987 lines
27 KiB
JSON
987 lines
27 KiB
JSON
{
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"resourceType": "Bundle",
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"id": "discharge-summary-example-01",
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"identifier": {
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"system": "https://nirmitee.io/bundle-ids",
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"value": "f7e8d9c0-b1a2-3456-7890-abcdef012345"
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},
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"type": "document",
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"timestamp": "2026-03-14T16:00:00+05:30",
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"meta": {
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"versionId": "1",
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"lastUpdated": "2026-03-14T16:00:00+05:30",
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentBundle"
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],
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"security": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
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"code": "V",
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"display": "very restricted"
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}
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]
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},
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"entry": [
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{
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"fullUrl": "urn:uuid:composition-ds-01",
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"resource": {
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"resourceType": "Composition",
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"id": "composition-ds-01",
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"meta": {
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/DischargeSummaryRecord"
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]
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},
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"status": "final",
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"type": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "373942005",
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"display": "Discharge summary"
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}
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]
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},
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"subject": {
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"reference": "urn:uuid:patient-ds-01"
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},
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"date": "2026-03-14T16:00:00+05:30",
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"author": [
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{
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"reference": "urn:uuid:practitioner-ds-01"
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}
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],
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"title": "Discharge Summary",
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"custodian": {
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"reference": "urn:uuid:organization-ds-01"
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},
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"encounter": {
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"reference": "urn:uuid:encounter-ds-01"
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},
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"section": [
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{
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"title": "Chief Complaint",
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "422843007",
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"display": "Chief complaint section"
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}
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]
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},
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"entry": [
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{
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"reference": "urn:uuid:condition-ds-chief-01"
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}
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]
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},
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{
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"title": "Admission Diagnosis",
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "148006",
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"display": "Preliminary diagnosis"
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}
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]
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},
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"entry": [
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{
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"reference": "urn:uuid:condition-ds-admission-01"
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}
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]
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},
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{
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"title": "Discharge Diagnosis",
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "397659008",
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"display": "Discharge diagnosis"
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}
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]
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},
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"entry": [
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{
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"reference": "urn:uuid:condition-ds-discharge-01"
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}
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]
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},
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{
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"title": "Procedures",
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "371525003",
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"display": "Clinical procedure report"
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}
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]
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},
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"entry": [
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{
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"reference": "urn:uuid:procedure-ds-01"
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}
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]
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},
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{
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"title": "Discharge Medications",
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "721981007",
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"display": "Medication list"
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}
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]
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},
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"entry": [
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{
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"reference": "urn:uuid:medication-request-ds-01"
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},
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{
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"reference": "urn:uuid:medication-request-ds-02"
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},
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{
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"reference": "urn:uuid:medication-request-ds-03"
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}
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]
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},
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{
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"title": "Follow-Up Instructions",
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "736271009",
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"display": "Follow-up plan"
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}
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]
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},
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"entry": [
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{
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"reference": "urn:uuid:care-plan-ds-01"
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}
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]
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}
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]
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}
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},
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{
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"fullUrl": "urn:uuid:patient-ds-01",
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"resource": {
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"resourceType": "Patient",
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"id": "patient-ds-01",
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"meta": {
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient"
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]
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},
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"identifier": [
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{
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"type": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
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"code": "MR",
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"display": "Medical record number"
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}
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]
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},
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"system": "https://fortishospital.example.in/patient-ids",
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"value": "FH-2026-045678"
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},
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{
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"type": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
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"code": "SB",
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"display": "Social Beneficiary Identifier"
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}
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]
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},
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"system": "https://healthid.ndhm.gov.in",
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"value": "56-7890-1234-5678"
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}
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],
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"name": [
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{
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"use": "official",
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"text": "Sunita Devi Gupta",
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"family": "Gupta",
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"given": [
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"Sunita",
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"Devi"
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]
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}
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],
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"telecom": [
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{
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"system": "phone",
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"value": "+91-9345678901",
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"use": "mobile"
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}
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],
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"gender": "female",
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"birthDate": "1965-09-20",
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"address": [
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{
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"use": "home",
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"text": "78 Sector 15, Gurgaon, Haryana 122001",
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"city": "Gurgaon",
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"district": "Gurgaon",
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"state": "Haryana",
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"postalCode": "122001",
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"country": "IN"
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}
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]
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}
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},
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{
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"fullUrl": "urn:uuid:practitioner-ds-01",
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"resource": {
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"resourceType": "Practitioner",
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"id": "practitioner-ds-01",
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"meta": {
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner"
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]
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},
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"identifier": [
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{
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"type": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
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"code": "MD",
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"display": "Medical License number"
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}
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]
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},
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"system": "https://doctor.ndhm.gov.in",
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"value": "HR-11223"
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}
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],
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"name": [
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{
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"use": "official",
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"text": "Dr. Vikram Singh Chauhan",
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"prefix": [
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"Dr."
