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
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. |
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 foundhere
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 foundhere
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 |