EHDS refined base model for Patient Summary

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

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 document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

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.

LOINC

Document title, such as Discharge Report, Laboratory Result Report, etc.

The status of the Discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

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.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

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.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

...

...

Information about substantial alerts or warnings that health professionals should be aware of.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

Reason for absence of data

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.

ISO IPS

Section: Allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Text summary of the content in section

List of structured allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)

1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason

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.

Conditions that are important to be known for a health professional during a health encounter.

Text summary of the content in the section

Use if no conditions are listed

!!Health conditions affecting the health of the patient.!!

Current and relevant past medicine.

Text summary of the content in the section

Use if no medicines are listed

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.

Section: Medical devices and implants

Narrative, potentially formatted, content of the section

Reason for absence of data

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.

Section: Procedures

Narrative, potentially formatted, content of the section

Reason for absence of data

List of procedures

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.

Narrative, potentially formatted, content of the section

Immunisations given to the patient and their status at the point of care.

eHN PS Guideline

Section: Functional status

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

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.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption

eHN PS Guideline, MyHealth@EU, ISO IPS

To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.

eHN PS Guideline, ISO IPS

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.

eHN PS Guideline, ISO IPS

Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown

eHN PS Guideline, ISO IPS

Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.

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.

eHN PS Guideline, ISO IPS

Text summary of the content in the section

Travel history for one country

eHN PS Guideline, ISO IPS

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.

ISO IPS

Text summary of the content in the section

Provision for healthcare decisions if, in the future, a person is unable to make those decisions.

Narrative, potentially formatted, content of the section

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.

Narrative, potentially formatted, content of the section

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.

EHDS refined base model for Patient Summary

Information about substantial alerts or warnings that health professionals should be aware of.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

Reason for absence of data

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.

ISO IPS

Section: Allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Text summary of the content in section

List of structured allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)

1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason

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.

Conditions that are important to be known for a health professional during a health encounter.

Text summary of the content in the section

Use if no conditions are listed

!!Health conditions affecting the health of the patient.!!

Current and relevant past medicine.

Text summary of the content in the section

Use if no medicines are listed

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.

Section: Medical devices and implants

Narrative, potentially formatted, content of the section

Reason for absence of data

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.

Section: Procedures

Narrative, potentially formatted, content of the section

Reason for absence of data

List of procedures

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.

Narrative, potentially formatted, content of the section

Immunisations given to the patient and their status at the point of care.

eHN PS Guideline

Section: Functional status

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

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.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption

eHN PS Guideline, MyHealth@EU, ISO IPS

To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.

eHN PS Guideline, ISO IPS

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.

eHN PS Guideline, ISO IPS

Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown

eHN PS Guideline, ISO IPS

Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.

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.

eHN PS Guideline, ISO IPS

Text summary of the content in the section

Travel history for one country

eHN PS Guideline, ISO IPS

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.

ISO IPS

Text summary of the content in the section

Provision for healthcare decisions if, in the future, a person is unable to make those decisions.

Narrative, potentially formatted, content of the section

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.

Narrative, potentially formatted, content of the section

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.

EHDS refined base model for Patient Summary

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

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 document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

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.

LOINC

Document title, such as Discharge Report, Laboratory Result Report, etc.

The status of the Discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

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.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

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.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

...

...

Information about substantial alerts or warnings that health professionals should be aware of.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

Reason for absence of data

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.

ISO IPS

Section: Allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Text summary of the content in section

List of structured allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)

1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason

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.

Conditions that are important to be known for a health professional during a health encounter.

Text summary of the content in the section

Use if no conditions are listed

!!Health conditions affecting the health of the patient.!!

Current and relevant past medicine.

Text summary of the content in the section

Use if no medicines are listed

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.

Section: Medical devices and implants

Narrative, potentially formatted, content of the section

Reason for absence of data

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.

Section: Procedures

Narrative, potentially formatted, content of the section

Reason for absence of data

List of procedures

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.

Narrative, potentially formatted, content of the section

Immunisations given to the patient and their status at the point of care.

eHN PS Guideline

Section: Functional status

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

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.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the section

Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption

eHN PS Guideline, MyHealth@EU, ISO IPS

To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.

eHN PS Guideline, ISO IPS

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.

eHN PS Guideline, ISO IPS

Overall status of previous pregnancies, including — Yes, previous pregnancies — No, previous pregnancies — Unknown

eHN PS Guideline, ISO IPS

Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.

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.

eHN PS Guideline, ISO IPS

Text summary of the content in the section

Travel history for one country

eHN PS Guideline, ISO IPS

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.

ISO IPS

Text summary of the content in the section

Provision for healthcare decisions if, in the future, a person is unable to make those decisions.

Narrative, potentially formatted, content of the section

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.

Narrative, potentially formatted, content of the section

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.