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],
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"family": "Chauhan",
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"given": [
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"Vikram",
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"Singh"
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]
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}
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],
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"qualification": [
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{
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "17561000",
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"display": "Cardiologist"
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}
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]
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},
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"issuer": {
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"display": "Haryana Medical Council"
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}
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}
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]
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}
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},
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{
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"fullUrl": "urn:uuid:organization-ds-01",
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"resource": {
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"resourceType": "Organization",
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"id": "organization-ds-01",
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"meta": {
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization"
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]
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},
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"identifier": [
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{
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"type": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
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"code": "PRN",
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"display": "Provider number"
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}
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]
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},
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"system": "https://facility.ndhm.gov.in",
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"value": "IN0610005432"
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}
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],
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"name": "Fortis Memorial Research Institute",
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"telecom": [
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{
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"system": "phone",
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"value": "+91-124-4962222",
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"use": "work"
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}
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],
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"address": [
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{
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"use": "work",
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"text": "Sector 44, Opposite HUDA City Centre, Gurgaon, Haryana 122002",
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"city": "Gurgaon",
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"state": "Haryana",
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"postalCode": "122002",
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"country": "IN"
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}
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]
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}
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},
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{
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"fullUrl": "urn:uuid:encounter-ds-01",
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"resource": {
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"resourceType": "Encounter",
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"id": "encounter-ds-01",
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"status": "finished",
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"class": {
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"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
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"code": "IMP",
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"display": "inpatient encounter"
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},
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"type": [
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{
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "32485007",
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"display": "Hospital admission"
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}
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]
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}
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],
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"subject": {
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"reference": "urn:uuid:patient-ds-01"
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},
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"participant": [
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{
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"type": [
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{
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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"code": "ATND",
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"display": "attender"
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}
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]
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}
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],
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"individual": {
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"reference": "urn:uuid:practitioner-ds-01"
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}
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}
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],
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"period": {
