EHDS Logical Information Models
0.1.0 - ci-build

EHDS Logical Information Models, published by Xt-EHR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Xt-EHR/xt-ehr-common/tree/stakeholder-consultation-D6-2 and changes regularly. See the Directory of published versions

## Logical Model: EHDSPatientSummary - Detailed Descriptions

Draft as of 2025-05-26

Definitions for the EHDSPatientSummary logical model.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be found here

0. EHDSPatientSummary
Definition | EHDS refined base model for Patient Summary Base definition for all types defined in FHIR type system.
Short | Patient summary modelBase for all types and resources
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSPatientSummary.header
Definition | Common header for all patient-related data
Short | Metadata for the patient summary document
Control | 1..*
Type | Base
4. EHDSPatientSummary.header.subject
Definition | Patient/subject information
Short | Subject
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
6. EHDSPatientSummary.header.identifier
Definition | Unique identifier of the document
Short | Document ID
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSPatientSummary.header.authorship
Definition | Resource authoring details
Short | Authorship
Control | 1..*
Type | Base
10. EHDSPatientSummary.header.authorship.author[x]
Definition | Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Short | Author
Control | 1..1
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
12. EHDSPatientSummary.header.authorship.datetime
Definition | Date and time of the issuing the document/resource by its author.
Short | Date and time of authoring/issuing
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
14. EHDSPatientSummary.header.lastUpdate
Definition | Date and time of the last update to the document/information
Short | Date and time of the last update to the resource
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSPatientSummary.header.status
Definition | Status of the resource
Short | Status of the resource
Control | 1..1
Type | CodeableConcept
18. EHDSPatientSummary.header.statusReason[x]
Definition | Reason for the current status of the resource.
Short | Reason for the current status of the resource.
Control | 0..1
Type | Choice of: CodeableConcept, string
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSPatientSummary.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
22. EHDSPatientSummary.header.version
Definition | Business version of the resource.
Short | Version
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
24. EHDSPatientSummary.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
26. EHDSPatientSummary.header.documentType
Definition | Identifies the type of document at hand, e.g. Hospital discharge report.
Short | Document type
Control | 1..1
Binding | LOINC
Type | CodeableConcept
28. EHDSPatientSummary.header.documentTitle
Definition | Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.
Short | Document title
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
30. EHDSPatientSummary.header.documentStatus
Definition | The status of the Hospital discharge report. E.g., preliminary, final.
Short | Document status
Control | 1..1
Binding | hl7:CompositionStatus
Type | CodeableConcept
32. EHDSPatientSummary.header.period
Definition | Time of service that is being documented
Short | Period
Control | 0..1
Type | Period
34. EHDSPatientSummary.header.attestation
Definition | Document attestation details
Short | Attestation
Control | 0..0
Type | Base
38. EHDSPatientSummary.header.legalAuthentication
Definition | Document legal authentication
Short | Legal authentication
Control | 0..0
Type | Base
42. EHDSPatientSummary.header.eventType
Definition | 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.
Short | Event type
Control | 0..0
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
44. EHDSPatientSummary.header.authorSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Specialty
Control | 0..0
Binding | SNOMED CT
Type | CodeableConcept
46. EHDSPatientSummary.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Document custodian
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
48. EHDSPatientSummary.header.documentFormat
Definition | An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
Short | Document format
Control | 0..1
Binding | HL7 Document Format Codes
Type | CodeableConcept
50. EHDSPatientSummary.header.confidentiality
Definition | Level of confidentiality of the document. Implicit value is normal.
Short | Confidentiality
Control | 0..1
Binding | hl7:Confidentiality
Type | CodeableConcept
52. EHDSPatientSummary.knowledgeResources
Definition | Related documents and information sources
Short | Related documents and information sources
Control | 0..*
Type | Base
54. EHDSPatientSummary.knowledgeResources.externalReference
Definition | ...
Short | ...
Control | 0..*
Type | RelatedArtifact
56. EHDSPatientSummary.knowledgeResources.relatedTo
Definition | ...
Short | ...
