International Patient Summary Implementation Guide
1.1.0 - CI Build International flag

International Patient Summary Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-ips/ and changes regularly. See the Directory of published versions

Example Bundle: IPS Bundle example with Immunization


Generated Narrative

Resource "30551ce1-5a28-4356-b684-1e639094ad4d"

identifier: id: 3f69e0a5-2177-4540-baab-7a5d0877428f

status: final

type: Patient summary Document (LOINC#60591-5)

date: 2017-12-11 02:30:00+0100

author: Beetje van Hulp, MD

title: Patient Summary as of December 11, 2017 14:30

confidentiality: N

attester

mode: legal

time: 2017-12-11 02:30:00+0100

party: Beetje van Hulp, MD

attester

mode: legal

time: 2017-12-11 02:30:00+0100

party: Anorg Aniza Tion BV

custodian: Anorg Aniza Tion BV

RelatesTos

-CodeTarget[x]
*appendsid: c2277753-9f90-4a95-8ddb-a0b3f6e7d292

Events

-CodePeriod
*care provision (ActClass#PCPR)?? --> 2017-12-11 02:30:00+0100

Active Problems

Hot flushes

Medication

Medication Strength Form Dosage Comment
Anastrozole 1 mg tablet once daily treatment for breast cancer
Black Cohosh Extract pil herbal supplement

Allergies and Intolerances

Allergy to penicillin, high criticality, active No known food allergies

History of Past Illness

Breast cancer Stage II with no evidence of recurrence following treatment

Plan of Treatment

Continue hormone medication with Anastrozole for total of 5 years and monitor for potential breast cancer recurrence

Results

Blood typing
Blood group A+
C Ab [Presence] in Serum or Plasma Positive
E Ab [Presence] in Serum or Plasma Positive
Little c Ab [Presence] in Serum or Plasma Negative
Hemoglobin A1c monitoring
Hemoglobin A1c/Hemoglobin.total in Blood by HPLC 7.5 %
Bacteriology
Methicillin resistant Staphylococcus aureus
Healthy carrier of MRSA

Immunizations

Marie Lux-Brennard (Apr 17, 1998)

Vaccin anti diphtérie-coqueluche-tétanos-poliomyélite, Jun 3, 1998, 10:00:00 PM

Voie intramusculaire, Cuisse droite


Additional Document Content


2. urn:uuid:2b90dd2b-2dab-4c75-9bb9-a355e07401e8 (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)

Anonymous Patient Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)


3. urn:uuid:1c616b24-3895-48c4-9a02-9a64110351ef (Practitioner/1c616b24-3895-48c4-9a02-9a64110351ef)

Generated Narrative: Practitioner

Resource Practitioner "1c616b24-3895-48c4-9a02-9a64110351ef"

identifier: urn:oid:2.16.528.1.1007.3.1/129854633

active: true

name: Beetje van Hulp

Qualifications

-Code
*Doctor of Medicine (v2-0360|2.7#MD)


4. urn:uuid:890751f4-2924-4636-bab7-efffc7f3cf15 (Organization/890751f4-2924-4636-bab7-efffc7f3cf15)

Generated Narrative: Organization

Resource Organization "890751f4-2924-4636-bab7-efffc7f3cf15"

identifier: urn:oid:2.16.528.1.1007.3.3/564738757

active: true

name: Anorg Aniza Tion BV / The best custodian ever

Contacts

-TelecomAddress
*+31-51-34343400Houttuinen 27 Dordrecht 3311 CE NL (work)


5. urn:uuid:c64139e7-f02d-409c-bf34-75e8bf23bc80 (Condition/c64139e7-f02d-409c-bf34-75e8bf23bc80)

Generated Narrative: Condition

Resource Condition "c64139e7-f02d-409c-bf34-75e8bf23bc80"

identifier: urn:oid:1.2.3.999/c87bf51c-e53c-4bfe-b8b7-aa62bdd93002

clinicalStatus: Active (Condition Clinical Status Codes#active)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Problem (LOINC#75326-9)

severity: Moderate (LOINC#LA6751-7)

code: Menopausal flushing (finding) (SNOMED CT#198436008; ICD-10#N95.1 "Menopausal and female climacteric states")