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"start": "2026-03-10T09:00:00+05:30",
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"end": "2026-03-14T14:00:00+05:30"
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},
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"hospitalization": {
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"admitSource": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/admit-source",
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"code": "emd",
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"display": "From accident/emergency department"
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}
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]
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},
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"dischargeDisposition": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/discharge-disposition",
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"code": "home",
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"display": "Home"
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}
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]
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}
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},
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"serviceProvider": {
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"reference": "urn:uuid:organization-ds-01"
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}
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}
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},
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{
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"fullUrl": "urn:uuid:condition-ds-chief-01",
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"resource": {
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"resourceType": "Condition",
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"id": "condition-ds-chief-01",
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"meta": {
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition"
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]
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},
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"clinicalStatus": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
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"code": "active",
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"display": "Active"
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}
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]
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},
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"verificationStatus": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
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"code": "confirmed",
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"display": "Confirmed"
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}
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]
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},
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"category": [
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{
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-category",
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"code": "encounter-diagnosis",
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"display": "Encounter Diagnosis"
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}
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]
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}
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],
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"code": {
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"coding": [
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{
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"system": "http://snomed.info/sct",
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"code": "29857009",
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"display": "Chest pain"
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}
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],
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"text": "Severe retrosternal chest pain radiating to left arm with sweating"
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},
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"subject": {
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"reference": "urn:uuid:patient-ds-01"
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},
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"encounter": {
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"reference": "urn:uuid:encounter-ds-01"
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},
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"onsetDateTime": "2026-03-10T07:30:00+05:30",
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"recordedDate": "2026-03-10T09:00:00+05:30"
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}
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},
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{
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"fullUrl": "urn:uuid:condition-ds-admission-01",
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"resource": {
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"resourceType": "Condition",
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"id": "condition-ds-admission-01",
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"meta": {
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition"
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]
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},
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"clinicalStatus": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
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"code": "active",
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"display": "Active"
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}
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]
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},
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"verificationStatus": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
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"code": "confirmed",
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"display": "Confirmed"
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}
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]
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},
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"category": [
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{
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-category",