Control | 0..*
Type | Reference
58. EHDSPatientSummary.header.natureOfTheDocument
Definition | 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)
Short | Nature of the document
Control | 1..1
Type | Base
60. EHDSPatientSummary.preferredHealthProfessional[x]
Definition | 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).
Short | A.1.3 - Preferred Health Professional
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
62. EHDSPatientSummary.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 1..1
Type | Base
Requirements | eHN PS Guideline
64. EHDSPatientSummary.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.alerts.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
68. EHDSPatientSummary.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
Requirements | eHN PS Guideline
70. EHDSPatientSummary.allergiesAndIntolerances
Definition | Section: Allergies and intolerances
Short | Section: Allergies and intolerances
Control | 1..1
Type | Base
72. EHDSPatientSummary.allergiesAndIntolerances.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSPatientSummary.allergiesAndIntolerances.emptyReason
Definition | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Short | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Control | 0..1
Type | CodeableConcept
76. EHDSPatientSummary.allergiesAndIntolerances.allergy
Definition | Allergy or intolerance information
Short | Allergy or intolerance information
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN PS Guideline
78. EHDSPatientSummary.medicalHistory
Definition | 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.
Short | Section: Medical History.
Control | 0..1
Type | Base
80. EHDSPatientSummary.medicalHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
82. EHDSPatientSummary.medicalHistory.pastProblems
Definition | 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)
Short | 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)
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements | eHN PS Guideline
84. EHDSPatientSummary.medicalHistory.description
Definition | Narrative description of past problems.
Short | Narrative description of past problems.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
86. EHDSPatientSummary.immunisations
Definition | 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.
Short | Section: Immunisations.
Control | 0..1
Type | Base
88. EHDSPatientSummary.immunisations.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSPatientSummary.immunisations.vaccination
Definition | Immunizations given to the patient and their status at the point of care.
Short | Immunizations given to the patient and their status at the point of care.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunization
Requirements | eHN PS Guideline
92. EHDSPatientSummary.currentProblems
Definition | Conditions that are important to be known for a health professional during a health encounter.
Short | Section: Current medical problems.
Control | 1..1
Type | Base
94. EHDSPatientSummary.currentProblems.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.currentProblems.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
98. EHDSPatientSummary.currentProblems.healthConditions
Definition | Health conditions affecting the health of the patient.
Short | Health conditions affecting the health of the patient.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
100. EHDSPatientSummary.medicalDevicesAndImplants
Definition | Section: Medical devices and implants
Short | Section: Medical devices and implants
Control | 1..1
Type | Base
102. EHDSPatientSummary.medicalDevicesAndImplants.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
104. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
106. EHDSPatientSummary.medicalDevicesAndImplants.medicalDevice
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
108. EHDSPatientSummary.procedures
Definition | Section: Procedures
Short | Section: Procedures
Control | 1..1
Type | Base
110. EHDSPatientSummary.procedures.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
112. EHDSPatientSummary.procedures.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
114. EHDSPatientSummary.procedures.procedure
Definition | Major procedures.
Short | Major procedures.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
116. EHDSPatientSummary.medicationSummary
Definition | Current and relevant past medicine.
Short | Section: Medication Summary.
Control | 1..1
Type | Base
118. EHDSPatientSummary.medicationSummary.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
120. EHDSPatientSummary.medicationSummary.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
122. EHDSPatientSummary.medicationSummary.medicationTreatment
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationAdministration
124. EHDSPatientSummary.functionalStatus
Definition | Section: Functional status
Short | Section: Functional status
Control | 0..1
Type | Base
126. EHDSPatientSummary.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
128. EHDSPatientSummary.functionalStatus.functionalStatusAssessment
Definition | An individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
130. EHDSPatientSummary.socialHistory
Definition | 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.
Short | Section: Social history.
Control | 0..1
Type | Base
132. EHDSPatientSummary.socialHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
134. EHDSPatientSummary.socialHistory.description
Definition | Textual description of the social history.
Short | Textual description of the social history.
