HL7 Czech Hospital Discharge Report Implementation Guide, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.0.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/hdr/ and changes regularly. See the Directory of published versions
Domovská stránka
Úvod
Příručka stanovuje sadu pravidel, která budou použita pro HL7 FHIR k definování způsobu reprezentace propouštěcí zprávy z nemocnice v českém národním kontextu, v souladu s evropskými směrnicemi eHN.
Hlavním cílem je definovat obsahové složky a preferovanou strukturu pro sestavení propouštěcí zprávy z nemocnice. Účelem tohoto standardu je definovat reprezentaci propouštěcí zprávy jako součásti zdravotnické dokumentace pacienta za účelem elektronické výměny zdravotních informací mezi jednotlivci, poskytovateli zdravotní péče a infrastrukturou v České republice.
Toto zahrnuje jak národní, tak přeshraniční scénáře.
Tato příručka nepopisuje, jak tuto zprávu elektronicky vyměňovat.
Fig. 1: Struktura propouštěcí zprávy
Základní sekce propouštěcí zprávy z nemocnice
Rozsah
Tento dokument představuje koncepty českého použití definované prostřednictvím FHIR artefaktů, které lze strojově zpracovat. Jedná se o výsledky spolupráce, ve kterých byly dohodnuty přístupy k různým typům zdravotnických informací, vycházející ze základní specifikace FHIR R4.
Tato příručka je rozdělena do několika stránek, které jsou uvedeny v horní části každé stránky v nabídce:
- Home: Tato stránka poskytuje úvod a rozsah této příručky.
- Artifacts: Tato stránka uvádí podrobné popisy a formální definice všech českých HDR artefaktů a logického modelu definovaného v této příručce.
Závislosti
Package hl7.fhir.uv.extensions.r4#5.2.0
This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Mon, Feb 10, 2025 21:45+1100+11:00)
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Package hl7.fhir.uv.ips#1.1.0
International Patient Summary (IPS) FHIR Implementation Guide (built Tue, Nov 22, 2022 03:24+0000+00:00)
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Package hl7.fhir.eu.extensions.r4#current
This guide lists the extensions speciifed for the European REALM. (built Wed, Apr 23, 2025 06:27+0000+00:00)
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Package hl7.fhir.eu.base#current
This guide collects base and core profiles to be used in the European context. It also includes common artifacts, such as the profiles describing the European Health Insurance Card. (built Sun, May 4, 2025 13:55+0000+00:00)
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Package hl7.fhir.cz.terminology#current
HL7 Czech Terminology Implementation Guide (built Thu, Jul 10, 2025 11:16+0000+00:00)
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Package hl7.fhir.cz.core#current
HL7 Czech Base and Core Resources Implementation Guide (built Fri, Jul 18, 2025 09:01+0000+00:00)
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Package hl7.fhir.eu.extensions.r4#0.1.1-ballot
This guide lists the extensions speciifed for the European REALM. (built Wed, Apr 30, 2025 13:56+0200+02:00)
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Package hl7.fhir.eu.laboratory#0.1.1
This guide describes how the Laboratory Report can be represented in the European REALM. (built Tue, Mar 25, 2025 12:00+0100+01:00)
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Package hl7.fhir.eu.base#0.1.0-ballot
This guide collects base and core profiles to be used in the European context. It also includes common artifacts, such as the profiles describing the European Health Insurance Card. (built Mon, May 5, 2025 21:42+0200+02:00)
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Package ihe.pharm.mpd.r4#1.0.0-comment-2
ImplementationGuide for IHE Pharmacy Medication Prescription and Dispense (MPD) profile (built Tue, May 27, 2025 16:32+0200+02:00)
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Package hl7.fhir.eu.hdr#current
This implementation guide specifies the Hospital Discharge Report in the European context, as defined in eHN Hospital Discharge Report guidelines. (built Sun, Jun 1, 2025 06:10+0000+00:00)
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Package hl7.fhir.eu.extensions#current
This guide lists the extensions speciifed for the European REALM. (built Wed, Apr 23, 2025 06:27+0000+00:00)
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Package hl7.fhir.eu.laboratory#current
This guide describes how the Laboratory Report can be represented in the European REALM. (built Wed, Jul 2, 2025 14:40+0000+00:00)
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Package ihe.pharm.mpd#current
ImplementationGuide for IHE Pharmacy Medication Prescription and Dispense (MPD) profile (built Mon, Jun 9, 2025 07:25+0000+00:00)
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Package hl7.fhir.cz.lab#current
Czech Laboratory Implementation Guide (built Tue, Jul 1, 2025 07:12+0000+00:00)
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Package hl7.fhir.cz.img-order#current
HL7 Czech Imaging Order Implementation Guide (built Fri, Jul 18, 2025 09:01+0000+00:00)
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Package hl7.fhir.eu.extensions#0.1.1-ballot
This guide lists the extensions speciifed for the European REALM. (built Wed, Apr 30, 2025 13:56+0200+02:00)
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Package hl7.fhir.cz.img#current
Czech Imaging Report Implementation Guide (built Fri, Jul 18, 2025 09:00+0000+00:00)
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Analýza mezi verzemi
This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B} systems. Packages for both R4 (hl7.fhir.cz.hdr.r4) and R4B (hl7.fhir.cz.hdr.r4b) are available.