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"code": "encounter-diagnosis",
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"display": "Encounter Diagnosis"
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}
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]
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}
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],
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"code": {
|
|
"coding": [
|
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{
|
|
"system": "http://snomed.info/sct",
|
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"code": "22298006",
|
|
"display": "Myocardial infarction"
|
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},
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{
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"system": "http://hl7.org/fhir/sid/icd-10",
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"code": "I21.0",
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"display": "Acute transmural myocardial infarction of anterior wall"
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}
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|
],
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|
"text": "Acute anterior wall STEMI"
|
|
},
|
|
"subject": {
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|
"reference": "urn:uuid:patient-ds-01"
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|
},
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"encounter": {
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"reference": "urn:uuid:encounter-ds-01"
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},
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"onsetDateTime": "2026-03-10T07:30:00+05:30",
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"recordedDate": "2026-03-10T10:00:00+05:30"
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}
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},
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{
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"fullUrl": "urn:uuid:condition-ds-discharge-01",
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"resource": {
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"resourceType": "Condition",
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"id": "condition-ds-discharge-01",
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"meta": {
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"profile": [
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"https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition"
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]
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},
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"clinicalStatus": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
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"code": "resolved",
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"display": "Resolved"
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}
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]
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},
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"verificationStatus": {
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
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"code": "confirmed",
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"display": "Confirmed"
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}
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]
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},
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"category": [
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{
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"coding": [
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{
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"system": "http://terminology.hl7.org/CodeSystem/condition-category",
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"code": "encounter-diagnosis",
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"display": "Encounter Diagnosis"
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}
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]
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}
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],
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"code": {
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"coding": [
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{
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|
"system": "http://snomed.info/sct",
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|
"code": "22298006",
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|
"display": "Myocardial infarction"
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},
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{
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"system": "http://hl7.org/fhir/sid/icd-10",
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|
"code": "I21.0",
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"display": "Acute transmural myocardial infarction of anterior wall"
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|
}
|
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],
|
|
"text": "Acute anterior wall STEMI — post PCI with stent to LAD, stable for discharge"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:patient-ds-01"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:encounter-ds-01"
|
|
},
|
|
"onsetDateTime": "2026-03-10T07:30:00+05:30",
|
|
"abatementDateTime": "2026-03-14T10:00:00+05:30",
|
|
"recordedDate": "2026-03-14T14:00:00+05:30"
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:procedure-ds-01",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "procedure-ds-01",
|
|
"meta": {
|
|
"profile": [
|
|
"https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure"
|
|
]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "415070008",
|
|
"display": "Percutaneous coronary intervention"
|
|
}
|
|
],
|
|
"text": "Primary PCI with drug-eluting stent deployment to LAD artery"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:patient-ds-01"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:encounter-ds-01"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "2026-03-10T11:00:00+05:30",
|
|
"end": "2026-03-10T12:30:00+05:30"
|
|
},
|
|
"performer": [
|
|
{
|
|
"actor": {
|
|
"reference": "urn:uuid:practitioner-ds-01"
|
|
}
|
|
}
|
|
],
|
|
"bodySite": [
|
|
{
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "68787002",
|
|
"display": "Left anterior descending coronary artery"
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"outcome": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "385669000",
|
|
"display": "Successful"
|
|
}
|
|
],
|
|
"text": "Successful stent deployment with TIMI 3 flow restored"
|
|
}
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:medication-request-ds-01",
|
|
"resource": {
|
|
"resourceType": "MedicationRequest",
|
|
"id": "medication-request-ds-01",
|
|
"meta": {
|
|
"profile": [
|
|
"https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest"
|
|
]
|
|
},
|
|
"status": "active",
|
|
"intent": "order",
|
|
"medicationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "372756006",
|
|
"display": "Clopidogrel"
|
|
}
|
|
],
|
|
"text": "Clopidogrel 75mg"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:patient-ds-01"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:encounter-ds-01"
|
|
},
|
|
"authoredOn": "2026-03-14T14:00:00+05:30",
|
|
"requester": {
|
|
"reference": "urn:uuid:practitioner-ds-01"
|
|
},
|
|
"dosageInstruction": [
|
|
{
|
|
"text": "Take 1 tablet once daily after lunch",
|
|
"timing": {
|
|
"repeat": {
|
|
"frequency": 1,
|
|
"period": 1,
|
|
"periodUnit": "d"
|
|
}
|
|
},
|
|
"route": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "26643006",
|
|
"display": "Oral route"
|
|
}
|
|
]
|
|
},
|
|
"doseAndRate": [
|
|
{
|
|
"doseQuantity": {
|
|
"value": 75,
|
|
"unit": "mg",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "mg"
|
|
}
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"dispenseRequest": {
|
|
"validityPeriod": {
|
|
"start": "2026-03-14",
|
|
"end": "2027-03-14"
|
|
},
|
|
"expectedSupplyDuration": {
|
|
"value": 365,
|
|
"unit": "days",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "d"
|
|
}
|
|
},
|
|
"note": [
|
|
{
|
|
"text": "Dual antiplatelet therapy — do NOT discontinue without consulting cardiologist"
|
|
}
|
|
]
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:medication-request-ds-02",
|
|
"resource": {
|
|
"resourceType": "MedicationRequest",
|
|
"id": "medication-request-ds-02",
|
|
"meta": {
|
|
"profile": [
|
|
"https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest"
|
|
]
|
|
},
|
|
"status": "active",
|
|
"intent": "order",
|
|
"medicationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "387458008",
|
|
"display": "Aspirin"
|
|
}
|
|
],
|
|
"text": "Aspirin 75mg (Ecosprin)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:patient-ds-01"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:encounter-ds-01"
|
|
},
|
|
"authoredOn": "2026-03-14T14:00:00+05:30",
|
|
"requester": {
|
|
"reference": "urn:uuid:practitioner-ds-01"
|
|
},
|
|
"dosageInstruction": [
|
|
{
|
|
"text": "Take 1 tablet once daily after dinner",
|
|
"timing": {
|
|
"repeat": {
|
|
"frequency": 1,
|
|
"period": 1,
|
|
"periodUnit": "d"
|
|
}
|
|
},
|
|
"route": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "26643006",
|
|
"display": "Oral route"
|
|
}
|
|
]
|
|
},
|
|
"doseAndRate": [
|
|
{
|
|
"doseQuantity": {
|
|
"value": 75,
|
|
"unit": "mg",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "mg"
|
|
}
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"dispenseRequest": {
|
|
"validityPeriod": {
|
|
"start": "2026-03-14",
|
|
"end": "2027-03-14"
|
|
}
|
|
}
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:medication-request-ds-03",
|
|
"resource": {
|
|
"resourceType": "MedicationRequest",
|
|
"id": "medication-request-ds-03",
|
|
"meta": {
|
|
"profile": [
|
|
"https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest"
|
|
]
|
|
},
|
|
"status": "active",
|
|
"intent": "order",
|
|
"medicationCodeableConcept": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "376988009",
|
|
"display": "Atorvastatin"
|
|
}
|
|
],
|
|
"text": "Atorvastatin 40mg"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:patient-ds-01"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:encounter-ds-01"
|
|
},
|
|
"authoredOn": "2026-03-14T14:00:00+05:30",
|
|
"requester": {
|
|
"reference": "urn:uuid:practitioner-ds-01"
|
|
},
|
|
"dosageInstruction": [
|
|
{
|
|
"text": "Take 1 tablet at bedtime",
|
|
"timing": {
|
|
"repeat": {
|
|
"frequency": 1,
|
|
"period": 1,
|
|
"periodUnit": "d",
|
|
"when": [
|
|
"HS"
|
|
]
|
|
}
|
|
},
|
|
"route": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "26643006",
|
|
"display": "Oral route"
|
|
}
|
|
]
|
|
},
|
|
"doseAndRate": [
|
|
{
|
|
"doseQuantity": {
|
|
"value": 40,
|
|
"unit": "mg",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "mg"
|
|
}
|
|
}
|
|
]
|
|
}
|
|
]
|
|
}
|
|
},
|
|
{
|
|
"fullUrl": "urn:uuid:care-plan-ds-01",
|
|
"resource": {
|
|
"resourceType": "CarePlan",
|
|
"id": "care-plan-ds-01",
|
|
"status": "active",
|
|
"intent": "plan",
|
|
"title": "Post-PCI Cardiac Rehabilitation and Follow-Up Plan",
|
|
"description": "Post-STEMI discharge plan including cardiac rehabilitation, medication compliance, and lifestyle modifications",
|
|
"subject": {
|
|
"reference": "urn:uuid:patient-ds-01"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:encounter-ds-01"
|
|
},
|
|
"period": {
|
|
"start": "2026-03-14",
|
|
"end": "2026-09-14"
|
|
},
|
|
"author": {
|
|
"reference": "urn:uuid:practitioner-ds-01"
|
|
},
|
|
"category": [
|
|
{
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "736271009",
|
|
"display": "Outpatient care plan"
|
|
}
|
|
]
|
|
}
|
|
],
|
|
"activity": [
|
|
{
|
|
"detail": {
|
|
"kind": "Appointment",
|
|
"code": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "390906007",
|
|
"display": "Follow-up encounter"
|
|
}
|
|
]
|
|
},
|
|
"status": "scheduled",
|
|
"scheduledPeriod": {
|
|
"start": "2026-03-21",
|
|
"end": "2026-03-21"
|
|
},
|
|
"description": "First follow-up visit — 1 week post discharge. Wound check, ECG, vitals."
|
|
}
|
|
},
|
|
{
|
|
"detail": {
|
|
"kind": "Appointment",
|
|
"code": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "390906007",
|
|
"display": "Follow-up encounter"
|
|
}
|
|
]
|
|
},
|
|
"status": "scheduled",
|
|
"scheduledPeriod": {
|
|
"start": "2026-04-14",
|
|
"end": "2026-04-14"
|
|
},
|
|
"description": "Second follow-up — 1 month post discharge. 2D Echo, lipid profile, CBC."
|
|
}
|
|
},
|
|
{
|
|
"detail": {
|
|
"kind": "ServiceRequest",
|
|
"code": {
|
|
"coding": [
|
|
{
|
|
"system": "http://snomed.info/sct",
|
|
"code": "229065009",
|
|
"display": "Exercise therapy"
|
|
}
|
|
]
|
|
},
|
|
"status": "scheduled",
|
|
"description": "Cardiac rehabilitation program: Start supervised walking 10-15 min daily. Gradually increase to 30-45 min over 6 weeks. Avoid heavy lifting (>5 kg) for 4 weeks."
|
|
}
|
|
}
|
|
],
|
|
"note": [
|
|
{
|
|
"text": "Dietary advice: Low salt (<5g/day), low fat diet. Avoid smoking and alcohol. Take all medications regularly. Report immediately if chest pain, breathlessness, or palpitations recur. Keep follow-up appointments without fail."
|
|
}
|
|
]
|
|
}
|
|
}
|
|
]
|
|
} |