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
136. EHDSPatientSummary.socialHistory.observation
Definition | Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
Short | Social history observations related to health
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
138. EHDSPatientSummary.pregnancyHistory
Definition | Section: Pregnancy history
Short | Section: Pregnancy history
Control | 0..1
Type | Base
140. EHDSPatientSummary.pregnancyHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
142. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition | Current pregnancy status
Short | Current pregnancy status
Control | 0..1
Type | Base
144. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.status
Definition | Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Short | Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
146. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.expectedDateOfDelivery
Definition | Date on which the woman is due to give birth.
Short | Expected date of delivery
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
148. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition | History of previous pregnancies
Short | History of previous pregnancies
Control | 0..1
Type | Base
150. EHDSPatientSummary.pregnancyHistory.previousPregnancies.status
Definition | Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Short | Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
152. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description
Definition | Previous pregnancy's descriptions in detail
Short | Previous pregnancy's descriptions in detail
Control | 0..*
Type | Base
154. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.outcome
Definition | Outcome of the pregnancy
Short | Outcome of the pregnancy
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
156. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.numberOfChildren
Definition | Number of children/fetuses in this specific pregnancy
Short | Number of children/fetuses in this specific pregnancy
Control | 0..1
Type | integer
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
158. EHDSPatientSummary.patientProvidedData
Definition | Section: Patient provided data
Short | Section: Patient provided data
Control | 0..1
Type | Base
160. EHDSPatientSummary.patientProvidedData.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
162. EHDSPatientSummary.patientProvidedData.travelHistory
Definition | 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.
Short | 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.
Control | 0..*
Type | Base
164. EHDSPatientSummary.patientProvidedData.travelHistory.country
Definition | Country code
Short | Country code
Control | 0..1
Binding | ISO 3166
Type | CodeableConcept
166. EHDSPatientSummary.patientProvidedData.travelHistory.period
Definition | Date of entry and departure
Short | Date of entry and departure
Control | 0..*
Type | Period
168. EHDSPatientSummary.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
170. EHDSPatientSummary.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
172. EHDSPatientSummary.advanceDirectives.documentation
Definition | May take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Short | May take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
174. EHDSPatientSummary.results
Definition | Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Short | Section: Observation results.
Control | 0..1
Type | Base
176. EHDSPatientSummary.results.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
178. EHDSPatientSummary.results.resultObservation[x]
Definition | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Short | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
180. EHDSPatientSummary.carePlan
Definition | Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
Short | Section: Care plans.
Control | 0..1
Type | Base
182. EHDSPatientSummary.carePlan.narrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
184. EHDSPatientSummary.carePlan.carePlanEntry
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan

Guidance on how to interpret the contents of this table can be found here

0. EHDSPatientSummary
Definition | EHDS refined base model for Patient Summary
Short | Patient summary model
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSPatientSummary.header
Short | Metadata for the patient summary document
4. EHDSPatientSummary.header.attestation
Control | 0..0
6. EHDSPatientSummary.header.legalAuthentication
Control | 0..0
8. EHDSPatientSummary.header.eventType
Control | 0..0
10. EHDSPatientSummary.header.authorSpecialty
Control | 0..0
12. EHDSPatientSummary.header.natureOfTheDocument
Definition | 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)
Short | Nature of the document
Control | 1..1
Type | Base
14. EHDSPatientSummary.preferredHealthProfessional[x]
Definition | 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).
Short | A.1.3 - Preferred Health Professional
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
16. EHDSPatientSummary.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 1..1
Type | Base
Requirements | eHN PS Guideline
18. EHDSPatientSummary.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSPatientSummary.alerts.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
22. EHDSPatientSummary.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
Requirements | eHN PS Guideline
24. EHDSPatientSummary.allergiesAndIntolerances
Definition | Section: Allergies and intolerances
Short | Section: Allergies and intolerances
Control | 1..1
Type | Base
26. EHDSPatientSummary.allergiesAndIntolerances.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
28. EHDSPatientSummary.allergiesAndIntolerances.emptyReason
Definition | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Short | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Control | 0..1
Type | CodeableConcept
30. EHDSPatientSummary.allergiesAndIntolerances.allergy
Definition | Allergy or intolerance information
Short | Allergy or intolerance information
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN PS Guideline
32. EHDSPatientSummary.medicalHistory
Definition | 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.
