De-Identification Handbook
2.0.0-comment - ballot

De-Identification Handbook, published by IHE IT Infrastructure Technical Committee. This guide is not an authorized publication; it is the continuous build for version 2.0.0-comment built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/ITI.DeIdHandbook/ and changes regularly. See the Directory of published versions

## Example Bundle: ex-Bundle-secondaryUse-pandemicIPS-example-patient

Document Details

Profile: Bundle (IPS)

Final Document at 2024-07-01 00:00:00+0000 by Practitioner Heps Simone MD(official) for Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

Document Subject

Generated Narrative: Patient ex-Patient-secondaryUse-pandemicIPS

Profile: Patient (IPS)

Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

Active: | true | Deceased: | 2024-06-30
Marital Status: | Never Married
Contact Detail | ph: 07 850 9900(Mobile) Grenzstraße Oberhausen 46045 GM (home)
Unknown: | Joe Smith
Links: | General Practitioner: Heps, Simone

Document Content

Generated Narrative: Composition ex-Composition-secondaryUse-pandemicIPS

Profile: Composition (IPS)

status: Final

type: Patient summary Document

date: 2024-07-01 00:00:00+0000

author: Practitioner Heps Simone MD(official)

title: International Patient Summary

confidentiality: normal

custodian: Organization IHE International PCC

### Events

- | Code | Period
* | care provision | 2024-07-01 00:00:00+0000 --> 2024-07-01 00:00:00+0000

## Problem List

Problem list section

## Allergies and Intolerances

Allergies and intolerances section

## Medication List

Medication section

## Past Problems

History of Past Problems Section

## History of Immunizations

Immunizations section

## History of Procedures

History of Procedures section

## Diagnostic Results

Results section

## Social History

Social History

## Pregnancy History

Pregnancy section

## Medical Devices

Results section

## Vital Signs

Vital Signs Section

## Plan of Care

Plan of Care Section

## Advance Directives

No Advanced Directives

## Alerts

Alerts Section

## Functional Status

Functional Status Section

## Additional Resources Included in Document

Entry 2 - fullUrl = http://example.org/Patient/ex-Patient-secondaryUse-pandemicIPS

Resource Patient:

> Generated Narrative: Patient ex-Patient-secondaryUse-pandemicIPS

> Profile: Patient (IPS)

> Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> Active: | true | Deceased: | 2024-06-30
> Marital Status: | Never Married
> Contact Detail | ph: 07 850 9900(Mobile) Grenzstraße Oberhausen 46045 GM (home)
> Unknown: | Joe Smith
> Links: | General Practitioner: Heps, Simone

Entry 3 - fullUrl = http://example.org/Organization/ex-Organization-secondaryUse-pandemicIPS

Resource Organization:

> Generated Narrative: Organization ex-Organization-secondaryUse-pandemicIPS

> Profile: Organization (IPS)

> identifier: `urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639`/IHEPCC-20260331 (use: usual, period: 2026-04-01 --> (ongoing))

> active: true

> type: Educational Institute

> name: IHE International PCC

> alias: IHE PCC

> telecom: +1 630-571-2670, pcc@ihe.net

> address: 820 Jorie Blvd, Suite 200, Oak Brook, IL 60523 USA

Entry 4 - fullUrl = http://example.org/Practitioner/ex-Practitioner-IPS-SimoneHeps

Resource Practitioner:

> Generated Narrative: Practitioner ex-Practitioner-IPS-SimoneHeps

> Profile: Practitioner (IPS)

> identifier: `urn:oid:2.16.528.1.1007.3.1`/874635264 (use: official, ), `urn:oid:2.16.840.1.113883.2.4.6.3`/567IUI51C154 (use: usual, )

> name: Heps Simone MD(Official)

> address: Galapagosweg 91 Den Burg 9105 PZ NLD (work)

