<confidentiality value="N"/> <custodian> <reference value="urn:uuid:8cb22830-dfb3-4f32-bc06-2c94e3178e20"/> </custodian> <section> <title value="Synthesis"/> <code> <coding> <system value="http://loinc.org"/> <code value="67781-5"/> <display value="Summarization of encounter note"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Substance dependence, treated and stabilised</div> </text> </section> <section> <title value="Hospital course note"/> <code> <coding> <system value="http://loinc.org"/> <code value="8648-8"/> <display value="Hospital course note"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Dear colleague, thank you for referring this 46-year-old female patient, admitted on 02.01.2020 due to substance dependence disorder. Upon admission, a comprehensive psychiatric and somatic assessment was performed, confirming dependence on multiple substances including opioids and benzodiazepines. Withdrawal symptoms were present and required immediate clinical management. During her inpatient stay, a structured detoxification protocol was initiated, including pharmacological withdrawal treatment and close monitoring of vital signs and neurological status. Motivational counselling sessions were conducted, and a psychosocial needs assessment was completed. The patient stabilised well without major complications. At discharge on 05.01.2020, she was referred to an outpatient addiction support programme and her primary care follow-up was arranged. We recommend continued monitoring and engagement with community addiction services. Please do not hesitate to contact us should further information be required.</div> </text> </section> <section> <title value="Diagnosis at Discharge"/> <code> <coding> <system value="http://loinc.org"/> <code value="11535-2"/> <display value="Hospital discharge diagnosis note"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__hdr"> <tr> <td>Mental and behavioural disorders due to multiple drug use – dependence syndrome</td> <td> <span class="nb">05-Jan-2020</span> </td> <td>active</td> </tr> </table> </div> </text> <entry> <reference value="urn:uuid:15fdd802-7e8a-4b47-9844-443170c47499"/> </entry> </section> <section> <title value="Significant procedures"/> <code> <coding> <system value="http://loinc.org"/> <code value="10185-7"/> <display value="Hospital discharge procedure note"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__hdr"> <tr> <td>Referral to outpatient addiction programme</td> <td> <span class="nb">05-Jan-2020</span> </td> <td>-</td> </tr> </table> </div> </text> <entry> <reference value="urn:uuid:1d11f366-6775-4c01-9414-bbde22178bd5"/> </entry> <entry> <reference value="urn:uuid:ac59796c-7ff5-4419-9860-2a7df90c3919"/> </entry> <entry> <reference value="urn:uuid:16cb7166-62dc-40b7-84c3-ae9b01863e4c"/> </entry> <entry> <reference value="urn:uuid:c9649a16-4ba8-4403-87a7-19845fe6608a"/> </entry> <entry> <reference value="urn:uuid:f2870320-891b-4047-9b1d-753f0b722d36"/> </entry> <entry> <reference value="urn:uuid:e33166d5-244c-463a-aa89-c53cfe68cfb3"/> </entry> <entry> <reference value="urn:uuid:fec6aba0-487b-4fbc-9739-99861c1a4d6d"/> </entry> <entry> <reference value="urn:uuid:41ff7d45-1050-4ea0-8bf3-ffd859f51e2c"/> </entry> </section> </Composition> </resource> </entry> <entry> <fullUrl value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <resource> <Patient> <id value="03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core"/> <security> <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/> <code value="HTEST"/> </security> <security> <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/> <code value="TRAIN"/> </security> <tag> <system value="https://synderai.net/fhir/CodeSystem/tags"/> <code value="synthetic"/> <display value="SYNDERAI Synthetic data"/> </tag> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Justine Renner</td> <td>female</td> <td>26-Aug-1979</td> </tr> </table> </div> </text> <extension url="http://hl7.org/fhir/StructureDefinition/patient-nationality"> <extension url="code"> <valueCodeableConcept> <coding> <system value="urn:iso:std:iso:3166"/> <code value="DE"/> </coding> </valueCodeableConcept> </extension> </extension> <identifier> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/> <code value="JHN"/> </coding> </type> <system value="http://ec.europa.eu/identifier/eci"/> <value value="5986-489081-5"/> </identifier> <identifier> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/> <code