Short | Section: Medical History.
Control | 0..1
Type | Base
34. EHDSPatientSummary.medicalHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
36. EHDSPatientSummary.medicalHistory.pastProblems
Definition | 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)
Short | 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)
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements | eHN PS Guideline
38. EHDSPatientSummary.medicalHistory.description
Definition | Narrative description of past problems.
Short | Narrative description of past problems.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
40. EHDSPatientSummary.immunisations
Definition | 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.
Short | Section: Immunisations.
Control | 0..1
Type | Base
42. EHDSPatientSummary.immunisations.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
44. EHDSPatientSummary.immunisations.vaccination
Definition | Immunizations given to the patient and their status at the point of care.
Short | Immunizations given to the patient and their status at the point of care.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunization
Requirements | eHN PS Guideline
46. EHDSPatientSummary.currentProblems
Definition | Conditions that are important to be known for a health professional during a health encounter.
Short | Section: Current medical problems.
Control | 1..1
Type | Base
48. EHDSPatientSummary.currentProblems.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
50. EHDSPatientSummary.currentProblems.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
52. EHDSPatientSummary.currentProblems.healthConditions
Definition | Health conditions affecting the health of the patient.
Short | Health conditions affecting the health of the patient.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
54. EHDSPatientSummary.medicalDevicesAndImplants
Definition | Section: Medical devices and implants
Short | Section: Medical devices and implants
Control | 1..1
Type | Base
56. EHDSPatientSummary.medicalDevicesAndImplants.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
58. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
60. EHDSPatientSummary.medicalDevicesAndImplants.medicalDevice
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
62. EHDSPatientSummary.procedures
Definition | Section: Procedures
Short | Section: Procedures
Control | 1..1
Type | Base
64. EHDSPatientSummary.procedures.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.procedures.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
68. EHDSPatientSummary.procedures.procedure
Definition | Major procedures.
Short | Major procedures.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
70. EHDSPatientSummary.medicationSummary
Definition | Current and relevant past medicine.
Short | Section: Medication Summary.
Control | 1..1
Type | Base
72. EHDSPatientSummary.medicationSummary.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSPatientSummary.medicationSummary.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
76. EHDSPatientSummary.medicationSummary.medicationTreatment
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationAdministration
78. EHDSPatientSummary.functionalStatus
Definition | Section: Functional status
Short | Section: Functional status
Control | 0..1
Type | Base
80. EHDSPatientSummary.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
82. EHDSPatientSummary.functionalStatus.functionalStatusAssessment
Definition | An individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
84. EHDSPatientSummary.socialHistory
Definition | 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.
Short | Section: Social history.
Control | 0..1
Type | Base
86. EHDSPatientSummary.socialHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
88. EHDSPatientSummary.socialHistory.description
Definition | Textual description of the social history.
Short | Textual description of the social history.
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSPatientSummary.socialHistory.observation
Definition | Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
Short | Social history observations related to health
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
92. EHDSPatientSummary.pregnancyHistory
Definition | Section: Pregnancy history
Short | Section: Pregnancy history
Control | 0..1
Type | Base
94. EHDSPatientSummary.pregnancyHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition | Current pregnancy status
Short | Current pregnancy status
Control | 0..1
Type | Base
98. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.status
Definition | Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Short | Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
100. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.expectedDateOfDelivery
Definition | Date on which the woman is due to give birth.
Short | Expected date of delivery
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
102. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition | History of previous pregnancies
Short | History of previous pregnancies
Control | 0..1
Type | Base
104. EHDSPatientSummary.pregnancyHistory.previousPregnancies.status
Definition | Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Short | Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
106. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description
Definition | Previous pregnancy's descriptions in detail
Short | Previous pregnancy's descriptions in detail
Control | 0..*
Type | Base
108. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.outcome
Definition | Outcome of the pregnancy
Short | Outcome of the pregnancy
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
110. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.numberOfChildren
Definition | Number of children/fetuses in this specific pregnancy
Short | Number of children/fetuses in this specific pregnancy
Control | 0..1
Type | integer
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
112. EHDSPatientSummary.patientProvidedData
Definition | Section: Patient provided data
Short | Section: Patient provided data
Control | 0..1
Type | Base
114. EHDSPatientSummary.patientProvidedData.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
116. EHDSPatientSummary.patientProvidedData.travelHistory
Definition | 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.
