FHIR Implementation Guide for ABDM
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This page is part of the FHIR Implementation Guide for ABDM (v6.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example Bundle: DischargeSummary-example-04

ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)

Generated Narrative: Composition

Resource Composition "f1ab8bba-a0ed-476a-a902-a1e08517020b" Version "1" Updated "2020-07-09 15:32:26+0530" (Language "en-IN")

Profile: DischargeSummaryRecord

Security Labels:

status: FINAL

type: Discharge Summary (SNOMED CT#373942005 "Discharge summary")

encounter: See above (urn:uuid:1d87ab20-8b86-4b41-a30d-984b2208d945: Encounter)

date: 2020-07-09 15:32:26+0530

author: See above (urn:uuid:dc36f7c9-7ea5-4984-a02e-7102c215db17: Practitioner)

title: Discharge Summary

custodian: See above (urn:uuid:f7941403-b480-48b3-985a-ec4b6b04c1c2: Organization)


Chief complaints

Medical History

Investigations

Procedures

Medications

Care Plan

Document Reference


Additional Document Content


2. urn:uuid:dc36f7c9-7ea5-4984-a02e-7102c215db17 (Practitioner/dc36f7c9-7ea5-4984-a02e-7102c215db17)

Generated Narrative: Practitioner

Resource Practitioner "dc36f7c9-7ea5-4984-a02e-7102c215db17" Version "1" Updated "2020-07-09 15:32:26+0530"

Profile: Practitioner

identifier: Medical License number/21-1521-3828-3227

name: DEF


3. urn:uuid:f7941403-b480-48b3-985a-ec4b6b04c1c2 (Organization/f7941403-b480-48b3-985a-ec4b6b04c1c2)

Generated Narrative: Organization

Resource Organization "f7941403-b480-48b3-985a-ec4b6b04c1c2"

Profile: Organization

identifier: Provider number/4567823

name: UVW Hospital

Contacts

-Telecom
*+91 273 2139 3632, contact@facility.uvw.org


4. urn:uuid:17d60df2-7d6d-455a-8046-2d8680bce946 (Organization/17d60df2-7d6d-455a-8046-2d8680bce946)

Generated Narrative: Organization

Resource Organization "17d60df2-7d6d-455a-8046-2d8680bce946"

Profile: Organization

identifier: Provider number/4567878

name: XYZ Lab Pvt.Ltd.

Contacts

-Telecom
*+91 243 2634 1234, contact@labs.xyz.org


5. urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41 (Patient/f8d9e19e-5598-428c-ae03-b1cd44968b41)

ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)


6. urn:uuid:1d87ab20-8b86-4b41-a30d-984b2208d945 (Encounter/1d87ab20-8b86-4b41-a30d-984b2208d945)

Not done yet


7. urn:uuid:9c1e7930-caec-4cce-bece-581fce5e2f17 (Appointment/9c1e7930-caec-4cce-bece-581fce5e2f17)

Generated Narrative: Appointment

Resource Appointment "9c1e7930-caec-4cce-bece-581fce5e2f17"

Profile: Appointment

status: BOOKED

serviceCategory: General medical practice (SNOMED CT#408443003)

serviceType: Consultation (SNOMED CT#11429006)

appointmentType: Follow-up visit (SNOMED CT#185389009)

description: Discussion on the results of your recent Lab Test and further consultation

start: 12-Jul-2020, 2:30:00 pm

end: 12-Jul-2020, 3:00:00 pm

created: 2020-07-09 14:58:58+0530

participant

actor: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)

status: ACCEPTED

participant

actor: See above (urn:uuid:dc36f7c9-7ea5-4984-a02e-7102c215db17: Practitioner)

status: ACCEPTED


8. urn:uuid:b650b103-5eee-43c3-b53a-228872e77488 (Condition/b650b103-5eee-43c3-b53a-228872e77488)

Generated Narrative: Condition

Resource Condition "b650b103-5eee-43c3-b53a-228872e77488"

Profile: Condition

clinicalStatus: Recurrence (Condition Clinical Status Codes#recurrence)

code: Patient complained about pain in left arm (SNOMED CT#440700005 "History of aortoiliac atherosclerosis")

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)


9. urn:uuid:cefb9cf6-c8ea-4872-b804-a9e415457e8b (Condition/cefb9cf6-c8ea-4872-b804-a9e415457e8b)

Generated Narrative: Condition

Resource Condition "cefb9cf6-c8ea-4872-b804-a9e415457e8b"

Profile: Condition

clinicalStatus: Active (Condition Clinical Status Codes#active)

code: pain in the chest, neck, back or arms, as well as fatigue, lightheadedness, abnormal heartbeat and anxiety. (SNOMED CT#22298006 "Myocardial infarction")

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)


10. urn:uuid:361b2a51-a3cf-4923-8c58-41141ce95ed5 (Specimen/361b2a51-a3cf-4923-8c58-41141ce95ed5)

Generated Narrative: Specimen

Resource Specimen "361b2a51-a3cf-4923-8c58-41141ce95ed5"

Profile: Specimen

type: Serum specimen (SNOMED CT#119364003)

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)

receivedTime: 2015-07-08 06:40:17+0000

Collections

-Collected[x]
*2020-07-08 06:40:17+0000


11. urn:uuid:690adbcf-8d17-4206-bfaa-c7de730d06d7 (DiagnosticReport/690adbcf-8d17-4206-bfaa-c7de730d06d7)

Lipid 1996 panel (Hematology service)

SubjectNot done yet
Reported2020-07-10 11:45:33+1100
Identifier: https://xyz.com/lab/reports/5234342

