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 header 1..* Base Metadata for the patient summary document attestation 0..0 legalAuthentication 0..0 eventType 0..0 authorSpecialty 0..0 <a href="StructureDefinition-EHDSPatientSummary-definitions.html#EHDSPatientSummary.header.natureOfTheDocument" title="Defines the context in which the document was generated. Distinguishes between four methodological approaches for generating the document: Created entirely by a HCP2; Manually created by HCP(s) and collected by machine(s); Created by machine(s) and checked by HCP(s); Created and collected by machine(s)">natureOfTheDocument 1..1 Base Nature of the document preferredHealthProfessional[x] 0..* A.1.3 - Preferred Health Professional preferredHealthProfessionalEHDSHealthProfessional EHDSHealthProfessional preferredHealthProfessionalEHDSOrganization EHDSOrganization alerts 1..1 Base Section: Alerts. narrative 0..1 string Narrative, potentially formatted, content of the section emptyReason 0..1 CodeableConcept Reason for absence of data medicalAlert 0..* EHDSAlertFlag 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. allergiesAndIntolerances 1..1 Base Section: Allergies and intolerances narrative 0..1 string Narrative, potentially formatted, content of the section emptyReason 0..1 CodeableConcept Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete) allergy 0..* EHDSAllergyIntolerance Allergy or intolerance information medicalHistory 0..1 Base Section: Medical History. narrative 0..1 string Narrative, potentially formatted, content of the section pastProblems 0..* EHDSCondition Problems or diagnoses that the patient suffered in the past, and which have been resolved, closed or declared as inactive (not included in current problems or diagnosis) description 0..1 string Narrative description of past problems. <a href="StructureDefinition-EHDSPatientSummary-definitions.html#EHDSPatientSummary.immunisations" title="The primary purpose is to enable communication of a patient's immunization status. The section should include current immunization status and may contain the entire immunization history that is relevant to the period of time being summarized. Adverse reactions against vaccines should be documented in the allergy section.">immunisations 0..1 Base Section: Immunisations. narrative 0..1 string Narrative, potentially formatted, content of the section vaccination 0..* EHDSImmunization Immunizations given to the patient and their status at the point of care. currentProblems 1..1 Base Section: Current medical problems. narrative 0..1 string Narrative, potentially formatted, content of the section emptyReason 0..1 CodeableConcept Reason for absence of data healthConditions 0..* EHDSCondition Health conditions affecting the health of the patient. medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants narrative 0..1 string Narrative, potentially formatted, content of the section emptyReason 0..1 CodeableConcept Reason for absence of data 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. procedures 1..1 Base Section: Procedures narrative 0..1 string Narrative, potentially formatted, content of the section emptyReason 0..1 CodeableConcept Reason for absence of data procedure 0..* EHDSProcedure Major procedures. medicationSummary 1..1 Base Section: Medication Summary. narrative 0..1 string Narrative, potentially formatted, content of the section emptyReason 0..1 CodeableConcept Reason for absence of data medicationTreatment 0..* EHDSMedicationAdministration 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. functionalStatus 0..1 Base Section: Functional status narrative 0..1 string Narrative, potentially formatted, content of the section 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 socialHistory 0..1 Base Section: Social history. narrative 0..1 string Narrative, potentially formatted, content of the section description 1..1 string Textual description of the social history. observation 0..* EHDSObservation Social history observations related to health pregnancyHistory 0..1 Base Section: Pregnancy history narrative 0..1 string Narrative, potentially formatted, content of the section currentPregnancyStatus 0..1 Base Current pregnancy status status 0..* EHDSObservation Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown expectedDateOfDelivery 0..1 dateTime Expected date of delivery previousPregnancies 0..1 Base History of previous pregnancies status 0..1 EHDSObservation Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown description 0..* Base Previous pregnancy's descriptions in detail outcome 0..1 EHDSObservation Outcome of the pregnancy numberOfChildren 0..1 integer Number of children/fetuses in this specific pregnancy patientProvidedData 0..1 Base Section: Patient provided data narrative 0..1 string Narrative, potentially formatted, content of the section <a href="StructureDefinition-EHDSPatientSummary-definitions.html#EHDSPatientSummary.patientProvidedData.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..* Base 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. country 0..1 CodeableConcept Country code Binding Description (No ValueSet): (preferred): ISO 3166 period 0..* Period Date of entry and departure advanceDirectives 0..1 Base Section: Advance Directives. narrative 0..1 string Narrative, potentially formatted, content of the section documentation 0..* CodeableConcept May take the form of a reference to a legal document (e.g., Living Will) or an external textual description. Binding Description (No ValueSet): (preferred): SNOMED CT results 0..1 Base Section: Observation results. narrative 0..1 string Narrative, potentially formatted, content of the section resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments resultObservationEHDSObservation EHDSObservation resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation carePlan 0..1 Base Section: Care plans. 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. 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. Documentation for this format
EHDS refined base model for Patient Summary
Metadata for the patient summary document
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. Hospital discharge report.
Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.
The status of the Hospital 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
Defines the context in which the document was generated. Distinguishes between four methodological approaches for generating the document: Created entirely by a HCP2; Manually created by HCP(s) and collected by machine(s); Created by machine(s) and checked by HCP(s); Created and collected by machine(s)
Preferred health professional (HP) - This section can be repeated and linked to any specific information in the document, for example a link between a rare disease problem and the rare disease specialist responsible for the care of the individual patient (this section).
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.
Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
This section may provide both synthetic anamnesis (e.g. description of phases of the pathology as a chronological summary of clustered clinical information) and anecdotal evidence that clinicians can collect from the patient, and can read in a narrative form.
Problems or diagnoses that the patient suffered in the past, and which have been resolved, closed or declared as inactive (not included in current problems or diagnosis)
The primary purpose is to enable communication of a patient's immunization status. The section should include current immunization status and may contain the entire immunization history that is relevant to the period of time being summarized. Adverse reactions against vaccines should be documented in the allergy section.
Immunizations given to the patient and their status at the point of care.
Conditions that are important to be known for a health professional during a health encounter.
Health conditions affecting the health of the patient.
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.
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.
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.
Textual description of the social history.
Social history observations related to health
Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Date on which the woman is due to give birth.
Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Previous pregnancy's descriptions in detail
Number of children/fetuses in this specific 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.
Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
May take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
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.