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

onset: 2015

recordedDate: 2016-10


6. urn:uuid:c220e36c-eb67-4fc4-9ba1-2fabc52acec6 (MedicationStatement/c220e36c-eb67-4fc4-9ba1-2fabc52acec6)

Generated Narrative: MedicationStatement

Resource MedicationStatement "c220e36c-eb67-4fc4-9ba1-2fabc52acec6"

identifier: urn:oid:1.2.3.999/b75f92cb-61d4-469a-9387-df5ef70d25f0

status: RECORDED

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2015-03 --> (ongoing)

dosage


7. urn:uuid:47524493-846a-4a26-bae2-4ab03e60f02e (MedicationStatement/47524493-846a-4a26-bae2-4ab03e60f02e)

Generated Narrative: MedicationStatement

Resource MedicationStatement "47524493-846a-4a26-bae2-4ab03e60f02e"

identifier: urn:oid:1.2.3.999/9e312d6b-c6b6-439a-a730-6efaa5dcf8bc

status: RECORDED

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2016-01 --> (ongoing)

Dosages

-Route
*Oral use (standardterms.edqm.eu#20053000)


8. urn:uuid:976d0804-cae0-45ae-afe3-a19f3ceba6bc (Medication/976d0804-cae0-45ae-afe3-a19f3ceba6bc)

Generated Narrative: Medication

Resource Medication "976d0804-cae0-45ae-afe3-a19f3ceba6bc"

code: Product containing anastrozole (medicinal product) (SNOMED CT#108774000; unknown#99872 "ANASTROZOL 1MG TABLET"; unknown#2076667 "ANASTROZOL CF TABLET FILMOMHULD 1MG"; WHO ATC#L02BG03 "anastrozole")


9. urn:uuid:8adc0999-9468-4ac9-9557-680fa133d626 (Medication/8adc0999-9468-4ac9-9557-680fa133d626)

Generated Narrative: Medication

Resource Medication "8adc0999-9468-4ac9-9557-680fa133d626"

code: Black Cohosh Extract herbal supplement (SNOMED CT#412588001 "Cimicifuga racemosa extract (substance)"; WHO ATC#G02CX04 "Cimicifugae rhizoma")


10. urn:uuid:72884cad-ebe6-4f43-a51a-2f978275f132 (AllergyIntolerance/72884cad-ebe6-4f43-a51a-2f978275f132)

Generated Narrative: AllergyIntolerance

Resource AllergyIntolerance "72884cad-ebe6-4f43-a51a-2f978275f132"

identifier: urn:oid:1.2.3.999/3a462598-009c-484a-965c-d6b24a821424

clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)

verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)

type: Allergy (AllergyIntoleranceType#allergy)

category: MEDICATION

criticality: HIGH

code: Substance with penicillin structure and antibacterial mechanism of action (substance) (SNOMED CT#373270004)

patient: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

onset: 2010


11. urn:uuid:c4597aa2-688a-401b-a658-70acc6de28c6 (Condition/c4597aa2-688a-401b-a658-70acc6de28c6)

Generated Narrative: Condition

Resource Condition "c4597aa2-688a-401b-a658-70acc6de28c6"

identifier: urn:oid:1.2.3.999/66d4a8c7-9081-43e0-a63f-489c2ae6edd6

clinicalStatus: Remission (Condition Clinical Status Codes#remission)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Problem (LOINC#75326-9)

severity: Severe (LOINC#LA6750-9)

code: Malignant tumor of breast (SNOMED CT#254837009; International Classification of Diseases for Oncology, version 3.#8500/3 "Infiltrating duct carcinoma, NOS")

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

onset: 2015-01

abatement: 2015-03


12. urn:uuid:45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7 (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)

Generated Narrative: Organization

Resource Organization "45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7"

active: true

type: Other (Organization type#other)

name: Laboratoire de charme


13. urn:uuid:aa11a2be-3e36-4be7-b58a-6fc3dace2741 (Observation/aa11a2be-3e36-4be7-b58a-6fc3dace2741)

Generated Narrative: Observation

Resource Observation "aa11a2be-3e36-4be7-b58a-6fc3dace2741"

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: ABO and Rh group [Type] in Blood (LOINC#882-1)

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2015-10-10 09:15:00+0100

performer: See on this page: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

value: Blood group A Rh(D) positive (SNOMED CT#278149003)


14. urn:uuid:6e39ccf3-f997-4a2b-8f28-b4b71c778c70 (Observation/6e39ccf3-f997-4a2b-8f28-b4b71c778c70)

Generated Narrative: Observation

Resource Observation "6e39ccf3-f997-4a2b-8f28-b4b71c778c70"

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: C Ab [Presence] in Serum or Plasma (LOINC#945-6)

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2015-10-10 09:35:00+0100

performer: See on this page: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

value: Positive (SNOMED CT#10828004)


15. urn:uuid:b4916505-a06b-460c-9be8-011609282457 (Observation/b4916505-a06b-460c-9be8-011609282457)

Generated Narrative: Observation

Resource Observation "b4916505-a06b-460c-9be8-011609282457"

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: E Ab [Presence] in Serum or Plasma (LOINC#1018-1)

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2015-10-10 09:35:00+0100

performer: See on this page: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

value: Positive (SNOMED CT#10828004)


16. urn:uuid:a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4 (Observation/a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4)

Generated Narrative: Observation

Resource Observation "a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4"

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: little c Ab [Presence] in Serum or Plasma (LOINC#1156-9)

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2015-10-10 09:35:00+0100

performer: See on this page: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

value: Negative (SNOMED CT#260385009)


17. urn:uuid:2639657a-c19a-48e2-82cc-471e13b8ad94 (Observation/2639657a-c19a-48e2-82cc-471e13b8ad94)

Generated Narrative: Observation

Resource Observation "2639657a-c19a-48e2-82cc-471e13b8ad94"

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Blood typing ()

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2015-10-10

performer: See on this page: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

hasMember:


18. urn:uuid:cc354e00-a419-47ea-8b6c-1768b2a01646 (Observation/cc354e00-a419-47ea-8b6c-1768b2a01646)

Generated Narrative: Observation

Resource Observation "cc354e00-a419-47ea-8b6c-1768b2a01646"

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Hemoglobin A1c/Hemoglobin.total in Blood by HPLC (LOINC#17856-6)

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2017-11-10 08:20:00+0100

performer: See on this page: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

value: 7.5 % (Details: UCUM code % = '%')

note: Above stated goal of 7.0 %


19. urn:uuid:26bee0a9-5997-4557-ab9d-c6adbb05b572 (Observation/26bee0a9-5997-4557-ab9d-c6adbb05b572)

Generated Narrative: Observation

Resource Observation "26bee0a9-5997-4557-ab9d-c6adbb05b572"

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Bacteria identified in Isolate (LOINC#42803-7)

subject: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8

effective: 2017-12-10 08:20:00+0100

performer: See on this page: Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

value: Methicillin resistant Staphylococcus aureus (SNOMED CT#115329001)

note: Healthy carrier of MRSA


20. urn:uuid:c7781f44-6df8-4a8b-9e06-0b34263a47c5 (AllergyIntolerance/c7781f44-6df8-4a8b-9e06-0b34263a47c5)

Generated Narrative: AllergyIntolerance

Resource AllergyIntolerance "c7781f44-6df8-4a8b-9e06-0b34263a47c5"

clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)

code: No known food allergies (Absent and Unknown Data - IPS#no-known-food-allergies)

patient: See on this page: Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8


21. urn:uuid:40b7b6a0-c043-423a-9959-be3707e728b2 (Immunization/40b7b6a0-c043-423a-9959-be3707e728b2)

Marie Lux-Brennard (Apr 17, 1998)

Vaccin anti diphtérie-coqueluche-tétanos-poliomyélite, Jun 3, 1998, 10:00:00 PM

Voie intramusculaire, Cuisse droite