HL7 Czech Shared Health Record Implementation Guide
0.0.1 - ci-build
HL7 Czech Shared Health Record Implementation Guide
0.0.1 - ci-build
HL7 Czech Shared Health Record Implementation Guide, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/szz/ and changes regularly. See the Directory of published versions
The Shared Health Record (SZZ) is an electronic health record containing selected data about the patient's health status, intended for central sharing between the patient, Healthcare Providers (healthcare provider), and other authorized entities.
It is composed of two parts:
§ 81d of the amended Act No. 378/2007 Coll.Healthcare Services Act, especially its Annex in part 13.According to the amendment to the Act on the Electronisation of Healthcare, the recording person is:
Each recording person who ascertains data mandatorily kept in the SZZ is obliged to record it without undue delay. They are also responsible for its correctness and obliged to ensure its update or deletion if it becomes outdated. The obligation applies to all healthcare provider regardless of the size or technical equipment of the practice.
An authorized person is an entity that has the right to view the SZZ to the extent determined by law:
The patient also has the right to grant or withdraw consent for authorized persons to view their data. Every access is recorded in the Activity Journal, and the patient has the right to view an overview of these accesses.
Basic Sections
The Shared Health Record can be divided into several parts: the document header and the document body, which consists of the results of screening examinations and the emergency health record.
Patient Identification This section contains basic patient data, including identifiers (RID/DRID), given name, surname, date of birth, nationality, and other supporting data that allow for unambiguous identification in the Czech national context.
Patient Contact Information The section includes the patient's contact persons (legal representatives, close relatives, or other persons) who can provide additional information about the patient. The contact type is differentiated by role (e.g., emergency contact, legal representative, other relationship to the patient).
Health Insurance Contains data on the patient's health insurance company, policy number, and any supplementary information on the insurance relationship.
Document Recipient Specification of the intended recipient of the report, usually the target acute inpatient care provider (CPALP) or another healthcare facility to which the patient is transferred.
Author Identification data of Shared Health Record Author which created the record and is responsible for it.
Document Metadata Contains other administrative information about the document – e.g., category, version, date and time of creation, document status, language, and degree of confidentiality.
Electronic Signatures
A section designated for electronic signature or timestamp according to Act No. 327/2011 Coll., § 54a.
Blood Group Records the AB0 system and Rh factor. Information listed in this section also includes the date of determination and a code identifying the type of examination performed.
Allergies and Adverse Reactions Lists allergies that have manifested in the patient and were assessed as allergies, as well as other manifestations of intolerance, referred to as adverse reactions to a substance or medicinal product. This primarily includes allergic reactions to medicinal products and other substances used in the provision of healthcare – the causative substance (agent), the type (character) of the reaction, and its severity.
Other Emergency Data Contains records of significant adverse events. Typically, this includes adverse drug effects, transfusion reactions, complications during the administration of blood derivatives, etc.
Medicinal Products Used During Healthcare Provision by Inpatient Care Providers This section contains a list of medicinal products that were used on the patient during the provision of healthcare services by inpatient care providers over the period of the last 12 months.
General Practitioner The section contains the results of examinations within the data collected by a general practitioner for adults, which may include examination results within the scope of:
Gynecology The section contains the results of examinations within the data collected by a gynecologist, which may include results within the scope of:
Gastroenterology The section contains the results of examinations within the data collected by a gastroenterologist, which may include the examination result within the scope of colorectal carcinoma screening.
Radiology The section contains the results of examinations within the scope of data collected by a radiologist, which may include results within the scope of:
Biochemistry Laboratory The section contains the results of examinations by a biochemistry laboratory, which may include examination results within the scope of:
Pulmonology The section contains the results of examinations within the scope of data collected by a pulmonologist, which may include the examination result within the scope of early detection of lung carcinoma.
Urology The section contains the results of examinations within the scope of data collected by a urologist, which may include the result of:
Angiology The section contains the results of examinations within the scope of data collected by an angiologist, which may include the examination result within the scope of abdominal aortic aneurysm screening.