value="MR"/> </coding> </type> <system value="http://local.setting.eu/identifier"/> <value value="df3d05c1-d6bc-1382-fabb-b6efa878f3c4"/> </identifier> <name> <text value="Justine Renner"/> <family value="Renner"/> <given value="Justine"/> </name> <telecom> <system value="phone"/> <value value="(06451) 696717"/> </telecom> <gender value="female"/> <birthDate value="1979-08-26"/> <address> <use value="home"/> <type value="physical"/> <line value="Willfried-Killer-Allee 54/21"/> <city value="Wolfratshausen"/> <postalCode value="82515"/> <country value="Germany"/> </address> </Patient> </resource> </entry> <entry> <fullUrl value="urn:uuid:9666c4e3-302e-409f-8475-c349cdd40acf"/> <resource> <Encounter> <id value="9666c4e3-302e-409f-8475-c349cdd40acf"/> <meta> <profile value="http://hl7.eu/fhir/hdr/StructureDefinition/encounter-eu-hdr"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Benedictus Krankenhaus Feldafing, Feldafing, Germany</td> <td>02-01-2020 - 05-01-2020</td> <td> <ul> <li>Substance dependence (disorder)</li> </ul> </td> </tr> </table> </div> </text> <status value="completed"/> <class> <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> <code value="IMP"/> </class> <subject> <reference value="Patient/03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <participant> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/> <code value="PPRF"/> <display value="primary performer"/> </coding> </type> <period> <end value="2020-01-05"/> </period> <individual> <reference value="urn:uuid:b38e74a5-2e58-4109-9313-c82fb7dc890b"/> </individual> </participant> <period> <start value="2020-01-05"/> </period> <reasonCode> <coding> <system value="http://snomed.info/sct"/> <code value="6525002"/> <display value="Substance dependence (disorder)"/> </coding> </reasonCode> <serviceProvider> <reference value="urn:uuid:8cb22830-dfb3-4f32-bc06-2c94e3178e20"/> </serviceProvider> </Encounter> </resource> </entry> <entry> <fullUrl value="urn:uuid:bcb8ef24-b39d-4e7d-839a-1bf5f08ca9d3"/> <resource> <PractitionerRole> <id value="bcb8ef24-b39d-4e7d-839a-1bf5f08ca9d3"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Hospital Role Id: bcb8ef24-b39d-4e7d-839a-1bf5f08ca9d3</div> </text> <practitioner> <reference value="urn:uuid:b38e74a5-2e58-4109-9313-c82fb7dc890b"/> </practitioner> <organization> <reference value="urn:uuid:8cb22830-dfb3-4f32-bc06-2c94e3178e20"/> </organization> </PractitionerRole> </resource> </entry> <entry> <fullUrl value="urn:uuid:8cb22830-dfb3-4f32-bc06-2c94e3178e20"/> <resource> <Organization> <id value="8cb22830-dfb3-4f32-bc06-2c94e3178e20"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Hospital: Benedictus Krankenhaus Feldafing, 82340 Feldafing, Germany</div> </text> <name value="Benedictus Krankenhaus Feldafing"/> <address> <city value="Feldafing"/> <postalCode value="82340"/> <country value="Germany"/> </address> </Organization> </resource> </entry> <entry> <fullUrl value="urn:uuid:b38e74a5-2e58-4109-9313-c82fb7dc890b"/> <resource> <Practitioner> <id value="b38e74a5-2e58-4109-9313-c82fb7dc890b"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Practitioner in Hospital: Leander Etzold</div> </text> <identifier> <system value="urn:oid:2.16.840.1.113883.2.51.999"/> <value value="f8a43cd9-ebb9-40d1-b992-154019dc011c"/> <assigner> <display value="HL7 Europe"/> </assigner> </identifier> <name> <family value="Etzold"/> <given value="Leander"/> </name> </Practitioner> </resource> </entry> <entry> <fullUrl value="urn:uuid:15fdd802-7e8a-4b47-9844-443170c47499"/> <resource> <Condition> <id value="15fdd802-7e8a-4b47-9844-443170c47499"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/condition-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Mental and behavioural disorders due to multiple drug use – dependence syndrome</td> <td> <span class="nb">05-Jan-2020</span> </td> <td>active</td> </tr> </table> </div> </text> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/condition-category"/> <code value="encounter-diagnosis"/> <display value="Encounter Diagnosis"/> </coding> </category> <code> <coding> <system value="http://hl7.org/fhir/sid/icd-10"/> <code value="F19.2"/> <display value="Mental and behavioural disorders due to multiple drug use – dependence syndrome"/> </coding> <text value="Mental and behavioural disorders due to multiple drug use – dependence syndrome"/> </code> <subject> <reference