FHIR Implementation Guide for ABDM
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This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: 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

Document Details

Generated Narrative: Bundle Discharge Summary

version: 1; Last updated: 2020-07-09 15:32:26+0530

Profile: DocumentBundle

Security Label: very restricted (Details: Confidentiality code V = 'very restricted')

Final Document at 2020-07-09 15:32:26+0530 by Practitioner for Patient in encounter Encounter


Document Subject

Generated Narrative: Patient f9f172bf-2f32-4bff-9383-9e1652105948

version: 1; Last updated: 2020-07-09 14:58:58+0530

Profile: Patient

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


Contact Detail+919818512600

Document Content

Chief complaints

Medical History

Investigations

Procedures

Medications

Care Plan

Document Reference


Additional Resources Included in Document


Entry 1 - fullUrl = urn:uuid:9233224f-772c-4d4d-82a6-db4fff0c070f

Resource Composition:

Generated Narrative: Composition 9233224f-772c-4d4d-82a6-db4fff0c070f

version: 1; Last updated: 2020-07-09 15:32:26+0530; Language: en-IN

Profile: DischargeSummaryRecord

Security Label: N (Details: [not stated] code N)

status: Final

type: Discharge Summary

encounter: Encounter

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

author: Practitioner

title: Discharge Summary

custodian: Organization


Entry 2 - fullUrl = urn:uuid:99d0674e-0520-4db6-b5ba-9345e082a620

Resource Practitioner:

Generated Narrative: Practitioner 99d0674e-0520-4db6-b5ba-9345e082a620

version: 1; Last updated: 2020-07-09 15:32:26+0530

Profile: Practitioner

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

name: DEF


Entry 3 - fullUrl = urn:uuid:920b1d0d-000c-458c-952c-9a5e6e9a5603

Resource Organization:

Generated Narrative: Organization 920b1d0d-000c-458c-952c-9a5e6e9a5603

identifier: Provider number/4567823

name: UVW Hospital

contact

telecom: +91 273 2139 3632, contact@facility.uvw.org


Entry 4 - fullUrl = urn:uuid:991eb642-d1ed-4487-8c95-eb80ac4fcd5f

Resource Organization:

Generated Narrative: Organization 991eb642-d1ed-4487-8c95-eb80ac4fcd5f

identifier: Provider number/4567878

name: XYZ Lab Pvt.Ltd.

contact

telecom: +91 243 2634 1234, contact@labs.xyz.org


Entry 5 - fullUrl = urn:uuid:f9f172bf-2f32-4bff-9383-9e1652105948

Resource Patient:

Generated Narrative: Patient f9f172bf-2f32-4bff-9383-9e1652105948

version: 1; Last updated: 2020-07-09 14:58:58+0530

Profile: Patient

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


Contact Detail+919818512600

Entry 6 - fullUrl = urn:uuid:c78ef40f-92ad-4211-bed8-c8211d426c45

Resource Encounter:

Generated Narrative: Encounter c78ef40f-92ad-4211-bed8-c8211d426c45

Last updated: 2020-07-09 14:58:58+0530

Profile: Encounter

identifier: https://ndhm.in/S100

status: completed

class: inpatient encounter

subject: Patient


Entry 7 - fullUrl = urn:uuid:9804b254-2466-42e8-b477-07382096bd03

Resource Appointment:

Generated Narrative: Appointment 9804b254-2466-42e8-b477-07382096bd03

status: Booked

serviceCategory: General medical practice

serviceType: No display for Appointment.serviceType (concept: Consultation)

appointmentType: Follow-up visit

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

start: 2020-07-12 09:00:00+0000

end: 2020-07-12 09:30:00+0000

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

participant

actor: Patient

status: Accepted

participant

actor: Practitioner

status: Accepted


Entry 8 - fullUrl = urn:uuid:65ca507a-efa3-4cfc-b25a-93d139cc5f30

Resource Condition:

Generated Narrative: Condition 65ca507a-efa3-4cfc-b25a-93d139cc5f30

clinicalStatus: Recurrence

code: Patient complained about pain in left arm

subject: Patient


Entry 9 - fullUrl = urn:uuid:b944fff7-425c-4d19-b388-f691623ea59f

Resource Condition:

Generated Narrative: Condition b944fff7-425c-4d19-b388-f691623ea59f

clinicalStatus: Active

code: pain in the chest, neck, back or arms, as well as fatigue, lightheadedness, abnormal heartbeat and anxiety.

subject: Patient


Entry 10 - fullUrl = urn:uuid:c1541dfd-5d57-424e-bb02-4cb5b34f21c9

Resource Specimen:

Generated Narrative: Specimen c1541dfd-5d57-424e-bb02-4cb5b34f21c9

type: Serum specimen

subject: Patient

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

Collections

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

Entry 11 - fullUrl = urn:uuid:e915ec3f-bd37-49bb-95dd-5a0e1457f3be

Resource DiagnosticReport:

Generated Narrative: DiagnosticReport e915ec3f-bd37-49bb-95dd-5a0e1457f3be

Lipid 1996 panel (Hematology service)

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

Report Details

CodeValue

Elevated cholesterol/high density lipoprotein ratio

Coded Conclusions:

  • Elevated cholesterol/high density lipoprotein ratio

Entry 12 - fullUrl = urn:uuid:3a1c7582-1466-43dc-bd62-f150992d4cde

Resource Observation:

Generated Narrative: Observation 3a1c7582-1466-43dc-bd62-f150992d4cde

status: Final

code: Cholesterol [Mass/volume] in Serum or Plasma

subject: Patient

effective: 2020-09-29

performer: Organization

value: 156 mg/dL (Details: SNOMED CT code258797006 = 'milligram/decilitre')

ReferenceRanges

-High
*200 mg/dL (Details: SNOMED CT code258797006 = 'milligram/decilitre')

Entry 13 - fullUrl = urn:uuid:d0862f3d-b64f-4581-af5e-cc85187f742b

Resource Observation:

Generated Narrative: Observation d0862f3d-b64f-4581-af5e-cc85187f742b

status: Final

code: Triglyceride [Mass/volume] in Serum or Plasma

subject: Patient

effective: 2020-09-29

performer: Organization

value: 146 mg/dL (Details: SNOMED CT code258797006 = 'milligram/decilitre')

ReferenceRanges

-High
*150 mg/dL (Details: SNOMED CT code258797006 = 'milligram/decilitre')

Entry 14 - fullUrl = urn:uuid:83981555-85f5-4a35-a05a-d487a1e8271e

Resource Observation:

Generated Narrative: Observation 83981555-85f5-4a35-a05a-d487a1e8271e

status: Final

code: Cholesterol in HDL [Mass/volume] in Serum or Plasma

subject: Patient

effective: 2020-09-29

performer: Organization

value: 45 mg/dL (Details: SNOMED CT code258797006 = 'milligram/decilitre')

ReferenceRanges

-Low
*40 mg/dL (Details: SNOMED CT code258797006 = 'milligram/decilitre')

Entry 15 - fullUrl = urn:uuid:f2c6a5fe-5b67-4579-b53d-40eec7d69661

Resource Procedure:

Generated Narrative: Procedure f2c6a5fe-5b67-4579-b53d-40eec7d69661

status: Completed

code: Placement of stent in coronary artery

subject: Patient

complication: No display for Procedure.complication (concept: Bleeding)


Entry 16 - fullUrl = urn:uuid:76a8100e-f025-4b5f-8ef1-e2506c861e06

Resource Procedure:

Generated Narrative: Procedure 76a8100e-f025-4b5f-8ef1-e2506c861e06

status: Completed

code: Coronary artery bypass grafting

subject: Patient


Entry 17 - fullUrl = urn:uuid:1ab8c0b9-c7de-4325-8352-ea1ff1f399ce

Resource MedicationRequest:

Generated Narrative: MedicationRequest 1ab8c0b9-c7de-4325-8352-ea1ff1f399ce

status: Active

intent: Order

subject: ABC

authoredOn: 2020-07-09

requester: DEF

DosageInstructions

-TextAdditionalInstructionTimingRouteMethod
*One tablet at onceWith or after foodOnce per 1 dayOral RouteSwallow

Entry 18 - fullUrl = urn:uuid:7ad6b011-d717-4e7d-a6a5-43c2d26ba474

Resource CarePlan:

Generated Narrative: CarePlan 7ad6b011-d717-4e7d-a6a5-43c2d26ba474

status: Active

intent: Plan

category: Coronary heart disease care plan

title: Coronary heart disease care plan

description: Treatment of coronary artery and related disease problems

subject: ABC

activity


Entry 19 - fullUrl = urn:uuid:1863138e-1e2b-475a-89bf-e3a9bcb73eaa

Resource DocumentReference:

Generated Narrative: DocumentReference 1863138e-1e2b-475a-89bf-e3a9bcb73eaa

status: Current

docStatus: Final

type: Discharge Summary

subject: Patient

content

Attachments

-ContentTypeLanguageDataTitleCreation
*application/pdfen-IN(base64 data - 402,952 base64 chars)Discharge Summary2020-07-09 11:46:09+0530