Generated Narrative: StructureDefinition EHDSPatientSummary Name Flags Card. Type Description & Constraints EHDSPatientSummary 0..* EHDSDocument Elements defined in Ancestors:header, presentedForm, header, knowledgeResources Patient summary model Instances of this logical model can be the target of a Reference #xD; alerts 1..1 Base Section: Alerts. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; emptyReason 0..1 CodeableConcept Reason for absence of data #xD; medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat. #xD; allergiesAndIntolerances 1..1 Base Section: Allergies and intolerances #xD; narrative 1..1 string Text summary of the content in section #xD; allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances #xD; emptyReason 0..1 CodeableConcept Use if no Allergies are listed Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason #xD; problems 1..1 Base Medical problems. #xD; narrative 0..1 string Text summary of the content in the section #xD; emptyReason 0..1 CodeableConcept Use if no conditions are listed #xD; problems 0..* EHDSCondition !!Health conditions affecting the health of the patient.!! #xD; medicationSummary 1..1 Base Section: Medication Summary. #xD; narrative 0..1 string Text summary of the content in the section #xD; emptyReason 0..1 CodeableConcept Use if no medicines are listed #xD; medicationTreatment 0..* EHDSMedicationStatement Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not. #xD; medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; emptyReason 0..1 CodeableConcept Reason for absence of data #xD; medicalDevice 0..* EHDSDeviceUse Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP. #xD; procedures 1..1 Base Section: Procedures #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; emptyReason 0..1 CodeableConcept Reason for absence of data #xD; procedure 0..* EHDSProcedure List of procedures #xD; vaccination 0..1 Base Section: Vaccination/prophylaxis. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; vaccination 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care. #xD; functionalStatus 0..1 Base Section: Functional status #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being #xD; socialHistory 0..1 Base Section: Social history. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; socialHistoryObservation 0..* EHDSSocialHistory Social history observations related to health #xD; pregnancyHistory 0..1 Base Section: Pregnancy history #xD; generatedNarrative 0..1 string Generated text summary of the content in the section, for human interpretation #xD; currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status #xD; previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies #xD; previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies #xD; <a href="StructureDefinition-EHDSPatientSummary-definitions.html#EHDSPatientSummary.travelHistory" title="Captures relevant information about the patient's recent travel history that may be of clinical relevance — particularly in relation to exposure to infectious diseases, epidemiological risks, or environmental factors. The intent is to support clinical decision-making and risk assessment, especially in contexts such as outbreaks or endemic disease regions.">travelHistory 0..1 Base Relevant information about the patient's recent travel history #xD; narrative 0..1 string Text summary of the content in the section #xD; travelHistory 0..* EHDSTravelHistory Travel history for one country #xD; patientStory 0..1 Base What the patient believes to be important for the attending clinician to know. #xD; narrative 0..1 string Text summary of the content in the section #xD; advanceDirectives 0..1 Base Section: Advance Directives. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions #xD; results 0..1 Base Section: Observation results. #xD; narrative 0..1 string Narrative, potentially formatted, content of the section #xD; resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments #xD; resultObservationEHDSObservation EHDSObservation #xD; resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation #xD; carePlan 0..1 Base Section: Care plans. #xD; narrative 0..1 string Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format. #xD; carePlanEntry 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions. #xD; Documentation for this format
EHDS refined base model for Patient Summary
Copyright HL7 Europe. Licensed under Creative Commons public domain (CC0 1.0).
Common header for all patient-related data
Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Date and time of the issuing the document/resource by its author.
Date and time of the last update to the resource
Date and time of the last update to the document/information
Reason for the current status of the resource.
Language in which the resource is written. Language is expressed by the IETF language tag.
A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Identifies the type of document at hand, e.g. Discharge report.
Document title, such as Discharge Report, Laboratory Result Report, etc.
The status of the Discharge report. E.g., preliminary, final.
Time of service that is being documented
Attester who validated the document. Mulitple attesters could be provided.
Date and time of the approval of the document by Attester.
The person taking responsibility for the medical content of the document
Date and time when the document was authorized.
Categorization of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.
Additional details about where the content was created (e.g. clinical specialty)
Organisation that is in charge of maintaining the document/report.
An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
Level of confidentiality of the document. Implicit value is normal.
Related documents and information sources
Information about substantial alerts or warnings that health professionals should be aware of.
Narrative, potentially formatted, content of the section
Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
List of structured allergies and intolerances
Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
This element is present in MyHealth@EU specifications and ISO IPS. The proposed way of modelling is identical to the newest version of FHIR IPS IG. See general description of Patient summary modelling for more information about this element. MH@EU has a similar concept, but it is modelled in slightly different way.
1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
Conditions that are important to be known for a health professional during a health encounter.
Text summary of the content in the section
!!Health conditions affecting the health of the patient.!!
Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.
Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.
A patient's immunisation status. The section should include current immunization status and may contain the entire immunization history that is relevant to the period of time being summarised. Adverse reactions against vaccines should be documented in the allergy section.
Immunisations given to the patient and their status at the point of care.
An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Observations on social factors such as alcohol consumption or smoking. From the healthcare perspective, life-style factors relate to well-being but can also provide a source of risk factors.
Social history observations related to health
Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Generated text summary of the content in the section, for human interpretation
Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown
Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Relevant information about the patient's recent travel history
Captures relevant information about the patient's recent travel history that may be of clinical relevance — particularly in relation to exposure to infectious diseases, epidemiological risks, or environmental factors. The intent is to support clinical decision-making and risk assessment, especially in contexts such as outbreaks or endemic disease regions.
What the patient believes to be important for the attending clinician to know.
A concise narrative from the patient’s perspective about their present health state. This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.
Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.