value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <onsetDateTime value="2020-01-05"/> </Condition> </resource> </entry> <entry> <fullUrl value="urn:uuid:1d11f366-6775-4c01-9414-bbde22178bd5"/> <resource> <Procedure> <id value="1d11f366-6775-4c01-9414-bbde22178bd5"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Psychiatric assessment on admission</td> <td> <span class="nb">02-Jan-2020</span> </td> <td>-</td> </tr> </table> </div> </text> <status value="completed"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="386806002"/> <display value="Impaired cognition (finding)"/> </coding> </code> <subject> <reference value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <performedDateTime value="2020-01-02"/> </Procedure> </resource> </entry> <entry> <fullUrl value="urn:uuid:ac59796c-7ff5-4419-9860-2a7df90c3919"/> <resource> <Procedure> <id value="ac59796c-7ff5-4419-9860-2a7df90c3919"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Physical examination on admission</td> <td> <span class="nb">02-Jan-2020</span> </td> <td>-</td> </tr> </table> </div> </text> <status value="completed"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="5880005"/> <display value="Physical examination procedure (procedure)"/> </coding> </code> <subject> <reference value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <performedDateTime value="2020-01-02"/> </Procedure> </resource> </entry> <entry> <fullUrl value="urn:uuid:16cb7166-62dc-40b7-84c3-ae9b01863e4c"/> <resource> <Procedure> <id value="16cb7166-62dc-40b7-84c3-ae9b01863e4c"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Neurological examination</td> <td> <span class="nb">02-Jan-2020</span> </td> <td>-</td> </tr> </table> </div> </text> <status value="completed"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="84728005"/> <display value="Neurological examination (procedure)"/> </coding> </code> <subject> <reference value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <performedDateTime value="2020-01-02"/> </Procedure> </resource> </entry> <entry> <fullUrl value="urn:uuid:c9649a16-4ba8-4403-87a7-19845fe6608a"/> <resource> <Procedure> <id value="c9649a16-4ba8-4403-87a7-19845fe6608a"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Blood specimen collection for toxicology screening</td> <td> <span class="nb">02-Jan-2020</span> </td> <td>-</td> </tr> </table> </div> </text> <status value="completed"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="396550006"/> <display value="Blood test (procedure)"/> </coding> </code> <subject> <reference value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <performedDateTime value="2020-01-02"/> </Procedure> </resource> </entry> <entry> <fullUrl 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<profile value="http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Administration of medication for withdrawal symptoms</td> <td> <span class="nb">02-Jan-2020</span> </td> <td>-</td> </tr> </table> </div> </text> <status value="completed"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="18629005"/> <display value="Administration of drug or medicament (procedure)"/> </coding> </code> <subject> <reference value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <performedDateTime value="2020-01-02"/> </Procedure> </resource> </entry> <entry> <fullUrl value="urn:uuid:fec6aba0-487b-4fbc-9739-99861c1a4d6d"/> <resource> <Procedure> <id value="fec6aba0-487b-4fbc-9739-99861c1a4d6d"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Monitoring of vital signs</td> <td> <span class="nb">04-Jan-2020</span> </td> <td>-</td> </tr> </table> </div> </text> <status value="completed"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="710830005"/> <display value="Assessment of passive range of motion (procedure)"/> </coding> </code> <subject> <reference value="urn:uuid:03f6bf5f-be0e-42ce-914f-d64434eea5f2"/> <display value="Justine Renner"/> </subject> <performedDateTime value="2020-01-04"/> </Procedure> </resource> </entry> <entry> <fullUrl value="urn:uuid:41ff7d45-1050-4ea0-8bf3-ffd859f51e2c"/> <resource> <Procedure> <id value="41ff7d45-1050-4ea0-8bf3-ffd859f51e2c"/> <meta> <profile value="http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table class="hl7__ips"> <tr> <td>Referral to outpatient addiction 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               intentionally left empty / not meaningful
            