Prohlášení k právům duševního vlastnictví
This publication includes IP covered under the following statements.
- Copyright HL7. Licensed under creative commons public domain
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- ISO maintains the copyright on the country codes, and controls its use carefully. For further details see the ISO 3166 web page: https://www.iso.org/iso-3166-country-codes.html
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- The UCUM codes, UCUM table (regardless of format), and UCUM Specification are copyright 1999-2009, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved. https://ucum.org/trac/wiki/TermsOfUse
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- Unified Code for Units of Measure (UCUM): Bundle/DischargeBundle-Novak-Petr, Observation/ExampleAbdominalCircumference... Show 11 more, Observation/ExampleBMI, Observation/ExampleBloodPressure, Observation/ExampleChestCircumference, Observation/ExampleHeadCircumference, Observation/ExampleHeight, Observation/ExampleWeight, Observation/hb-result, Observation/hct-result, Observation/plt-result, Observation/rbc-result and Observation/wbc-result
- This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.
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- LOINC: Bundle/DischargeBundle-Novak-Petr, CZ_CompositionHdr... Show 25 more, CZ_ImmunizationRecommendationHdr, CZ_ObservationAbdominalCircumferenceHdr, CZ_ObservationBMIHdr, CZ_ObservationChestCircumferenceHdr, CZ_ObservationHeadCircumferenceHdr, CZ_ObservationHeightHdr, CZ_ObservationSdohHdr, CZ_ObservationTravelHdr, CZ_ObservationWeightHdr, Composition/cdae7735-f7ee-4bc7-9cf3-3dc806a4eaaf, DocumentReference/DischargeDocumenPDF, DocumentReference/DischargeDocumentHTML, Observation/CZObservationSdohHdrExample, Observation/ExampleAbdominalCircumference, Observation/ExampleBMI, Observation/ExampleBloodPressure, Observation/ExampleChestCircumference, Observation/ExampleHeadCircumference, Observation/ExampleHeight, Observation/ExampleWeight, Observation/Observation-CRP-Novak, Observation/Observation-DischargeCondition, Observation/Observation-InfectiousContact, Observation/Observation-TravelHistory-Madagaskar and Observation/Observation-UZV-Novak
- This material contains content that is copyright of SNOMED International. Implementers of these specifications must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/get-snomed or info@snomed.org.
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- SNOMED Clinical Terms® (SNOMED CT®): AllergyIntolerance/Allergy-Strawberry-Novak, AllergyIntolerance/AllergyInfoUnknown... Show 57 more, AllergyIntolerance/MilkAllergy, AllergyIntolerance/NoKnownAllergy, AllergyIntolerance/PenicillinAllergy, AllergyIntolerance/StrawberryAllergy, Bundle/DischargeBundle-Novak-Petr, CZConsentCategory, CZProvisionCode, CZ_ConditionHdr, CZ_ConsentHdr, CZ_DeviceUseStatementHdr, CZ_EncounterHdr, CZ_FamilyMemberHistoryHdr, CZ_ImmunizationHdr, CZ_ImmunizationRecommendationHdr, CZ_ObservationInfectiousContactHdr, CZ_ObservationSdohHdr, CZ_ProcedureHdr, Condition/AngiodysplasiaCondition, Condition/AtrialFibrillationCondition, Condition/CZ-Condition-HDR-Example, Condition/CZ-Condition-HDR-Example-2, Condition/CZ-Condition-HDR-Example-3, Condition/Condition-E890-Novak, Condition/Condition-K409, Condition/HypercholesterolemiaCondition, Condition/HypothyroidismCondition, Condition/IronDeficiencyAnemiaCondition, Condition/OsteoporosisCondition, Condition/PresbycusisCondition, Condition/TIACondition, Condition/VaricoseVeinsCondition, Device/Device-Pacemaker, DeviceUseStatement/DeviceUseStatement-Pacemaker, EHDSIConditionPOA, EHDSITreatmentClass, Encounter/CZ-Encounter-HDR-Example, Immunization/Immunization, ImmunizationRecommendation/ImmunizationRecommendation, Observation/CZObservationSdohHdrExample, Observation/ExampleSdohAlcohol, Observation/ExampleSdohAlcoholSporadic, Observation/ExampleSdohSmoking, Observation/ExampleSdohSmokingEnded, Observation/Observation-DischargeCondition, Observation/Observation-InfectiousContact, Patient/3f85726c-ad2f-441b-89ce-100000000000, Patient/Mracena2, PractitionerRole/Practitioner-Author-detail, PractitionerRole/Practitioner-Referrer-detail, PractitionerRole/practitionerrole1, Procedure/CZ-Procedure-HDR-Example-Acute-appendicitis, Procedure/ColonoscopyProcedure, Procedure/Procedure-Appendectomy, Procedure/Procedure-Insert-Pacemaker, Procedure/Procedure-Insert-Pacemaker2, Procedure/Procedure-inguinal-hernia and Specimen/Specimen-EDTA-1