> gender: Female

> birthDate: 1971-11-07

Entry 5 - fullUrl = http://example.org/Practitioner/ex-Practitioner2-secondaryUse-pandemicIPS

Resource Practitioner:

> Generated Narrative: Practitioner ex-Practitioner2-secondaryUse-pandemicIPS

> Profile: Practitioner (IPS)

> name: Joseph Yaser

Entry 6 - fullUrl = http://example.org/MedicationStatement/ex-MedicationStatement-secondaryUse-pandemicIPS

Resource MedicationStatement:

> Generated Narrative: MedicationStatement ex-MedicationStatement-secondaryUse-pandemicIPS

> Profile: MedicationStatement (IPS)

> status: Completed

> medication: Product containing oseltamivir (medicinal product)

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-16

> dateAsserted: 2024-06-16

Entry 7 - fullUrl = http://example.org/Condition/ex-Condition1-secondaryUse-pandemicIPS

Resource Condition:

> Generated Narrative: Condition ex-Condition1-secondaryUse-pandemicIPS

> Profile: Condition (IPS)

> clinicalStatus: Active

> verificationStatus: Confirmed

> category: Problem List Item

> severity: Severe

> code: Influenza caused by pandemic influenza virus (disorder)

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> onset: 2024-06-15

> asserter: Practitioner Joseph Yaser

Entry 8 - fullUrl = http://example.org/Condition/ex-Condition2-secondaryUse-pandemicIPS

Resource Condition:

> Generated Narrative: Condition ex-Condition2-secondaryUse-pandemicIPS

> Profile: Condition (IPS)

> clinicalStatus: Active

> verificationStatus: Confirmed

> category: Problem List Item

> severity: Severe

> code: Severe asthma (disorder)

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> onset: 2006-01-03

> asserter: Practitioner Joseph Yaser

Entry 9 - fullUrl = http://example.org/Condition/ex-Condition3-secondaryUse-pandemicIPS

Resource Condition:

> Generated Narrative: Condition ex-Condition3-secondaryUse-pandemicIPS

> Profile: Condition (IPS)

> clinicalStatus: Resolved

> verificationStatus: Confirmed

> category: Encounter Diagnosis

> severity: Severe

> code: Fracture of femur (disorder)

> bodySite: Structure of left thigh (body structure)

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> onset: 2023-11-16

> asserter: Practitioner Joseph Yaser

Entry 10 - fullUrl = http://example.org/Procedure/ex-Procedure-secondaryUse-pandemicIPS

Resource Procedure:

> Generated Narrative: Procedure ex-Procedure-secondaryUse-pandemicIPS

> Profile: Procedure (IPS)

> status: Completed

> code: Artificial ventilation using ventilator

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> performed: 2024-06-25

> bodySite: Lung structure

> note:

> > Artificial ventilation using ventilaton performed

Entry 11 - fullUrl = http://example.org/AllergyIntolerance/ex-Allergy-secondaryUse-pandemicIPS

Resource AllergyIntolerance:

> Generated Narrative: AllergyIntolerance ex-Allergy-secondaryUse-pandemicIPS

> Profile: AllergyIntolerance (IPS)

> clinicalStatus: Active

> verificationStatus: Confirmed

> type: Allergy

> category: Medication

> criticality: High Risk

> code: Allergy to component of vaccine product containing Influenza virus antigen (finding)

> patient: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> onset: 2020-10-01

> lastOccurrence: 2020-10-01

> ### Reactions

> - | Manifestation | Severity
> * | Rash | Moderate

Entry 12 - fullUrl = http://example.org/Observation/ex-Lab-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-Lab-secondaryUse-pandemicIPS

> Profile: Observation Results - Laboratory/Pathology (IPS)

> status: Final

> category: Laboratory

> code: Influenza virus A Ag [Presence] in Nasopharynx

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15

> performer: Practitioner Heps Simone MD(official)

> value: 13.2 g/dL

> interpretation: High

> note:

> > Positive for Influenza A

Entry 13 - fullUrl = http://example.org/Immunization/ex-Immunization-secondaryUse-pandemicIPS

Resource Immunization:

> Generated Narrative: Immunization ex-Immunization-secondaryUse-pandemicIPS

> Profile: Immunization (IPS)

> status: Completed

> vaccineCode: Invluenza Vaccination

> patient: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> occurrence: 2024-05-01

> site: Structure of part of left upper limb

> route: Intramuscular route

> doseQuantity: 0.5 mL

> ### Performers

> - | Function | Actor
> * | Ordering Provider | Practitioner Joseph Yaser

> ### ProtocolApplieds

> - | TargetDisease | DoseNumber[x]
> * | Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder) | 2

Entry 14 - fullUrl = http://example.org/Observation/ex-PastPresJob-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-PastPresJob-secondaryUse-pandemicIPS

> Profile: Past Or Present Job

> status: Final

> category: Social History

> code: History of Occupation

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2016-03-10 --> 2020-04-14

> issued: 2024-06-06 13:28:53+0200

> performer: Practitioner Heps Simone MD(official)

> value: Health Care Assistants

> ### Components

> - | Code | Value[x]
> * | History of Occupation Industry | Residential nursing care facilities

Entry 15 - fullUrl = http://example.org/Observation/ex-PregStat-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-PregStat-secondaryUse-pandemicIPS

> Profile: Observation Pregnancy - Status (IPS)

> status: Final

> code: Pregnancy status

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2014-02-01

> performer: Practitioner Heps Simone MD(official)

> value: Pregnant

> hasMember: Observation Delivery date Estimated

Entry 16 - fullUrl = http://example.org/Observation/ex-EDD-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-EDD-secondaryUse-pandemicIPS

> Profile: Observation Pregnancy - Expected Delivery Date (IPS)

> status: Final

> code: Delivery date Estimated

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-02

> performer: Practitioner Heps Simone MD(official)

> value: 2024-12-01

Entry 17 - fullUrl = http://example.org/DeviceUseStatement/ex-DeviceUse-secondaryUse-pandemicIPS

Resource DeviceUseStatement:

> Generated Narrative: DeviceUseStatement ex-DeviceUse-secondaryUse-pandemicIPS

> Profile: DeviceUseStatement (IPS)

> status: Completed

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> timing: 2014-02-01

> device: Device: type = No known device use

> note:

> > Device data required

Entry 18 - fullUrl = http://example.org/Device/ex-Device-secondaryUse-pandemicIPS

Resource Device:

> Generated Narrative: Device ex-Device-secondaryUse-pandemicIPS

> Profile: Device (IPS)

> type: No known device use

> patient: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

Entry 19 - fullUrl = http://example.org/CarePlan/ex-CarePlan-secondaryUse-pandemicIPS

Resource CarePlan:

> Generated Narrative: CarePlan ex-CarePlan-secondaryUse-pandemicIPS

> status: Completed

> intent: Order

> title: Plan of Care

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> period: 2024-06-16 --> (ongoing)

> created: 2024-06-16

> note: ,

> > Treat with antiviral medication for 5 days

> > Provide Assisted Breathing on Ventilator

Entry 20 - fullUrl = http://example.org/Flag/ex-Alert-secondaryUse-pandemicIPS

Resource Flag:

> Generated Narrative: Flag ex-Alert-secondaryUse-pandemicIPS

> Profiles: Flag - Alert (IPS), Flag version: 4.0.1

> status: Active

> category: Clinical

> code: Severe asthma (disorder)

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

Entry 21 - fullUrl = http://example.org/ClinicalImpression/ex-ClinicalImp-secondaryUse-pandemicIPS

Resource ClinicalImpression:

> Generated Narrative: ClinicalImpression ex-ClinicalImp-secondaryUse-pandemicIPS

