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/main and changes regularly. See the Directory of published versions

Logical Model: EHDSPatientSummary - Detailed Descriptions

Draft as of 2025-06-10

Definitions for the EHDSPatientSummary logical model.

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

0. EHDSPatientSummary
Definition

EHDS refined base model for Patient Summary


Base definition for all types defined in FHIR type system.

ShortPatient summary modelBase for all types and resources
Control0..*
Is Modifierfalse
Logical ModelInstances 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

ShortMetadata for the patient summary document
Control1..*
TypeBase
4. EHDSPatientSummary.header.subject
Definition

Patient/subject information

ShortSubject
Control1..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
6. EHDSPatientSummary.header.identifier
Definition

Unique identifier of the document

ShortDocument ID
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..*
TypeIdentifier
8. EHDSPatientSummary.header.authorship
Definition

Resource authoring details

ShortAuthorship
Control1..*
TypeBase
10. EHDSPatientSummary.header.authorship.author[x]
Definition

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

ShortAuthor
Control1..1
TypeChoice 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] NoteSeeChoice 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.

ShortDate and time of authoring/issuing
Control1..1
TypedateTime
Primitive ValueThis 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

ShortDate and time of the last update to the resource
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
16. EHDSPatientSummary.header.status
Definition

Status of the resource

ShortStatus of the resource
Control1..1
TypeCodeableConcept
18. EHDSPatientSummary.header.statusReason[x]
Definition

Reason for the current status of the resource.

ShortReason for the current status of the resource.
Control0..1
TypeChoice of: CodeableConcept, string
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Primitive ValueThis 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.

ShortLanguage
Control0..1
Binding

BCP 47

TypeCodeableConcept
22. EHDSPatientSummary.header.version
Definition

Business version of the resource.

ShortVersion
NoteThis is a business version Id, not a resource version Id (see discussion)
Control0..1
Typestring
Primitive ValueThis 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

ShortA narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control0..*
Typehttps://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.

ShortDocument type
Control1..1
Binding

LOINC

TypeCodeableConcept
28. EHDSPatientSummary.header.documentTitle
Definition

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

ShortDocument title
Control1..1
Typestring
Primitive ValueThis 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.

ShortDocument status
Control1..1
Binding

hl7:CompositionStatus

TypeCodeableConcept
32. EHDSPatientSummary.header.period
Definition

Time of service that is being documented

ShortPeriod
Control0..1
TypePeriod
34. EHDSPatientSummary.header.attestation
Definition

Document attestation details

ShortAttestation
Control0..0
TypeBase
38. EHDSPatientSummary.header.legalAuthentication
Definition

Document legal authentication

ShortLegal authentication
Control0..0
TypeBase
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.

ShortEvent type
Control0..0
Binding

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

TypeCodeableConcept
44. EHDSPatientSummary.header.authorSpecialty
Definition

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

ShortSpecialty
Control0..0
Binding

SNOMED CT

TypeCodeableConcept
46. EHDSPatientSummary.header.custodian
Definition

Organisation that is in charge of maintaining the document/report.

ShortDocument custodian
Control1..1
Typehttps://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.

ShortDocument format
Control0..1
Binding

HL7 Document Format Codes

TypeCodeableConcept
50. EHDSPatientSummary.header.confidentiality
Definition

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

ShortConfidentiality
Control0..1
Binding

hl7:Confidentiality

TypeCodeableConcept
52. EHDSPatientSummary.knowledgeResources
Definition

Related documents and information sources

ShortRelated documents and information sources
Control0..*
TypeBase
54. EHDSPatientSummary.knowledgeResources.externalReference
Definition

...

Short...
Control0..*
TypeRelatedArtifact
56. EHDSPatientSummary.knowledgeResources.relatedTo
Definition

...

Short...
Control0..*
TypeReference
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)

ShortNature of the document
Control1..1
TypeBase
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).

ShortA.1.3 - Preferred Health Professional
Control0..*
TypeChoice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
[x] NoteSeeChoice 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.

