Logical model for health issues in the Patient Summary.

Nosological entities (diseases with defined or presumed etiology and pathophysiology), as well as clinical syndromes or other clinically significant conditions not yet classified.

Health conditions affecting the patient that must be known to the healthcare professional. Free-text description.

Formal coded representation of the health problem (classification).

Date of disease onset. Exact or approximate date.

Date when the problem was resolved or went into remission. Problems with an 'active' clinical status do not have this element populated.

Reason why the problem status changed to inactive (e.g., surgical procedure, medical treatment). Used only if not documented elsewhere in the Patient Summary.

Clinician’s subjective assessment of the severity of the problem.

Stage or grading of the disease expressed as text and/or code according to the selected scale (e.g., TNM, ICD-O).

Status of diagnostic confirmation (e.g., suspected, provisional, confirmed).

Relevant therapeutic and diagnostic or diagnostic-therapeutic procedures with impact on current or future care.

Procedure code in the selected coding system.

Free-text description of the

Anatomical location and laterality of the procedure using controlled terminology.

Date when the procedure was performed.

Reason for performing the procedure, expressed as text or code.

Formal coded representation of the procedure outcome.

Complications associated with the procedure.

Reference to a medical device that was implanted, removed, or otherwise manipulated during the procedure.

Number of times the procedure was performed.

Implanted or external medical devices on which the patient depends or which significantly affect the health status.

Coded and/or textual description of the medical device (implanted or external).

Normalized identifier (e.g., UDI) according to Regulation (EU) 2017/745.

Date of implantation or start of device use (exact or approximate).

Date of explantation or end of device use (exact or approximate).

Clinical reason for implantation or removal of the medical device (text and/or code).

Assessment of the patient’s ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL).

Date and time of the functional status assessment.

Person who performed the assessment or is the source of the information.

Free-text description of the patient’s functional status.

Formalized functional status assessment according to a selected evaluation system (e.g., ICF).

Date when the functional limitation began.

Assessment result expressed as free text.

Assessment description including code (default system: ICF).

Coded result of the functional status assessment.

Logical model for health issues in the Patient Summary.

Nosological entities (diseases with defined or presumed etiology and pathophysiology), as well as clinical syndromes or other clinically significant conditions not yet classified.

Health conditions affecting the patient that must be known to the healthcare professional. Free-text description.

Formal coded representation of the health problem (classification).

Date of disease onset. Exact or approximate date.

Date when the problem was resolved or went into remission. Problems with an 'active' clinical status do not have this element populated.

Reason why the problem status changed to inactive (e.g., surgical procedure, medical treatment). Used only if not documented elsewhere in the Patient Summary.

Clinician’s subjective assessment of the severity of the problem.

Stage or grading of the disease expressed as text and/or code according to the selected scale (e.g., TNM, ICD-O).

Status of diagnostic confirmation (e.g., suspected, provisional, confirmed).

Relevant therapeutic and diagnostic or diagnostic-therapeutic procedures with impact on current or future care.

Procedure code in the selected coding system.

Free-text description of the

Anatomical location and laterality of the procedure using controlled terminology.

Date when the procedure was performed.

Reason for performing the procedure, expressed as text or code.

Formal coded representation of the procedure outcome.

Complications associated with the procedure.

Reference to a medical device that was implanted, removed, or otherwise manipulated during the procedure.

Number of times the procedure was performed.

Implanted or external medical devices on which the patient depends or which significantly affect the health status.

Coded and/or textual description of the medical device (implanted or external).

Normalized identifier (e.g., UDI) according to Regulation (EU) 2017/745.

Date of implantation or start of device use (exact or approximate).

Date of explantation or end of device use (exact or approximate).

Clinical reason for implantation or removal of the medical device (text and/or code).

Assessment of the patient’s ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL).

Date and time of the functional status assessment.

Person who performed the assessment or is the source of the information.

Free-text description of the patient’s functional status.

Formalized functional status assessment according to a selected evaluation system (e.g., ICF).

Date when the functional limitation began.

Assessment result expressed as free text.

Assessment description including code (default system: ICF).

Coded result of the functional status assessment.

Logical model for health issues in the Patient Summary.

Nosological entities (diseases with defined or presumed etiology and pathophysiology), as well as clinical syndromes or other clinically significant conditions not yet classified.

Health conditions affecting the patient that must be known to the healthcare professional. Free-text description.

Formal coded representation of the health problem (classification).

Date of disease onset. Exact or approximate date.

Date when the problem was resolved or went into remission. Problems with an 'active' clinical status do not have this element populated.

Reason why the problem status changed to inactive (e.g., surgical procedure, medical treatment). Used only if not documented elsewhere in the Patient Summary.

Clinician’s subjective assessment of the severity of the problem.

Stage or grading of the disease expressed as text and/or code according to the selected scale (e.g., TNM, ICD-O).

Status of diagnostic confirmation (e.g., suspected, provisional, confirmed).

Relevant therapeutic and diagnostic or diagnostic-therapeutic procedures with impact on current or future care.

Procedure code in the selected coding system.

Free-text description of the

Anatomical location and laterality of the procedure using controlled terminology.

Date when the procedure was performed.

Reason for performing the procedure, expressed as text or code.

Formal coded representation of the procedure outcome.

Complications associated with the procedure.

Reference to a medical device that was implanted, removed, or otherwise manipulated during the procedure.

Number of times the procedure was performed.

Implanted or external medical devices on which the patient depends or which significantly affect the health status.

Coded and/or textual description of the medical device (implanted or external).

Normalized identifier (e.g., UDI) according to Regulation (EU) 2017/745.

Date of implantation or start of device use (exact or approximate).

Date of explantation or end of device use (exact or approximate).

Clinical reason for implantation or removal of the medical device (text and/or code).

Assessment of the patient’s ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL).

Date and time of the functional status assessment.

Person who performed the assessment or is the source of the information.

Free-text description of the patient’s functional status.

Formalized functional status assessment according to a selected evaluation system (e.g., ICF).

Date when the functional limitation began.

Assessment result expressed as free text.

Assessment description including code (default system: ICF).

Coded result of the functional status assessment.