> status: Completed

> code: General problem AND/OR complaint (finding)

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-16

> date: 2024-06-16

> assessor: Practitioner Heps Simone MD(official)

> ### Findings

> - | ItemCodeableConcept
> * | Finding of walking aid use (finding)

Entry 22 - fullUrl = http://example.org/Observation/ex-VitalSignsPanel-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-VitalSignsPanel-secondaryUse-pandemicIPS

> Profile: Vital Signs Profile

> status: Final

> category: Vital Signs

> code: Vital signs, weight, height, head circumference, oxygen saturation and BMI panel

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15 09:44:00+0600

> performer: Practitioner Heps Simone MD(official)

> hasMember:

> - Observation Body height
> - Observation Body weight
> - Observation Body mass index (BMI) [Ratio]
> - Observation Blood pressure panel with all children optional
> - Observation Heart rate
> - Observation Oxygen saturation in Arterial blood

Entry 23 - fullUrl = http://example.org/Observation/ex-VitalSigns-Height-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-VitalSigns-Height-secondaryUse-pandemicIPS

> Profile: Vital Signs Profile

> status: Final

> category: Vital Signs

> code: Body height

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15 09:44:00+0600

> performer: Practitioner Heps Simone MD(official)

> value: 71 in_i (Details: UCUM code[in_i] = '[in_i]')

Entry 24 - fullUrl = http://example.org/Observation/ex-VitalSigns-Weight-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-VitalSigns-Weight-secondaryUse-pandemicIPS

> Profile: Vital Signs Profile

> status: Final

> category: Vital Signs

> code: Body weight

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15 09:44:00+0600

> performer: Practitioner Heps Simone MD(official)

> value: 230 lbs (Details: UCUM code[lb_av] = '[lb_av]')

Entry 25 - fullUrl = http://example.org/Observation/ex-VitalSigns-BMI-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-VitalSigns-BMI-secondaryUse-pandemicIPS

> Profile: Vital Signs Profile

> status: Final

> category: Vital Signs

> code: Body mass index (BMI) [Ratio]

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15 09:44:00+0600

> performer: Practitioner Heps Simone MD(official)

> value: 32.1 kg/m2 (Details: UCUM codekg/m2 = 'kg/m2')

Entry 26 - fullUrl = http://example.org/Observation/ex-VitalSigns-BP-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-VitalSigns-BP-secondaryUse-pandemicIPS

> Profile: Vital Signs Profile

> status: Final

> category: Vital Signs

> code: Blood pressure panel with all children optional

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15 09:44:00+0600

> performer: Practitioner Heps Simone MD(official)

> > component

> > code: Systolic blood pressure

> > value: 80 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')

> > component

> > code: Diastolic blood pressure

> > value: 130 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 27 - fullUrl = http://example.org/Observation/ex-VitalSigns-HeartRate-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-VitalSigns-HeartRate-secondaryUse-pandemicIPS

> Profile: Vital Signs Profile

> status: Final

> category: Vital Signs

> code: Heart rate

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15 09:44:00+0600

> performer: Practitioner Heps Simone MD(official)

> value: 80 /min (Details: UCUM code/min = '/min')

Entry 28 - fullUrl = http://example.org/Observation/ex-VitalSigns-OxygenSaturation-secondaryUse-pandemicIPS

Resource Observation:

> Generated Narrative: Observation ex-VitalSigns-OxygenSaturation-secondaryUse-pandemicIPS

> Profile: Vital Signs Profile

> status: Final

> category: Vital Signs

> code: Oxygen saturation in Arterial blood

> subject: Patricia Jordana(official) Female, DoB: 1996-05-01 ( urn:oid:1.3.6.1.4.1.21367.2011.2.5.5639#IHEEX-33159)

> effective: 2024-06-15 09:44:00+0600

> performer: Practitioner Heps Simone MD(official)

> value: 85 % (Details: UCUM code% = '%')