ShortSection: Alerts.
Control1..1
TypeBase
Requirements

eHN PS Guideline

64. EHDSPatientSummary.alerts.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.alerts.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortDescription 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
Requirements

eHN PS Guideline

70. EHDSPatientSummary.allergiesAndIntolerances
Definition

Section: Allergies and intolerances

ShortSection: Allergies and intolerances
Control1..1
TypeBase
72. EHDSPatientSummary.allergiesAndIntolerances.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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)

ShortReason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Control0..1
TypeCodeableConcept
76. EHDSPatientSummary.allergiesAndIntolerances.allergy
Definition

Allergy or intolerance information

ShortAllergy or intolerance information
Control0..*
Typehttps://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.

ShortSection: Medical History.
Control0..1
TypeBase
80. EHDSPatientSummary.medicalHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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)

ShortProblems 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)
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements

eHN PS Guideline

84. EHDSPatientSummary.medicalHistory.description
Definition

Narrative description of past problems.

ShortNarrative description of past problems.
Control0..1
Typestring
Primitive ValueThis 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.

ShortSection: Immunisations.
Control0..1
TypeBase
88. EHDSPatientSummary.immunisations.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

ShortImmunizations given to the patient and their status at the point of care.
Control0..*
Typehttps://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.

ShortSection: Current medical problems.
Control1..1
TypeBase
94. EHDSPatientSummary.currentProblems.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.currentProblems.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
98. EHDSPatientSummary.currentProblems.healthConditions
Definition

Health conditions affecting the health of the patient.

ShortHealth conditions affecting the health of the patient.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
100. EHDSPatientSummary.medicalDevicesAndImplants
Definition

Section: Medical devices and implants

ShortSection: Medical devices and implants
Control1..1
TypeBase
102. EHDSPatientSummary.medicalDevicesAndImplants.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
104. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortDescribes 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
108. EHDSPatientSummary.procedures
Definition

Section: Procedures

ShortSection: Procedures
Control1..1
TypeBase
110. EHDSPatientSummary.procedures.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
112. EHDSPatientSummary.procedures.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
114. EHDSPatientSummary.procedures.procedure
Definition

Major procedures.

ShortMajor procedures.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
116. EHDSPatientSummary.medicationSummary
Definition

Current and relevant past medicine.

ShortSection: Medication Summary.
Control1..1
TypeBase
118. EHDSPatientSummary.medicationSummary.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
120. EHDSPatientSummary.medicationSummary.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortMedication 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationAdministration
124. EHDSPatientSummary.functionalStatus
Definition

Section: Functional status

ShortSection: Functional status
Control0..1
TypeBase
126. EHDSPatientSummary.functionalStatus.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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

ShortAn individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control0..*
Typehttps://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.

ShortSection: Social history.
Control0..1
TypeBase
132. EHDSPatientSummary.socialHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
134. EHDSPatientSummary.socialHistory.description
Definition

Textual description of the social history.

ShortTextual description of the social history.
Control1..1
Typestring
Primitive ValueThis 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

ShortSocial history observations related to health
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
138. EHDSPatientSummary.pregnancyHistory
Definition

Section: Pregnancy history

ShortSection: Pregnancy history
Control0..1
TypeBase
140. EHDSPatientSummary.pregnancyHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
142. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition

Current pregnancy status

ShortCurrent pregnancy status
Control0..1
TypeBase
144. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.status
Definition

Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown

ShortCurrent state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
146. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.expectedDateOfDelivery
Definition

Date on which the woman is due to give birth.

ShortExpected date of delivery
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
148. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition

History of previous pregnancies

ShortHistory of previous pregnancies
Control0..1
TypeBase
150. EHDSPatientSummary.pregnancyHistory.previousPregnancies.status
Definition

Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown

ShortPrevious pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Control0..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
152. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description
Definition

Previous pregnancy's descriptions in detail

ShortPrevious pregnancy's descriptions in detail
Control0..*
TypeBase
154. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.outcome
Definition

Outcome of the pregnancy

ShortOutcome of the pregnancy
Control0..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
156. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.numberOfChildren
Definition

Number of children/fetuses in this specific pregnancy

ShortNumber of children/fetuses in this specific pregnancy
Control0..1
Typeinteger
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
158. EHDSPatientSummary.patientProvidedData
Definition

Section: Patient provided data

ShortSection: Patient provided data
Control0..1
TypeBase
160. EHDSPatientSummary.patientProvidedData.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

Shortcaptures 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.
Control0..*
TypeBase
164. EHDSPatientSummary.patientProvidedData.travelHistory.country
Definition

Country code

ShortCountry code
Control0..1
Binding

ISO 3166

TypeCodeableConcept
166. EHDSPatientSummary.patientProvidedData.travelHistory.period
Definition

Date of entry and departure

ShortDate of entry and departure
Control0..*
TypePeriod
168. EHDSPatientSummary.advanceDirectives
Definition

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

ShortSection: Advance Directives.
Control0..1
TypeBase
170. EHDSPatientSummary.advanceDirectives.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

ShortMay take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Control0..*
Binding

SNOMED CT

TypeCodeableConcept
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.