- This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
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- Admit source: Encounter/CZ-Encounter-HDR-Example
- AllergyIntolerance Clinical Status Codes: AllergyIntolerance/Allergy-Strawberry-Novak, AllergyIntolerance/MilkAllergy... Show 4 more, AllergyIntolerance/NoKnownAllergy, AllergyIntolerance/PenicillinAllergy, AllergyIntolerance/StrawberryAllergy and Bundle/DischargeBundle-Novak-Petr
- AllergyIntolerance Verification Status: AllergyIntolerance/Allergy-Strawberry-Novak, AllergyIntolerance/MilkAllergy... Show 4 more, AllergyIntolerance/NoKnownAllergy, AllergyIntolerance/PenicillinAllergy, AllergyIntolerance/StrawberryAllergy and Bundle/DischargeBundle-Novak-Petr
- Condition Category Codes: Condition/AngiodysplasiaCondition, Condition/AtrialFibrillationCondition... Show 8 more, Condition/CZ-Condition-HDR-Example, Condition/HypercholesterolemiaCondition, Condition/HypothyroidismCondition, Condition/IronDeficiencyAnemiaCondition, Condition/OsteoporosisCondition, Condition/PresbycusisCondition, Condition/TIACondition and Condition/VaricoseVeinsCondition
- Condition Clinical Status Codes: CZ_ConditionHdr, Condition/AngiodysplasiaCondition... Show 8 more, Condition/AtrialFibrillationCondition, Condition/HypercholesterolemiaCondition, Condition/HypothyroidismCondition, Condition/IronDeficiencyAnemiaCondition, Condition/OsteoporosisCondition, Condition/PresbycusisCondition, Condition/TIACondition and Condition/VaricoseVeinsCondition
- ConditionVerificationStatus: CZ_ConditionHdr, Condition/AngiodysplasiaCondition... Show 8 more, Condition/AtrialFibrillationCondition, Condition/HypercholesterolemiaCondition, Condition/HypothyroidismCondition, Condition/IronDeficiencyAnemiaCondition, Condition/OsteoporosisCondition, Condition/PresbycusisCondition, Condition/TIACondition and Condition/VaricoseVeinsCondition
- Consent Scope Codes: Bundle/DischargeBundle-Novak-Petr and Consent/CZ-AdvanceDirectives-HDR-DNR
- Diagnosis Role: Encounter/CZ-Encounter-HDR-Example
- Discharge disposition: Bundle/DischargeBundle-Novak-Petr, Encounter/CZ-Encounter-HDR-Example and Encounter/HospitalEncounter-Novak-Petr
- Encounter type: Encounter/CZ-Encounter-HDR-Example
- Immunization Recommendation Status Codes: ImmunizationRecommendation/ImmunizationRecommendation
- Observation Category Codes: Bundle/DischargeBundle-Novak-Petr, CZ_ObservationSdohHdr... Show 11 more, Observation/CZObservationSdohHdrExample, Observation/ExampleBloodPressure, Observation/ExampleSdohAlcohol, Observation/ExampleSdohAlcoholSporadic, Observation/ExampleSdohSmoking, Observation/ExampleSdohSmokingEnded, Observation/Observation-CRP-Novak, Observation/Observation-DischargeCondition, Observation/Observation-UZV-Novak, Observation/bloodcount-panel and Observation/hb-result
- identifierType: Patient/Mracena2
- ActClass: CZ_ObservationInfectiousContactHdr
- ActCode: Bundle/DischargeBundle-Novak-Petr, CZ_EncounterHdr, Encounter/CZ-Encounter-HDR-Example, Encounter/HospitalEncounter and Encounter/HospitalEncounter-Novak-Petr
- ActPriority: CZ_EncounterHdr
- ObservationInterpretation: Bundle/DischargeBundle-Novak-Petr, Observation/Observation-CRP-Novak... Show 6 more, Observation/Observation-DischargeCondition, Observation/hb-result, Observation/hct-result, Observation/plt-result, Observation/rbc-result and Observation/wbc-result
- ParticipationType: CZ_EncounterHdr, CZ_ObservationInfectiousContactHdr and Encounter/CZ-Encounter-HDR-Example
- RoleCode: Bundle/DischargeBundle-Novak-Petr, Patient/3f85726c-ad2f-441b-89ce-100000000000 and Patient/Mracena2