Short | 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.
Control | 0..*
Type | Base
118. EHDSPatientSummary.patientProvidedData.travelHistory.country
Definition | Country code
Short | Country code
Control | 0..1
Binding | ISO 3166
Type | CodeableConcept
120. EHDSPatientSummary.patientProvidedData.travelHistory.period
Definition | Date of entry and departure
Short | Date of entry and departure
Control | 0..*
Type | Period
122. EHDSPatientSummary.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
124. EHDSPatientSummary.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
126. EHDSPatientSummary.advanceDirectives.documentation
Definition | May take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Short | May take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
128. EHDSPatientSummary.results
Definition | Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Short | Section: Observation results.
Control | 0..1
Type | Base
130. EHDSPatientSummary.results.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
132. EHDSPatientSummary.results.resultObservation[x]
Definition | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Short | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
134. EHDSPatientSummary.carePlan
Definition | Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
Short | Section: Care plans.
Control | 0..1
Type | Base
136. EHDSPatientSummary.carePlan.narrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
138. EHDSPatientSummary.carePlan.carePlanEntry
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan

Guidance on how to interpret the contents of this table can be found here

0. EHDSPatientSummary
Definition | EHDS refined base model for Patient Summary
Short | Patient summary model
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSPatientSummary.header
Definition | Common header for all patient-related data
Short | Metadata for the patient summary document
Control | 1..*
Type | Base
4. EHDSPatientSummary.header.subject
Definition | Patient/subject information
Short | Subject
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
6. EHDSPatientSummary.header.identifier
Definition | Unique identifier of the document
Short | Document ID
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSPatientSummary.header.authorship
Definition | Resource authoring details
Short | Authorship
Control | 1..*
Type | Base
10. EHDSPatientSummary.header.authorship.author[x]
Definition | Author(s) by whom the resource was/were authored. Multiple authors could be provided.
Short | Author
Control | 1..1
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
12. EHDSPatientSummary.header.authorship.datetime
Definition | Date and time of the issuing the document/resource by its author.
Short | Date and time of authoring/issuing
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
14. EHDSPatientSummary.header.lastUpdate
Definition | Date and time of the last update to the document/information
Short | Date and time of the last update to the resource
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSPatientSummary.header.status
Definition | Status of the resource
Short | Status of the resource
Control | 1..1
Type | CodeableConcept
18. EHDSPatientSummary.header.statusReason[x]
Definition | Reason for the current status of the resource.
Short | Reason for the current status of the resource.
Control | 0..1
Type | Choice of: CodeableConcept, string
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSPatientSummary.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
22. EHDSPatientSummary.header.version
Definition | Business version of the resource.
Short | Version
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
24. EHDSPatientSummary.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAttachment
26. EHDSPatientSummary.header.documentType
Definition | Identifies the type of document at hand, e.g. Hospital discharge report.
Short | Document type
Control | 1..1
Binding | LOINC
Type | CodeableConcept
28. EHDSPatientSummary.header.documentTitle
Definition | Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.
Short | Document title
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
30. EHDSPatientSummary.header.documentStatus
Definition | The status of the Hospital discharge report. E.g., preliminary, final.
Short | Document status
Control | 1..1
Binding | hl7:CompositionStatus
Type | CodeableConcept
32. EHDSPatientSummary.header.period
Definition | Time of service that is being documented
Short | Period
Control | 0..1
Type | Period
34. EHDSPatientSummary.header.attestation
Definition | Document attestation details
Short | Attestation
Control | 0..0
Type | Base
38. EHDSPatientSummary.header.legalAuthentication
Definition | Document legal authentication
Short | Legal authentication
Control | 0..0
Type | Base
42. EHDSPatientSummary.header.eventType
Definition | 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.