ShortSection: Observation results.
Control0..1
TypeBase
176. EHDSPatientSummary.results.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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

ShortObservation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control0..*
TypeChoice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] NoteSeeChoice 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

ShortSection: Care plans.
Control0..1
TypeBase
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.

ShortNarrative 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.
Control0..1
Typestring
Primitive ValueThis 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.

ShortDescribes 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan

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

0. EHDSPatientSummary
Definition

EHDS refined base model for Patient Summary

ShortPatient summary model
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. EHDSPatientSummary.header
ShortMetadata for the patient summary document
4. EHDSPatientSummary.header.attestation
Control0..0
6. EHDSPatientSummary.header.legalAuthentication
Control0..0
8. EHDSPatientSummary.header.eventType
Control0..0
10. EHDSPatientSummary.header.authorSpecialty
Control0..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)

ShortNature of the document
Control1..1
TypeBase
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).

ShortA.1.3 - Preferred Health Professional
Control0..*
TypeChoice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
[x] NoteSeeChoice 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.

ShortSection: Alerts.
Control1..1
TypeBase
Requirements

eHN PS Guideline

18. EHDSPatientSummary.alerts.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
20. EHDSPatientSummary.alerts.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortDescription 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
Requirements

eHN PS Guideline

24. EHDSPatientSummary.allergiesAndIntolerances
Definition

Section: Allergies and intolerances

ShortSection: Allergies and intolerances
Control1..1
TypeBase
26. EHDSPatientSummary.allergiesAndIntolerances.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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)

ShortReason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Control0..1
TypeCodeableConcept
30. EHDSPatientSummary.allergiesAndIntolerances.allergy
Definition

Allergy or intolerance information

ShortAllergy or intolerance information
Control0..*
Typehttps://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.

ShortSection: Medical History.
Control0..1
TypeBase
34. EHDSPatientSummary.medicalHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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)

ShortProblems 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)
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements

eHN PS Guideline

38. EHDSPatientSummary.medicalHistory.description
Definition

Narrative description of past problems.

ShortNarrative description of past problems.
Control0..1
Typestring
Primitive ValueThis 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.

ShortSection: Immunisations.
Control0..1
TypeBase
42. EHDSPatientSummary.immunisations.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

ShortImmunizations given to the patient and their status at the point of care.
Control0..*
Typehttps://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.

ShortSection: Current medical problems.
Control1..1
TypeBase
48. EHDSPatientSummary.currentProblems.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
50. EHDSPatientSummary.currentProblems.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
52. EHDSPatientSummary.currentProblems.healthConditions
Definition

Health conditions affecting the health of the patient.

ShortHealth conditions affecting the health of the patient.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
54. EHDSPatientSummary.medicalDevicesAndImplants
Definition

Section: Medical devices and implants

ShortSection: Medical devices and implants
Control1..1
TypeBase
56. EHDSPatientSummary.medicalDevicesAndImplants.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
58. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortDescribes 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
62. EHDSPatientSummary.procedures
Definition

Section: Procedures

ShortSection: Procedures
Control1..1
TypeBase
64. EHDSPatientSummary.procedures.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.procedures.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
68. EHDSPatientSummary.procedures.procedure
Definition

Major procedures.

ShortMajor procedures.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
70. EHDSPatientSummary.medicationSummary
Definition

Current and relevant past medicine.

ShortSection: Medication Summary.
Control1..1
TypeBase
72. EHDSPatientSummary.medicationSummary.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
74. EHDSPatientSummary.medicationSummary.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortMedication 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationAdministration
78. EHDSPatientSummary.functionalStatus
Definition

Section: Functional status

ShortSection: Functional status
Control0..1
TypeBase
80. EHDSPatientSummary.functionalStatus.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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

ShortAn individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control0..*
Typehttps://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.