            
               
               
               
                  
               
            
            
            
               
                  
                  
                  
               
               
            
            
               
               
            
            
            
               
            
            
            <confidentiality value="N"/>
            <custodian>
               <reference value="urn:uuid:8cb22830-dfb3-4f32-bc06-2c94e3178e20"/>
            </custodian>
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               <title value="Synthesis"/>
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                  <coding>
                     <system value="http://loinc.org"/>
                     <code value="67781-5"/>
                     <display value="Summarization of encounter note"/>
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                  <status value="generated"/>
                  <div xmlns="http://www.w3.org/1999/xhtml">Substance dependence, treated and stabilised</div>
               </text>
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            <section>
               <title value="Hospital course note"/>
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                  <coding>
                     <system value="http://loinc.org"/>
                     <code value="8648-8"/>
                     <display value="Hospital course note"/>
                  </coding>
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               <text>
                  <status value="generated"/>
                  <div xmlns="http://www.w3.org/1999/xhtml">Dear colleague, thank you for referring this 46-year-old female patient, admitted on 02.01.2020 due to substance dependence disorder. Upon admission, a comprehensive psychiatric and somatic assessment was performed, confirming dependence on multiple substances including opioids and benzodiazepines. Withdrawal symptoms were present and required immediate clinical management. During her inpatient stay, a structured detoxification protocol was initiated, including pharmacological withdrawal treatment and close monitoring of vital signs and neurological status. Motivational counselling sessions were conducted, and a psychosocial needs assessment was completed. The patient stabilised well without major complications. At discharge on 05.01.2020, she was referred to an outpatient addiction support programme and her primary care follow-up was arranged. We recommend continued monitoring and engagement with community addiction services. Please do not hesitate to contact us should further information be required.</div>
               </text>
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                     <code value="11535-2"/>
                     <display value="Hospital discharge diagnosis note"/>
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                     <table class="hl7__hdr">
                        <tr>
                           <td>Mental and behavioural disorders due to multiple drug use – dependence syndrome</td>
                           <td>
                              <span class="nb">05-Jan-2020</span>
                           </td>
                           <td>active</td>
                        </tr>
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                  <coding>
                     <system value="http://loinc.org"/>
                     <code value="10185-7"/>
                     <display value="Hospital discharge procedure note"/>
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                     <table class="hl7__hdr">
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                           <td>Referral to outpatient addiction programme</td>
                           <td>
                              <span class="nb">05-Jan-2020</span>
                           </td>
                           <td>-</td>
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               <profile value="http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core"/>
               <security>
                  <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
                  <code value="HTEST"/>
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               <security>
                  <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
                  <code value="TRAIN"/>
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               <tag>
                  <system value="https://synderai.net/fhir/CodeSystem/tags"/>
                  <code value="synthetic"/>
                  <display value="SYNDERAI Synthetic data"/>
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            <text>
               <status value="generated"/>
               <div xmlns="http://www.w3.org/1999/xhtml">
                  <table class="hl7__ips">
                     <tr>
                        <td>Justine Renner</td>
                        <td>female</td>
                        <td>26-Aug-1979</td>
                     </tr>
                  </table>
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            </text>
            <extension url="http://hl7.org/fhir/StructureDefinition/patient-nationality">
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                        <system value="urn:iso:std:iso:3166"/>
                        <code value="DE"/>
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            <identifier>
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                  <coding>
                     <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                     <code value="JHN"/>
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               <system value="http://ec.europa.eu/identifier/eci"/>
               <value value="5986-489081-5"/>
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                     <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
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               <system value="http://local.setting.eu/identifier"/>
               <value value="df3d05c1-d6bc-1382-fabb-b6efa878f3c4"/>
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               <text value="Justine Renner"/>
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                        <td>Benedictus Krankenhaus Feldafing, Feldafing, Germany</td>
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                              <li>Substance dependence (disorder)</li>
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                  <code value="6525002"/>
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                           <span class="nb">02-Jan-2020</span>
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                           <span class="nb">02-Jan-2020</span>
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                           <span class="nb">02-Jan-2020</span>
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