International Patient Summary Implementation Guide
2.0.0 - STU 2

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 2.0.0 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: Bundle - IPS with Data

Document Details

Language: en-GB

Profile: Bundle (IPS)

Final Document at 2017-12-11 14:30:00+0100 by Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100 for Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

Document Subject

Martha DeLarosa Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)

Active: | true
Contact Detail | +31788700800 Laan Van Europa 1600 Dordrecht 3317 DB NL
mother: | Martha Mum Promenade des Anglais 111 Lyon 69001 FR +33-555-20036

Document Content

## 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 Problems

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

## Additional Resources Included in Document

Entry 2 - fullUrl = urn:uuid:2b90dd2b-2dab-4c75-9bb9-a355e07401e8

Resource Patient:

> Martha DeLarosa Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)

> Active: | true
> Contact Detail | +31788700800 Laan Van Europa 1600 Dordrecht 3317 DB NL
> mother: | Martha Mum Promenade des Anglais 111 Lyon 69001 FR +33-555-20036

Entry 3 - fullUrl = urn:uuid:1c616b24-3895-48c4-9a02-9a64110351ef

Resource Practitioner:

> identifier: `urn:oid:2.16.528.1.1007.3.1`/129854633

> active: true

> name: Beetje van Hulp

> ### Qualifications

> - | Code
> * | Doctor of Medicine

Entry 4 - fullUrl = urn:uuid:890751f4-2924-4636-bab7-efffc7f3cf15

Resource Organization:

> identifier: `urn:oid:2.16.528.1.1007.3.3`/564738757

> active: true

> name: Anorg Aniza Tion BV / The best custodian ever

> ### Contacts

> - | Telecom | Address
> * | +31-51-34343400 | Houttuinen 27 Dordrecht 3311 CE NL (work)

Entry 5 - fullUrl = urn:uuid:c64139e7-f02d-409c-bf34-75e8bf23bc80

Resource Condition:

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

> clinicalStatus: Active

> verificationStatus: Confirmed

> category: Problem

> severity: Moderate severity

> code: Menopausal flushing (finding)

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> onset: 2015

> recordedDate: 2016-10

Entry 6 - fullUrl = urn:uuid:c220e36c-eb67-4fc4-9ba1-2fabc52acec6

Resource MedicationStatement:

> status: active

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

> status: recorded

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> effective: 2015-03 --> (ongoing)

> > dosage

> > timing: Count 1 times, Once

> > route: Oral use

> > ### DoseAndRates

> > - | Dose[x]
> > * | 1 tablet (Details: UCUM code1 = '1')

Entry 7 - fullUrl = urn:uuid:47524493-846a-4a26-bae2-4ab03e60f02e

Resource MedicationStatement:

> status: active

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

> status: recorded

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> effective: 2016-01 --> (ongoing)

> ### Dosages

> - | Route
> * | Oral use

Entry 8 - fullUrl = urn:uuid:976d0804-cae0-45ae-afe3-a19f3ceba6bc

Resource Medication:

> code: Product containing anastrozole (medicinal product)

Entry 9 - fullUrl = urn:uuid:8adc0999-9468-4ac9-9557-680fa133d626

Resource Medication:

> code: Black Cohosh Extract herbal supplement

Entry 10 - fullUrl = urn:uuid:72884cad-ebe6-4f43-a51a-2f978275f132

Resource AllergyIntolerance:

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

> clinicalStatus: Active

> verificationStatus: Confirmed

> type: Allergy

> category: Medication

> criticality: High Risk

> code: Substance with penicillin structure (substance)

> patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> onset: 2010

Entry 11 - fullUrl = urn:uuid:c4597aa2-688a-401b-a658-70acc6de28c6

Resource Condition:

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

> clinicalStatus: Remission

> verificationStatus: Confirmed

> category: Problem

> severity: Severe

> code: Malignant tumor of breast

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> onset: 2015-01

> abatement: 2015-03

Entry 12 - fullUrl = urn:uuid:45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

Resource Organization:

> active: true

> type: Other

> name: Laboratoire de charme

Entry 13 - fullUrl = urn:uuid:aa11a2be-3e36-4be7-b58a-6fc3dace2741

Resource Observation:

> status: Final

> category: Laboratory

> code: ABO and Rh group [Type] in Blood

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

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

> performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> value: Blood group A Rh(D) positive

Entry 14 - fullUrl = urn:uuid:6e39ccf3-f997-4a2b-8f28-b4b71c778c70

Resource Observation:

> status: Final

> category: Laboratory

> code: C Ab [Presence] in Serum or Plasma

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

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

> performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> value: Positive

Entry 15 - fullUrl = urn:uuid:b4916505-a06b-460c-9be8-011609282457

Resource Observation:

> status: Final

> category: Laboratory

> code: E Ab [Presence] in Serum or Plasma

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

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

> performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> value: Positive

Entry 16 - fullUrl = urn:uuid:a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4

Resource Observation:

> status: Final

> category: Laboratory

> code: little c Ab [Presence] in Serum or Plasma

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

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

> performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> value: Negative

Entry 17 - fullUrl = urn:uuid:2639657a-c19a-48e2-82cc-471e13b8ad94

Resource Observation:

> status: Final

> category: Laboratory

> code: Blood typing

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> effective: 2015-10-10

> performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> hasMember:

> - Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
> - Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
> - Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
> - Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

Entry 18 - fullUrl = urn:uuid:cc354e00-a419-47ea-8b6c-1768b2a01646

Resource Observation:

> status: Final

> category: Laboratory

> code: Hemoglobin A1c/Hemoglobin.total in Blood by HPLC

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

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

> performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

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

> note:

> > Above stated goal of 7.0 %

Entry 19 - fullUrl = urn:uuid:26bee0a9-5997-4557-ab9d-c6adbb05b572

Resource Observation:

> status: Final

> category: Laboratory

> code: Bacteria identified in Isolate

> subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

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

> performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

> value: Methicillin resistant Staphylococcus aureus

> note:

> > Healthy carrier of MRSA

Entry 20 - fullUrl = urn:uuid:c7781f44-6df8-4a8b-9e06-0b34263a47c5

Resource AllergyIntolerance:

> clinicalStatus: Active

> code: No known food allergy (situation)

> patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100