ShortSection: Social history.
Control0..1
TypeBase
86. EHDSPatientSummary.socialHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
88. EHDSPatientSummary.socialHistory.description
Definition

Textual description of the social history.

ShortTextual description of the social history.
Control1..1
Typestring
Primitive ValueThis 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

ShortSocial history observations related to health
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
92. EHDSPatientSummary.pregnancyHistory
Definition

Section: Pregnancy history

ShortSection: Pregnancy history
Control0..1
TypeBase
94. EHDSPatientSummary.pregnancyHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition

Current pregnancy status

ShortCurrent pregnancy status
Control0..1
TypeBase
98. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.status
Definition

Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown

ShortCurrent state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
100. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.expectedDateOfDelivery
Definition

Date on which the woman is due to give birth.

ShortExpected date of delivery
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
102. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition

History of previous pregnancies

ShortHistory of previous pregnancies
Control0..1
TypeBase
104. EHDSPatientSummary.pregnancyHistory.previousPregnancies.status
Definition

Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown

ShortPrevious pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Control0..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
106. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description
Definition

Previous pregnancy's descriptions in detail

ShortPrevious pregnancy's descriptions in detail
Control0..*
TypeBase
108. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.outcome
Definition

Outcome of the pregnancy

ShortOutcome of the pregnancy
Control0..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
110. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.numberOfChildren
Definition

Number of children/fetuses in this specific pregnancy

ShortNumber of children/fetuses in this specific pregnancy
Control0..1
Typeinteger
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
112. EHDSPatientSummary.patientProvidedData
Definition

Section: Patient provided data

ShortSection: Patient provided data
Control0..1
TypeBase
114. EHDSPatientSummary.patientProvidedData.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

Shortcaptures 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.
Control0..*
TypeBase
118. EHDSPatientSummary.patientProvidedData.travelHistory.country
Definition

Country code

ShortCountry code
Control0..1
Binding

ISO 3166

TypeCodeableConcept
120. EHDSPatientSummary.patientProvidedData.travelHistory.period
Definition

Date of entry and departure

ShortDate of entry and departure
Control0..*
TypePeriod
122. EHDSPatientSummary.advanceDirectives
Definition

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

ShortSection: Advance Directives.
Control0..1
TypeBase
124. EHDSPatientSummary.advanceDirectives.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

ShortMay take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Control0..*
Binding

SNOMED CT

TypeCodeableConcept
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.

ShortSection: Observation results.
Control0..1
TypeBase
130. EHDSPatientSummary.results.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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

ShortObservation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control0..*
TypeChoice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] NoteSeeChoice 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

ShortSection: Care plans.
Control0..1
TypeBase
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.

ShortNarrative 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.
Control0..1
Typestring
Primitive ValueThis 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.

ShortDescribes 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan

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

0. EHDSPatientSummary
Definition

EHDS refined base model for Patient Summary

ShortPatient summary model
Control0..*
Is Modifierfalse
Logical ModelInstances 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

ShortMetadata for the patient summary document
Control1..*
TypeBase
4. EHDSPatientSummary.header.subject
Definition

Patient/subject information

ShortSubject
Control1..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient
6. EHDSPatientSummary.header.identifier
Definition

Unique identifier of the document

ShortDocument ID
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..*
TypeIdentifier
8. EHDSPatientSummary.header.authorship
Definition

Resource authoring details

ShortAuthorship
Control1..*
TypeBase
10. EHDSPatientSummary.header.authorship.author[x]
Definition

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

ShortAuthor
Control1..1
TypeChoice 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] NoteSeeChoice 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.

ShortDate and time of authoring/issuing
Control1..1
TypedateTime
Primitive ValueThis 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

ShortDate and time of the last update to the resource
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
16. EHDSPatientSummary.header.status
Definition

Status of the resource

ShortStatus of the resource
Control1..1
TypeCodeableConcept
18. EHDSPatientSummary.header.statusReason[x]
Definition

Reason for the current status of the resource.

ShortReason for the current status of the resource.
Control0..1
TypeChoice of: CodeableConcept, string
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Primitive ValueThis 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.

ShortLanguage
Control0..1
Binding

BCP 47

TypeCodeableConcept
22. EHDSPatientSummary.header.version
Definition

Business version of the resource.