Short | Event type
Control | 0..0
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
44. EHDSPatientSummary.header.authorSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Specialty
Control | 0..0
Binding | SNOMED CT
Type | CodeableConcept
46. EHDSPatientSummary.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Document custodian
Control | 1..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
48. EHDSPatientSummary.header.documentFormat
Definition | An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
Short | Document format
Control | 0..1
Binding | HL7 Document Format Codes
Type | CodeableConcept
50. EHDSPatientSummary.header.confidentiality
Definition | Level of confidentiality of the document. Implicit value is normal.
Short | Confidentiality
Control | 0..1
Binding | hl7:Confidentiality
Type | CodeableConcept
52. EHDSPatientSummary.knowledgeResources
Definition | Related documents and information sources
Short | Related documents and information sources
Control | 0..*
Type | Base
54. EHDSPatientSummary.knowledgeResources.externalReference
Definition | ...
Short | ...
Control | 0..*
Type | RelatedArtifact
56. EHDSPatientSummary.knowledgeResources.relatedTo
Definition | ...
Short | ...
Control | 0..*
Type | Reference
58. EHDSPatientSummary.header.natureOfTheDocument
Definition | 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)
Short | Nature of the document
Control | 1..1
Type | Base
60. EHDSPatientSummary.preferredHealthProfessional[x]
Definition | 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).
Short | A.1.3 - Preferred Health Professional
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
62. EHDSPatientSummary.alerts
Definition | Information about substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts.
Control | 1..1
Type | Base
Requirements | eHN PS Guideline
64. EHDSPatientSummary.alerts.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.alerts.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
68. EHDSPatientSummary.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
Requirements | eHN PS Guideline
70. EHDSPatientSummary.allergiesAndIntolerances
Definition | Section: Allergies and intolerances
Short | Section: Allergies and intolerances
Control | 1..1
Type | Base
72. EHDSPatientSummary.allergiesAndIntolerances.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSPatientSummary.allergiesAndIntolerances.emptyReason
Definition | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Short | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Control | 0..1
Type | CodeableConcept
76. EHDSPatientSummary.allergiesAndIntolerances.allergy
Definition | Allergy or intolerance information
Short | Allergy or intolerance information
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN PS Guideline
78. EHDSPatientSummary.medicalHistory
Definition | 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.
Short | Section: Medical History.
Control | 0..1
Type | Base
80. EHDSPatientSummary.medicalHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
82. EHDSPatientSummary.medicalHistory.pastProblems
Definition | 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)
Short | 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)
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements | eHN PS Guideline
84. EHDSPatientSummary.medicalHistory.description
Definition | Narrative description of past problems.
Short | Narrative description of past problems.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
86. EHDSPatientSummary.immunisations
Definition | 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.
Short | Section: Immunisations.
Control | 0..1
Type | Base
88. EHDSPatientSummary.immunisations.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSPatientSummary.immunisations.vaccination
Definition | Immunizations given to the patient and their status at the point of care.
Short | Immunizations given to the patient and their status at the point of care.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSImmunization
Requirements | eHN PS Guideline
92. EHDSPatientSummary.currentProblems
Definition | Conditions that are important to be known for a health professional during a health encounter.
Short | Section: Current medical problems.
Control | 1..1
Type | Base
94. EHDSPatientSummary.currentProblems.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.currentProblems.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
98. EHDSPatientSummary.currentProblems.healthConditions
Definition | Health conditions affecting the health of the patient.
Short | Health conditions affecting the health of the patient.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
100. EHDSPatientSummary.medicalDevicesAndImplants
Definition | Section: Medical devices and implants
Short | Section: Medical devices and implants
Control | 1..1
Type | Base
102. EHDSPatientSummary.medicalDevicesAndImplants.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
104. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
106. EHDSPatientSummary.medicalDevicesAndImplants.medicalDevice
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
108. EHDSPatientSummary.procedures
Definition | Section: Procedures
Short | Section: Procedures
Control | 1..1
Type | Base
110. EHDSPatientSummary.procedures.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
112. EHDSPatientSummary.procedures.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
114. EHDSPatientSummary.procedures.procedure
Definition | Major procedures.
Short | Major procedures.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
116. EHDSPatientSummary.medicationSummary
Definition | Current and relevant past medicine.
Short | Section: Medication Summary.
Control | 1..1
Type | Base
118. EHDSPatientSummary.medicationSummary.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
120. EHDSPatientSummary.medicationSummary.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
122. EHDSPatientSummary.medicationSummary.medicationTreatment
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationAdministration
124. EHDSPatientSummary.functionalStatus
Definition | Section: Functional status
Short | Section: Functional status
Control | 0..1
Type | Base
126. EHDSPatientSummary.functionalStatus.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
128. EHDSPatientSummary.functionalStatus.functionalStatusAssessment
Definition | An individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Short | An individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSFunctionalStatus
130. EHDSPatientSummary.socialHistory
Definition | 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.
Short | Section: Social history.
Control | 0..1
Type | Base
132. EHDSPatientSummary.socialHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
134. EHDSPatientSummary.socialHistory.description
Definition | Textual description of the social history.
Short | Textual description of the social history.
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
136. EHDSPatientSummary.socialHistory.observation
Definition | Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
Short | Social history observations related to health
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
138. EHDSPatientSummary.pregnancyHistory
Definition | Section: Pregnancy history
Short | Section: Pregnancy history
Control | 0..1
Type | Base
140. EHDSPatientSummary.pregnancyHistory.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
142. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition | Current pregnancy status
Short | Current pregnancy status
Control | 0..1
Type | Base
144. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.status
Definition | Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Short | Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
146. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.expectedDateOfDelivery
Definition | Date on which the woman is due to give birth.
Short | Expected date of delivery
Control | 0..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
148. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition | History of previous pregnancies
Short | History of previous pregnancies
Control | 0..1
Type | Base
150. EHDSPatientSummary.pregnancyHistory.previousPregnancies.status
Definition | Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Short | Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
152. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description
Definition | Previous pregnancy's descriptions in detail
Short | Previous pregnancy's descriptions in detail
Control | 0..*
Type | Base
154. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.outcome
Definition | Outcome of the pregnancy
Short | Outcome of the pregnancy
Control | 0..1
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
156. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.numberOfChildren
Definition | Number of children/fetuses in this specific pregnancy
Short | Number of children/fetuses in this specific pregnancy
Control | 0..1
Type | integer
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
158. EHDSPatientSummary.patientProvidedData
Definition | Section: Patient provided data
Short | Section: Patient provided data
Control | 0..1
Type | Base
160. EHDSPatientSummary.patientProvidedData.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
162. EHDSPatientSummary.patientProvidedData.travelHistory
Definition | 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.
Short | 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.
Control | 0..*
Type | Base
164. EHDSPatientSummary.patientProvidedData.travelHistory.country
Definition | Country code
Short | Country code
Control | 0..1
Binding | ISO 3166
Type | CodeableConcept
166. EHDSPatientSummary.patientProvidedData.travelHistory.period
Definition | Date of entry and departure
Short | Date of entry and departure
Control | 0..*
Type | Period
168. EHDSPatientSummary.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives.
Control | 0..1
Type | Base
170. EHDSPatientSummary.advanceDirectives.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
172. EHDSPatientSummary.advanceDirectives.documentation
Definition | May take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Short | May take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
174. EHDSPatientSummary.results
Definition | Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Short | Section: Observation results.
Control | 0..1
Type | Base
176. EHDSPatientSummary.results.narrative
Definition | Narrative, potentially formatted, content of the section
Short | Narrative, potentially formatted, content of the section
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
178. EHDSPatientSummary.results.resultObservation[x]
Definition | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Short | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control | 0..*
Type | Choice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
180. EHDSPatientSummary.carePlan
Definition | Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
Short | Section: Care plans.
Control | 0..1
Type | Base
182. EHDSPatientSummary.carePlan.narrative
Definition | 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.
Short | 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.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
184. EHDSPatientSummary.carePlan.carePlanEntry
Definition | 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.
Short | 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.
Control | 0..*
Type | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan