International Patient Summary (Bundle) - Cross Border Data Exchange IG v1.0.0

Cross Border Data Exchange IG, published by IEHR-Workgroup. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/InteropEHRate-project/cross-border-data-exchange/ and changes regularly. See the Directory of published versions

Example Bundle: International Patient Summary (Bundle)

Generated Narrative: Composition

Resource Composition "158355"

Profile: Composition-IEHR

ProvenanceExtension-IEHR: Provenance/1

status: PRELIMINARY

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

date: 2021-10-04

author:

See on this page: Practitioner/21
See on this page: Organization/34432

title: International Patient Summary

Allergies

This is the allergy section

See on this page: AllergyIntolerance/1111
See on this page: AllergyIntolerance/1112
See on this page: AllergyIntolerance/1113
See on this page: AllergyIntolerance/1114
See on this page: AllergyIntolerance/1115

Medication Section

This is the medications section

See on this page: MedicationStatement/7347
See on this page: MedicationStatement/7358
See on this page: MedicationStatement/7349
See on this page: MedicationStatement/7301
See on this page: MedicationStatement/73014

Problems Section

This is the problems section

See on this page: Condition/1111
See on this page: Condition/1112
See on this page: Condition/1114
See on this page: Condition/1115
See on this page: Condition/1116
See on this page: Condition/1117

History of Past Illness

This is the history of past illnesses section

See on this page: Condition/1113

VitalSign Section

This is the vital sign section

Result Section

This is the result section

See on this page: DiagnosticReport/3111

History of Procedures Section

This is the history of procedures section

See on this page: Procedure/1111
See on this page: Procedure/1112

Additional Document Content

2. http://interopEHRate.eu/fhir-resource/Patient/3466 (Patient/3466)

Anonymous Patient Male, DoB: 2013-12-05 ( http://interopEHRate.eu/fhir-resource/#Patient/MS01)

3. http://interopEHRate.eu/fhir-resource/Organization/34432 (Organization/34432)

Generated Narrative: Organization
Resource Organization "34432" (Language "it-IT")
Profile: Organization (IPS)
identifier: http://interopEHRate.eu/fhir-resource//Organization/FTGM01
name: Fondazione Gabriele Monasterio
Contacts
- Address
* Via Giuseppe Moruzzi 1 Pisa IT

4. http://interopEHRate.eu/fhir-resource/Practitioner/21 (Practitioner/21)

Generated Narrative: Practitioner
Resource Practitioner "21" (Language "it-IT")
Profile: Practitioner (IPS)
identifier: http://interopEHRate.eu/fhir-resource//Practitioner/MA01
name: Mark Antonio

5. http://interopEHRate.eu/fhir-resource/AllergyIntolerance/1111 (AllergyIntolerance/1111)

Generated Narrative: AllergyIntolerance
Resource AllergyIntolerance "1111"
Profile: AllergyIntolerance-IEHR
clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)
verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)
type: Allergy (AllergyIntoleranceType#allergy)
category: MEDICATION
criticality: HIGH
code: Blood product (product) (SNOMED CT#410652009)
patient: See on this page: Patient/3466
onset: 2021-09-24
Reactions
- Manifestation
* Anaphylaxis (disorder) (SNOMED CT#39579001)

6. http://interopEHRate.eu/fhir-resource/AllergyIntolerance/1112 (AllergyIntolerance/1112)

Generated Narrative: AllergyIntolerance
Resource AllergyIntolerance "1112"
Profile: AllergyIntolerance-IEHR
clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)
verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)
type: Intolerance (AllergyIntoleranceType#intolerance)
category: MEDICATION
criticality: LOW
code: Product containing dextran (medicinal product) (SNOMED CT#13132007)
patient: See on this page: Patient/3466
onset: 2021-03-21
Reactions
- Manifestation
* Tight chest (finding) (SNOMED CT#23924001)

7. http://interopEHRate.eu/fhir-resource/AllergyIntolerance/1113 (AllergyIntolerance/1113)

Generated Narrative: AllergyIntolerance
Resource AllergyIntolerance "1113"
Profile: AllergyIntolerance-IEHR
clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)
verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)
type: Intolerance (AllergyIntoleranceType#intolerance)
category: FOOD
criticality: LOW
code: Strawberry (substance) (SNOMED CT#102261002)
patient: See on this page: Patient/3466
onset: 2004-10-04
Reactions
- Manifestation
* Tight chest (finding) (SNOMED CT#23924001)

8. http://interopEHRate.eu/fhir-resource/AllergyIntolerance/1114 (AllergyIntolerance/1114)

Generated Narrative: AllergyIntolerance
Resource AllergyIntolerance "1114"
Profile: AllergyIntolerance-IEHR
clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)
verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)
type: Intolerance (AllergyIntoleranceType#intolerance)
category: ENVIRONMENT
criticality: LOW
code: Tree and shrub pollen (substance) (SNOMED CT#256260009)
patient: See on this page: Patient/3466
onset: 2017-07-04
Reactions
- Manifestation
* Cough (finding) (SNOMED CT#49727002)

9. http://interopEHRate.eu/fhir-resource/AllergyIntolerance/1115 (AllergyIntolerance/1115)

Generated Narrative: AllergyIntolerance
Resource AllergyIntolerance "1115"
Profile: AllergyIntolerance-IEHR
clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)
verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)
type: Intolerance (AllergyIntoleranceType#intolerance)
category: BIOLOGIC
criticality: HIGH
code: Rabies vaccine, human (product) (SNOMED CT#3526007; SNOMED CT#256260009 "Tree and shrub pollen (substance)")
patient: See on this page: Patient/3466
onset: 2020-11-11
Reactions
- Manifestation
* Cardiac arrhythmia (disorder) (SNOMED CT#698247007)

10. http://interopEHRate.eu/fhir-resource/MedicationStatement/7347 (MedicationStatement/7347)

Generated Narrative: MedicationStatement
Resource MedicationStatement "7347"
Profile: MedicationStatement-IEHR
status: RECORDED
subject: See on this page: Patient/3466
effective: 2022-07-14 12:04:15+0200
Dosages
- Text Timing Route
* 1 pill at 08:00 AM Once per 1 days Oral use (standardterms.edqm.eu#20053000)

11. http://interopEHRate.eu/fhir-resource/MedicationStatement/7358 (MedicationStatement/7358)

Generated Narrative: MedicationStatement
Resource MedicationStatement "7358"
Profile: MedicationStatement-IEHR
status: RECORDED
subject: See on this page: Patient/3466
effective: 2022-07-14 12:04:16+0200
Dosages
- Text Timing Route
* 1 pill at 08:00 AM, 1 pill at 08:00 PM 2 per 1 days Oral use (standardterms.edqm.eu#20053000)

12. http://interopEHRate.eu/fhir-resource/MedicationStatement/7349 (MedicationStatement/7349)

Generated Narrative: MedicationStatement
Resource MedicationStatement "7349"
Profile: MedicationStatement-IEHR
status: RECORDED
subject: See on this page: Patient/3466
effective: 2022-07-14 12:04:17+0200
Dosages
- Text Timing Route
* 1 subcutaneous injection at 08:00 PM up to INR >2, then stop Once per 1 days Subcutaneous use (standardterms.edqm.eu#20066000)

13. http://interopEHRate.eu/fhir-resource/MedicationStatement/7301 (MedicationStatement/7301)

Generated Narrative: MedicationStatement
Resource MedicationStatement "7301"
Profile: MedicationStatement-IEHR
status: RECORDED
subject: See on this page: Patient/3466
effective: 2022-07-14 12:04:18+0200
Dosages
- Text Timing Route
* 1 pill at 08:00 PM Once per 1 days Oral use (standardterms.edqm.eu#20053000)

14. http://interopEHRate.eu/fhir-resource/MedicationStatement/73014 (MedicationStatement/73014)

Generated Narrative: MedicationStatement
Resource MedicationStatement "73014"
Profile: MedicationStatement-IEHR
status: RECORDED
subject: See on this page: Patient/3466
effective: 2022-07-14 12:04:19+0200
Dosages
- Text Timing Route
* 1 pill at 08:00 AM Once per 1 days Oral use (standardterms.edqm.eu#20053000)

15. http://interopEHRate.eu/fhir-resource/Condition/1111 (Condition/1111)

Generated Narrative: Condition
Resource Condition "1111"
Profile: Condition-IEHR
ProvenanceExtension-IEHR: Provenance/1
clinicalStatus: Resolved (Condition Clinical Status Codes#resolved)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
code: Acute ischemic heart disease, unspecified (ICD-10#I24.9)
subject: See on this page: Patient/3466
onset: 2021-03-22
abatement: 2021-09-22

16. http://interopEHRate.eu/fhir-resource/Condition/1112 (Condition/1112)

Generated Narrative: Condition
Resource Condition "1112"
Profile: Condition-IEHR
ProvenanceExtension-IEHR: Provenance/2
clinicalStatus: Active (Condition Clinical Status Codes#active)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
code: Heart Failure, Unspecified (ICD-10#I50.9)
subject: See on this page: Patient/3466
onset: 2021-03-20

17. http://interopEHRate.eu/fhir-resource/Condition/1113 (Condition/1113)

Generated Narrative: Condition
Resource Condition "1113"
Profile: Condition-IEHR
ProvenanceExtension-IEHR: Provenance/3
clinicalStatus: resolved (Condition Clinical Status Codes#resolved)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
code: Chronic obstructive pulmonary disease (ICD-10#J44.9)
subject: See on this page: Patient/3466
onset: 2021-02-20
abatement: 2021-09-22

18. http://interopEHRate.eu/fhir-resource/Condition/1114 (Condition/1114)

Generated Narrative: Condition
Resource Condition "1114"
Profile: Condition-IEHR
ProvenanceExtension-IEHR: Provenance/4
clinicalStatus: Resolved (Condition Clinical Status Codes#resolved)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
code: Chronic kidney disease, unspecified (ICD-10#N18.9)
subject: See on this page: Patient/3466
onset: 2021-02-20
abatement: 2021-09-22

19. http://interopEHRate.eu/fhir-resource/Condition/1115 (Condition/1115)

Generated Narrative: Condition
Resource Condition "1115"
Profile: Condition-IEHR
ProvenanceExtension-IEHR: Provenance/5
clinicalStatus: Active (Condition Clinical Status Codes#active)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
code: Abnormal results of liver function studies (ICD-10#R94.5)
subject: See on this page: Patient/3466
onset: 2020-02-20

20. http://interopEHRate.eu/fhir-resource/Condition/1116 (Condition/1116)

Generated Narrative: Condition
Resource Condition "1116"
Profile: Condition-IEHR
ProvenanceExtension-IEHR: Provenance/6
clinicalStatus: Active (Condition Clinical Status Codes#active)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
code: Malignant neoplasm, without specification of site (ICD-10#C80)
subject: See on this page: Patient/3466
onset: 2020-06-09

21. http://interopEHRate.eu/fhir-resource/Condition/1117 (Condition/1117)

Generated Narrative: Condition
Resource Condition "1117"
Profile: Condition-IEHR
ProvenanceExtension-IEHR: Provenance/7
clinicalStatus: Active (Condition Clinical Status Codes#active)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
category: Pulmonary hypertension [Class] (LOINC#95932-0)
code: primary pulmonary hypertension (ICD-10#I27.0)
subject: See on this page: Patient/3466
onset: 2021-06-09

22. http://interopEHRate.eu/fhir-resource/DiagnosticReport/3111 (DiagnosticReport/3111)

Relevant diagnostic tests/laboratory data Narrative (Radiology)
Subject Markus Smith male, DoB: 2013-12-05 ( http://interopEHRate.eu/fhir-resource//Patient/MS01)
When For 2022-07-14 12:04:26+0200
Identifier: Provider number/1a2-3b4-5c6-7d8
Report Details
Code Value Flags When For
XR Chest 2 Views Checkup after heart pacemaker surgery Normal 2021-09-27

23. http://interopEHRate.eu/fhir-resource/Observation/3111 (Observation/3111)

Generated Narrative: Observation
Resource Observation "3111"
Profile: Observation-IEHR
ProvenanceExtension-IEHR: Provenance/2
status: FINAL
code: XR Chest 2 Views (LOINC#36643-5)
subject: See on this page: Patient/3466
effective: 2021-09-27
performer: See on this page: Organization/34432
value: Checkup after heart pacemaker surgery
interpretation: Normal (ObservationInterpretation#N)

24. http://interopEHRate.eu/fhir-resource/Procedure/1111 (Procedure/1111)

Generated Narrative: Procedure
Resource Procedure "1111" (Language "en")
Profile: Procedure (IPS)
status: COMPLETED
code: Laparoscopic appendectomy (SNOMED CT#6025007)
subject: See on this page: Patient/3466
Performers
- Actor
* See on this page: Practitioner/21

25. http://interopEHRate.eu/fhir-resource/Procedure/1112 (Procedure/1112)

Generated Narrative: Procedure
Resource Procedure "1112" (Language "en")
Profile: Procedure (IPS)
status: COMPLETED
code: Tonsillectomy (SNOMED CT#173422009)
subject: See on this page: Patient/3466
Performers
- Actor
* See on this page: Practitioner/21