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Transaction: Provisional discharge letter

STATUS:

Published

OWNER:

eHealth Platform

STANDARD:

KMEHR

VERSION:

1.0

DATE:

2002-10-15

DEFINITION:

The provisional discharge letter is a quick summary of a hospital stay that should normally be followed by a complete discharge letter.

Generalities

This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).

Transaction elements

id

id of the transaction according to the ID-KMEHR conventions.

cd

You must use the value ‘quickdischargereport’ from CD-TRANSACTION. You can always add your own local codes.

date

This is the date of reporting.

time

This is the time of reporting.

author

This is the person assuming the responsibility of medical content of the letter.

iscomplete

If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later.

isvalidated

If this is false, this means that the information has not been validated medically.

Structure overview

You have the choice between:

  • text(s): to transfer your letter as free text,
  • lnk(s): to encapsulate your letter as a multimedia object (Word document for example),
  • heading(s) and/or item(s): to further structure your letter.

Headings

We recommend the use of the following headings from CD-HEADING.

history

Patient's history (antecedents)

clinical

Clinical investigation (including patient's complaints)

technical

Technical investigation

assessment

Current diagnoses and hypotheses

clinicalplan

Clinical plan of action

technicalplan

Technical plan of action

treatment

Proposed treatment

Each heading can contain:

  • text(s): to transfer your paragraph as free text,
  • lnk(s): to encapsulate your paragraph as a multimedia object (Word document for example),
  • item(s): to further structure your paragraph.


Items

Most items of CD-ITEM are useful. A few items are more specific for the discharge letter.

Item type (cd)

Item purpose

Item structure

encounternumber

your local admission number

Any national standard dictionary could be used to code the content of the items but at this stage of the specification, we recommend to transfer the content of the items as free text.

encountertype

hospitalisation, emergency, etc ...

encounterdatetime

admission date and time

encounterlocation

to document institution, site, unit, room and bed

encounterresponsible

responsible of the encounter (can be used to identify the individual and/or the medical department in charge of the patient)

transactionreason

reason for admission

encounterorigin

origin of the patient before admission (ambulance, home, ...)

referrer

the type of entity that referred the patient to the organisation

admissiontype

type of admission process: (planned admission, emergency, ...)

dischargedatetime

date and time of the death

dischargetype

the type of discharge

dischargedestination

the destination after discharge

healthissue

to specify current problem(s), diagnoses, hypotheses but also antecedents.

allergy

allergy

adr

adverse drug reaction

vaccine

vaccine administration

medication

pharmaceutical treatment

treatment

treatment other than pharmaceutical

habits

usage of alcohol, tobacco, drug, ...

complaint

patient's complaint

clinical

results of clinical investigations

technical

results of technical investigations

risk factor

like communicable disease, work hazard, ...

socialrisk

like unemployed, junkie, ...
Name XML
quickdischargereport_1_0 xml