ShortVersion
NoteThis is a business version Id, not a resource version Id (see discussion)
Control0..1
Typestring
Primitive ValueThis 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

ShortA narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control0..*
Typehttps://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.

ShortDocument type
Control1..1
Binding

LOINC

TypeCodeableConcept
28. EHDSPatientSummary.header.documentTitle
Definition

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

ShortDocument title
Control1..1
Typestring
Primitive ValueThis 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.

ShortDocument status
Control1..1
Binding

hl7:CompositionStatus

TypeCodeableConcept
32. EHDSPatientSummary.header.period
Definition

Time of service that is being documented

ShortPeriod
Control0..1
TypePeriod
34. EHDSPatientSummary.header.attestation
Definition

Document attestation details

ShortAttestation
Control0..0
TypeBase
38. EHDSPatientSummary.header.legalAuthentication
Definition

Document legal authentication

ShortLegal authentication
Control0..0
TypeBase
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.

ShortEvent type
Control0..0
Binding

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

TypeCodeableConcept
44. EHDSPatientSummary.header.authorSpecialty
Definition

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

ShortSpecialty
Control0..0
Binding

SNOMED CT

TypeCodeableConcept
46. EHDSPatientSummary.header.custodian
Definition

Organisation that is in charge of maintaining the document/report.

ShortDocument custodian
Control1..1
Typehttps://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.

ShortDocument format
Control0..1
Binding

HL7 Document Format Codes

TypeCodeableConcept
50. EHDSPatientSummary.header.confidentiality
Definition

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

ShortConfidentiality
Control0..1
Binding

hl7:Confidentiality

TypeCodeableConcept
52. EHDSPatientSummary.knowledgeResources
Definition

Related documents and information sources

ShortRelated documents and information sources
Control0..*
TypeBase
54. EHDSPatientSummary.knowledgeResources.externalReference
Definition

...

Short...
Control0..*
TypeRelatedArtifact
56. EHDSPatientSummary.knowledgeResources.relatedTo
Definition

...

Short...
Control0..*
TypeReference
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)

ShortNature of the document
Control1..1
TypeBase
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).

ShortA.1.3 - Preferred Health Professional
Control0..*
TypeChoice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization
[x] NoteSeeChoice 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.

ShortSection: Alerts.
Control1..1
TypeBase
Requirements

eHN PS Guideline

64. EHDSPatientSummary.alerts.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.alerts.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortDescription 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSAlertFlag
Requirements

eHN PS Guideline

70. EHDSPatientSummary.allergiesAndIntolerances
Definition

Section: Allergies and intolerances

ShortSection: Allergies and intolerances
Control1..1
TypeBase
72. EHDSPatientSummary.allergiesAndIntolerances.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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)

ShortReason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Control0..1
TypeCodeableConcept
76. EHDSPatientSummary.allergiesAndIntolerances.allergy
Definition

Allergy or intolerance information

ShortAllergy or intolerance information
Control0..*
Typehttps://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.

ShortSection: Medical History.
Control0..1
TypeBase
80. EHDSPatientSummary.medicalHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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)

ShortProblems 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)
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
Requirements

eHN PS Guideline

84. EHDSPatientSummary.medicalHistory.description
Definition

Narrative description of past problems.

ShortNarrative description of past problems.
Control0..1
Typestring
Primitive ValueThis 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.

ShortSection: Immunisations.
Control0..1
TypeBase
88. EHDSPatientSummary.immunisations.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

ShortImmunizations given to the patient and their status at the point of care.
Control0..*
Typehttps://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.

ShortSection: Current medical problems.
Control1..1
TypeBase
94. EHDSPatientSummary.currentProblems.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.currentProblems.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
98. EHDSPatientSummary.currentProblems.healthConditions
Definition

Health conditions affecting the health of the patient.

ShortHealth conditions affecting the health of the patient.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition
100. EHDSPatientSummary.medicalDevicesAndImplants
Definition

Section: Medical devices and implants

ShortSection: Medical devices and implants
Control1..1
TypeBase
102. EHDSPatientSummary.medicalDevicesAndImplants.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
104. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortDescribes 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDeviceUse
108. EHDSPatientSummary.procedures
Definition

Section: Procedures

ShortSection: Procedures
Control1..1
TypeBase
110. EHDSPatientSummary.procedures.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
112. EHDSPatientSummary.procedures.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
114. EHDSPatientSummary.procedures.procedure
Definition

Major procedures.

