grove Street, Overtown

City: Leeds

Post Code: LS21 1PF

Composition.section[9].entry[0].reference[0]urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5
Composition.section[10].title[0]Person completing record
Composition.section[10].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[10].code[0].coding[0].code[0]person-completing-record
Composition.section[10].code[0].coding[0].display[0]Person completing record
Composition.section[10].text[0].status[0]generated
Composition.section[10].text[0].div[0]
Name

Prefix: Dr

Given Name: Paul

Family Name: Rastall

Composition.section[10].entry[0].reference[0]urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb
Composition.section[11].title[0]Plan and requested actions
Composition.section[11].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[11].code[0].coding[0].code[0]plan-and-requested-actions
Composition.section[11].code[0].coding[0].display[0]Plan and requested actions
Composition.section[11].text[0].status[0]additional
Composition.section[11].text[0].div[0]
Action

Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of his chest pain on 12 February 2015.

Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's University Hospital Accident and Emergency Department)

Status: Completed

Outcome: Patient expects to find out the more information about the reasons for his chest pain when tests are carried out after admission.

Composition.section[12].title[0]Presenting complaints or issues
Composition.section[12].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[12].code[0].coding[0].code[0]presenting-complaints-or-issues
Composition.section[12].code[0].coding[0].display[0]Presenting complaints or issues
Composition.section[12].text[0].status[0]generated
Composition.section[12].text[0].div[0]
Presenting complaints or issueChest pain
Composition.section[12].entry[0].reference[0]urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f
Composition.section[13].title[0]Procedures
Composition.section[13].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[13].code[0].coding[0].code[0]procedures
Composition.section[13].code[0].coding[0].display[0]Procedures
Composition.section[13].text[0].status[0]additional
Composition.section[13].text[0].div[0]
Procedure nameElectrocardiographic monitoring
CommentECGs showed inferior ischaemic changes.
Composition.section[13].entry[0].reference[0]urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1
Composition.section[14].title[0]Referrer details
Composition.section[14].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[14].code[0].coding[0].code[0]referrer-details
Composition.section[14].code[0].coding[0].display[0]Referrer details
Composition.section[14].text[0].status[0]additional
Composition.section[14].text[0].div[0]
Referrer detailsSelf-referral to accident and emergency department
Composition.section[15].title[0]Senior reviewing clinician
Composition.section[15].code[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings
Composition.section[15].code[0].coding[0].code[0]senior-reviewing-clinician
Composition.section[15].code[0].coding[0].display[0]Senior reviewing clinician
Composition.section[15].text[0].status[0]generated
Composition.section[15].text[0].div[0]
Name

Prefix: Mr

Family Name: Abacus

Composition.section[15].entry[0].reference[0]urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9

XML View

<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 &amp; Emergency Discharge summary" />
    <!-- Identifies the organisation responsible for ongoing maintenance of and 
access to the composition/document information. -->
    <custodian>
        <reference value="urn:uuid:120633ae-1a20-4e0e-b807-b78fb59679cc" />
    </custodian>
    <!-- Allergies and adverse reactions -->
    <section>
        <title value="Allergies and adverse reaction" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="allergies-and-adverse-reaction" />
                <display value="Allergies and adverse reaction" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Causative agent</th><td>Penicillin -class of antibiotic</td></tr><tr><th>Description of reaction</th><td>Eruption due to drug</td></tr><tr><th>Severity</th><td>Mild</td></tr><tr><th>Certainty</th><td>Certain</td></tr><tr><th>Comment</th><td>No swelling</td></tr></tbody></table></div>
        </text>
        <!-- Reference to Allergies List as the source of information for this section -->
        <entry>
            <reference value="urn:uuid:b37c89af-c5da-425f-8e6d-58c043ccf94b" />
        </entry>
    </section>
    <!-- Attendance details -->
    <section>
        <title value="Attendance details" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="attendance-details" />
                <display value="Attendance details" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Date and time of contact</th><td>12-Feb-2015 07:00</td></tr></tbody></table></div>
        </text>
    </section>
    <!-- Clinical narrative -->
    <section>
        <title value="Clinical narrative" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="clinical-narrative" />
                <display value="Clinical narrative" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Clinical narrative</th></tr><tr><td><p>60 year old man complaining of chest pain lasting around 2 hours.</p><p>Examination unremarkable.</p><p>Inferior ischaemic changes on ECG.</p></td></tr></tbody></table><table><tbody><tr><td><pre>
Full Blood Count 

TestValueUnitsReference Range
White Cell Count11.1x10*9/L3.5 - 10.0
Red Cell Count5.0x10*12/L4.25 - 5.75 
Haemoglobin150g/L13.0 - 17.0
Haematocrit0.230L/L0.400 - 0.500
Mean Cell Volume90fL84 - 98
Mean Cell Hb33.0pg27.5 - 32.0
Mean Cell Hb Con34.0pg31.0 - 35.0
RDW12.0%&lt; 14.5
Platelet Count300x10*9/L150 - 400

Machine Differential 

TestValueUnitsReference Range
Neutrophils7.0x10*9/L1.7 - 7.5
Lymphocytes3.5x10*9/L1.0 - 3.5
Monocytes0.3x10*9/L&lt; 0.6
Eosinophils0.4x10*9/L&lt; 0.4
Basophils0.1x10*9/L&lt; 0.1
LUCs0.2x10*9/L&lt; 0.4
                                </pre></td></tr></tbody></table></div>
        </text>
    </section>
    <!-- Contact for further information -->
    <section>
        <title value="Contact for further information" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="contact-for-further-information" />
                <display value="Contact for further information" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Contact for further information</th><td>Dr Paul Rastall Tel: 0113 6323200</td></tr></tbody></table></div>
        </text>
    </section>
    <!-- Diagnoses -->
    <section>
        <title value="Diagnoses" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="diagnoses" />
                <display value="Diagnoses" />
            </coding>
        </code>
        <text>
            <status value="generated" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Acute ST segment elevation myocardial infarction</td></tr></tbody></table></div>
        </text>
        <!-- Reference to information in the Condition list resource -->
        <entry>
            <reference value="urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" />
        </entry>
    </section>
    <!-- Discharge details -->
    <section>
        <title value="Discharge details" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="discharge-details" />
                <display value="Discharge details" />
            </coding>
        </code>
        <text>
            <status value="extensions" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Discharge status</th><td>Streamed from emergency department to urgent care service following initial assessment</td></tr><tr><th>Date/time of discharge</th><td>12-Feb-2015 08:00</td></tr><tr><th>Discharge destination</th><td>NHS other Hospital Provider - Ward for general Patients or the younger physically disabled</td></tr></tbody></table></div>
        </text>
        <!-- Reference to the Encounter entry as the source of information for this section -->
        <entry>
            <reference value="urn:uuid:9a20cb92-354a-4015-82ec-ab0252efc5b9" />
        </entry>
    </section>
    <!--  GP Practice -->
    <section>
        <title value="GP practice" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="general-practitioner-practice" />
                <display value="General practitioner practice" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>GP name</th><td><p>Prefix: Dr</p><p>Given Name: John</p><p>Family Name: Lorenzo</p></td></tr><tr><th>GP practice details</th><td><p>Name: MGP Medical Centre</p><p>Address:</p><p>Address Line: 1 MGP House, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 7PA</p></td></tr></tbody></table></div>
        </text>
        <!-- Reference to the Organisation entry as the source of information for this section -->
        <entry>
            <reference value="urn:uuid:e4058bb2-bf1a-47a4-ab10-1471161380a1" />
        </entry>
    </section>
    <!--  Information and advice given -->
    <section>
        <title value="Information and advice given" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="information-and-advice-given" />
                <display value="Information and advice given" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Information and advice given</th><td>Patient advised to be admitted to ward for further tests after ECG results 
showed inferior ischaemic changes.</td></tr></tbody></table></div>
        </text>
    </section>
    <!-- Medications and medical devices -->
    <section>
        <title value="Medications and medical devices" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="medications-and-medical-devices" />
                <display value="Medications and medical devices" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Medication name</th><td>Ramipril 2.5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>One 2.5mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Aspirin 75mg tablets (Sigma Pharmaceuticals Plc)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 75mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Simvastatin 40mg tablets (Brown &amp; Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width="100%"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>
        </text>
        <!-- Reference to medication list -->
        <entry>
            <reference value="urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca" />
        </entry>
    </section>
    <!--  Patient demographics -->
    <section>
        <title value="Patient demographics" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="patient-demographics" />
                <display value="Patient demographics" />
            </coding>
        </code>
        <text>
            <status value="generated" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div>
        </text>
        <!-- reference to further information carried in the patient resource -->
        <entry>
            <reference value="urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5" />
        </entry>
    </section>
    <!-- Person completing record -->
    <section>
        <title value="Person completing record" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="person-completing-record" />
                <display value="Person completing record" />
            </coding>
        </code>
        <text>
            <status value="generated" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div>
        </text>
        <!-- Reference to the practitioner entry as the source of information for this section -->
        <entry>
            <reference value="urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb" />
        </entry>
    </section>
    <!-- Plan and requested actions -->
    <section>
        <title value="Plan and requested actions" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="plan-and-requested-actions" />
                <display value="Plan and requested actions" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of 
his chest pain on 12 February 2015.</p><p>Person responsible: Dr. Paul Rastall (Accident and Emergency Consultant, St. James's 
University Hospital Accident and Emergency Department)</p><p>Status: Completed</p><p>Outcome: Patient expects to find out the more information about the reasons for his 
chest pain when tests are carried out after admission.</p></td></tr></tbody></table></div>
        </text>
    </section>
    <!-- Presenting complaints or issues -->
    <section>
        <title value="Presenting complaints or issues" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="presenting-complaints-or-issues" />
                <display value="Presenting complaints or issues" />
            </coding>
        </code>
        <text>
            <status value="generated" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Presenting complaints or issue</th><td>Chest pain</td></tr></tbody></table></div>
        </text>
        <!-- Reference to information in the Condition list resource -->
        <entry>
            <reference value="urn:uuid:0a46351b-bfe1-4085-956e-15d3b172e36f" />
        </entry>
    </section>
    <!-- Procedures -->
    <section>
        <title value="Procedures" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="procedures" />
                <display value="Procedures" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Procedure name</th><td>Electrocardiographic monitoring</td></tr><tr><th>Comment</th><td>ECGs showed inferior ischaemic changes.</td></tr></tbody></table></div>
        </text>
        <!-- reference to further information carried in the procedure list resource -->
        <entry>
            <reference value="urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1" />
        </entry>
    </section>
    <!-- Referrer details -->
    <section>
        <title value="Referrer details" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="referrer-details" />
                <display value="Referrer details" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Referrer details</th><td>Self-referral to accident and emergency department</td></tr></tbody></table></div>
        </text>
    </section>
    <!-- Senior reviewing clinician -->
    <section>
        <title value="Senior reviewing clinician" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="senior-reviewing-clinician" />
                <display value="Senior reviewing clinician" />
            </coding>
        </code>
        <text>
            <status value="generated" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Name</th><td><p>Prefix: Mr</p><p>Family Name: Abacus</p></td></tr></tbody></table></div>
        </text>
        <!-- reference to further information carried in the practitioner resource -->
        <entry>
            <reference value="urn:uuid:d25fd1c6-2658-4db7-9af0-86c5f95e8ec9" />
        </entry>
    </section>
</Composition>

JSON View

{
    "resourceType": "Composition",
    "id": "UKCore-Composition-Discharge-Example",
    "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%&lt; 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&lt; 0.6\nEosinophils0.4x10*9/L&lt; 0.4\nBasophils0.1x10*9/L&lt; 0.1\nLUCs0.2x10*9/L&lt; 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 &amp; Burk UK Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 40mg tablet once a day.</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Medication name</th><td>Bisoprolol 5mg tablets (A A H Pharmaceuticals Ltd)</td></tr><tr><th>Form</th><td>Tablet</td></tr><tr><th>Route</th><td>Oral</td></tr><tr><th>Dose directions description</th><td>Take one 5mg tablet daily.</td></tr><tr><th>Comment/recommendation</th><td>Recommend Uptitrate according to BP and HR</td></tr><tr><th>Status</th><td>Continued</td></tr></tbody></table></div>"
            },
            "entry":  [
                {
                    "reference": "urn:uuid:e3c8b45f-22d4-4ce6-970c-10a959831dca"
                }
            ]
        },
        {
            "title": "Patient demographics",
            "code": {
                "coding":  [
                    {
                        "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                        "code": "patient-demographics",
                        "display": "Patient demographics"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Patient name</th><td><p>Prefix: Mr</p><p>Given Name: Richard</p><p>Family Name: Smith</p></td></tr><tr><th>Date of birth</th><td>1 January 1957</td></tr><tr><th>Gender</th><td>Male</td></tr><tr><th>NHS number</th><td>1352465790</td></tr><tr><th>Patient address</th><td><p>Address Line: 21, Grove Street, Overtown</p><p>City: Leeds</p><p>Post Code: LS21 1PF</p></td></tr></tbody></table></div>"
            },
            "entry":  [
                {
                    "reference": "urn:uuid:c8225cc8-8026-466f-80f8-fc2832a4b9d5"
                }
            ]
        },
        {
            "title": "Person completing record",
            "code": {
                "coding":  [
                    {
                        "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                        "code": "person-completing-record",
                        "display": "Person completing record"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Name</th><td><p>Prefix: Dr</p><p>Given Name: Paul</p><p>Family Name: Rastall</p></td></tr></tbody></table></div>"
            },
            "entry":  [
                {
                    "reference": "urn:uuid:369d88a8-9f6b-407f-8560-6ee9d7ccc8bb"
                }
            ]
        },
        {
            "title": "Plan and requested actions",
            "code": {
                "coding":  [
                    {
                        "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                        "code": "plan-and-requested-actions",
                        "display": "Plan and requested actions"
                    }
                ]
            },
            "text": {
                "status": "additional",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Action</th><td><p>Patient has agreed to be admitted to Cramer ward for further tests to investigate causes of \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"
                }
            ]
        }
    ]
}

back to top