Report Details

CodeValueReference RangeWhen For
Cholesterol [Mass/volume] in Serum or Plasma156 mg/dL<200.0 mg/dL2020-09-29
Triglyceride [Mass/volume] in Serum or Plasma146.0 mg/dL<150.0 mg/dL2020-09-29
Cholesterol in HDL [Mass/volume] in Serum or Plasma45.0 mg/dL>40.0 mg/dL2020-09-29

Elevated cholesterol/high density lipoprotein ratio

Coded Conclusions :

  • Elevated cholesterol/high density lipoprotein ratio


12. urn:uuid:33ec33a8-5378-4f77-87cc-81ce161cab6f (Observation/33ec33a8-5378-4f77-87cc-81ce161cab6f)

Generated Narrative: Observation

Resource Observation "33ec33a8-5378-4f77-87cc-81ce161cab6f"

Profile: Observation

status: FINAL

code: Cholesterol [Mass/volume] in Serum or Plasma (LOINC#2093-3)

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)

effective: 2020-09-29

performer: See above (urn:uuid:17d60df2-7d6d-455a-8046-2d8680bce946: Organization)

value: 156 mg/dL (Details: SNOMED CT code 258797006 = 'milligram/decilitre')

ReferenceRanges

-High
*200.0 mg/dL (Details: SNOMED CT code 258797006 = 'milligram/decilitre')


13. urn:uuid:7f080c22-0b63-4d3c-9d7f-588729288fbd (Observation/7f080c22-0b63-4d3c-9d7f-588729288fbd)

Generated Narrative: Observation

Resource Observation "7f080c22-0b63-4d3c-9d7f-588729288fbd"

Profile: Observation

status: FINAL

code: Triglyceride [Mass/volume] in Serum or Plasma (LOINC#2571-8)

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)

effective: 2020-09-29

performer: See above (urn:uuid:17d60df2-7d6d-455a-8046-2d8680bce946: Organization)

value: 146.0 mg/dL (Details: SNOMED CT code 258797006 = 'milligram/decilitre')

ReferenceRanges

-High
*150.0 mg/dL (Details: SNOMED CT code 258797006 = 'milligram/decilitre')


14. urn:uuid:16425add-3878-4a6c-a659-a50782be8fa7 (Observation/16425add-3878-4a6c-a659-a50782be8fa7)

Generated Narrative: Observation

Resource Observation "16425add-3878-4a6c-a659-a50782be8fa7"

Profile: Observation

status: FINAL

code: Cholesterol in HDL [Mass/volume] in Serum or Plasma (LOINC#2085-9)

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)

effective: 2020-09-29

performer: See above (urn:uuid:17d60df2-7d6d-455a-8046-2d8680bce946: Organization)

value: 45.0 mg/dL (Details: SNOMED CT code 258797006 = 'milligram/decilitre')

ReferenceRanges

-Low
*40.0 mg/dL (Details: SNOMED CT code 258797006 = 'milligram/decilitre')


15. urn:uuid:201f6c48-c041-4d95-9b28-4e2b4b9144c7 (Procedure/201f6c48-c041-4d95-9b28-4e2b4b9144c7)

Generated Narrative: Procedure

Resource Procedure "201f6c48-c041-4d95-9b28-4e2b4b9144c7"

Profile: Procedure

status: COMPLETED

code: Placement of stent in coronary artery (SNOMED CT#36969009)

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)

complication: Bleeding (SNOMED CT#131148009)


16. urn:uuid:c78d56c3-3602-4bab-b727-6dda59968d18 (Procedure/c78d56c3-3602-4bab-b727-6dda59968d18)

Generated Narrative: Procedure

Resource Procedure "c78d56c3-3602-4bab-b727-6dda59968d18"

Profile: Procedure

status: COMPLETED

code: Coronary artery bypass grafting (SNOMED CT#232717009)

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)


17. urn:uuid:bceda2f2-484f-45f3-8bf1-f8bcd7631f50 (MedicationRequest/bceda2f2-484f-45f3-8bf1-f8bcd7631f50)

Generated Narrative: MedicationRequest

Resource MedicationRequest "bceda2f2-484f-45f3-8bf1-f8bcd7631f50"

Profile: MedicationRequest

status: ACTIVE

intent: ORDER

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: ABC)

authoredOn: 2020-07-09

requester: See above (urn:uuid:dc36f7c9-7ea5-4984-a02e-7102c215db17: DEF)

DosageInstructions

-TextAdditionalInstructionTimingRouteMethod
*One tablet at onceWith or after food (SNOMED CT#311504000)Once per 1 daysOral Route (SNOMED CT#26643006)Swallow (SNOMED CT#421521009)


18. urn:uuid:419b0145-7812-41af-9a6a-8d308e44f3a1 (CarePlan/419b0145-7812-41af-9a6a-8d308e44f3a1)

Generated Narrative: CarePlan

Resource CarePlan "419b0145-7812-41af-9a6a-8d308e44f3a1"

Profile: CarePlan

status: ACTIVE

intent: PLAN

category: Coronary heart disease care plan (SNOMED CT#736368003)

title: Coronary heart disease care plan

description: Treatment of coronary artery and related disease problems

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: ABC)

activity


19. urn:uuid:44486a09-bcad-420b-ba14-b769fafb7f84 (DocumentReference/44486a09-bcad-420b-ba14-b769fafb7f84)

Generated Narrative: DocumentReference

Resource DocumentReference "44486a09-bcad-420b-ba14-b769fafb7f84"

Profile: DocumentReference

status: CURRENT

docStatus: FINAL

type: Discharge Summary (SNOMED CT#373942005)

subject: See above (urn:uuid:f8d9e19e-5598-428c-ae03-b1cd44968b41: Patient)

content

Attachments

-ContentTypeLanguageDataTitleCreation
*application/pdfen-IN(base64 data - 302213 bytes)Discharge Summary2020-07-09 11:46:09+0530