ShortMajor procedures.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure
116. EHDSPatientSummary.medicationSummary
Definition

Current and relevant past medicine.

ShortSection: Medication Summary.
Control1..1
TypeBase
118. EHDSPatientSummary.medicationSummary.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
120. EHDSPatientSummary.medicationSummary.emptyReason
Definition

Reason for absence of data

ShortReason for absence of data
Control0..1
TypeCodeableConcept
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.

ShortMedication 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSMedicationAdministration
124. EHDSPatientSummary.functionalStatus
Definition

Section: Functional status

ShortSection: Functional status
Control0..1
TypeBase
126. EHDSPatientSummary.functionalStatus.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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

ShortAn individual’s ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
Control0..*
Typehttps://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.

ShortSection: Social history.
Control0..1
TypeBase
132. EHDSPatientSummary.socialHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
134. EHDSPatientSummary.socialHistory.description
Definition

Textual description of the social history.

ShortTextual description of the social history.
Control1..1
Typestring
Primitive ValueThis 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

ShortSocial history observations related to health
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
138. EHDSPatientSummary.pregnancyHistory
Definition

Section: Pregnancy history

ShortSection: Pregnancy history
Control0..1
TypeBase
140. EHDSPatientSummary.pregnancyHistory.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
142. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition

Current pregnancy status

ShortCurrent pregnancy status
Control0..1
TypeBase
144. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.status
Definition

Current state at the date the observation was made: e.g. pregnant, not pregnant, unknown

ShortCurrent state at the date the observation was made: e.g. pregnant, not pregnant, unknown
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
146. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus.expectedDateOfDelivery
Definition

Date on which the woman is due to give birth.

ShortExpected date of delivery
Control0..1
TypedateTime
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
148. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition

History of previous pregnancies

ShortHistory of previous pregnancies
Control0..1
TypeBase
150. EHDSPatientSummary.pregnancyHistory.previousPregnancies.status
Definition

Previous pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown

ShortPrevious pregnancies status: Yes, previous pregnancies; No, previous pregnancies; Unknown
Control0..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
152. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description
Definition

Previous pregnancy's descriptions in detail

ShortPrevious pregnancy's descriptions in detail
Control0..*
TypeBase
154. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.outcome
Definition

Outcome of the pregnancy

ShortOutcome of the pregnancy
Control0..1
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation
156. EHDSPatientSummary.pregnancyHistory.previousPregnancies.description.numberOfChildren
Definition

Number of children/fetuses in this specific pregnancy

ShortNumber of children/fetuses in this specific pregnancy
Control0..1
Typeinteger
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
158. EHDSPatientSummary.patientProvidedData
Definition

Section: Patient provided data

ShortSection: Patient provided data
Control0..1
TypeBase
160. EHDSPatientSummary.patientProvidedData.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

Shortcaptures 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.
Control0..*
TypeBase
164. EHDSPatientSummary.patientProvidedData.travelHistory.country
Definition

Country code

ShortCountry code
Control0..1
Binding

ISO 3166

TypeCodeableConcept
166. EHDSPatientSummary.patientProvidedData.travelHistory.period
Definition

Date of entry and departure

ShortDate of entry and departure
Control0..*
TypePeriod
168. EHDSPatientSummary.advanceDirectives
Definition

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

ShortSection: Advance Directives.
Control0..1
TypeBase
170. EHDSPatientSummary.advanceDirectives.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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.

ShortMay take the form of a reference to a legal document (e.g., Living Will) or an external textual description.
Control0..*
Binding

SNOMED CT

TypeCodeableConcept
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.

ShortSection: Observation results.
Control0..1
TypeBase
176. EHDSPatientSummary.results.narrative
Definition

Narrative, potentially formatted, content of the section

ShortNarrative, potentially formatted, content of the section
Control0..1
Typestring
Primitive ValueThis 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

ShortObservation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control0..*
TypeChoice of: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation, https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLaboratoryObservation
[x] NoteSeeChoice 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

ShortSection: Care plans.
Control0..1
TypeBase
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.

ShortNarrative 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.
Control0..1
Typestring
Primitive ValueThis 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.

ShortDescribes 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.
Control0..*
Typehttps://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCarePlan