Cross Border Data Exchange IG
1.0.0 - CI Build
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
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"title" : "Medical visit",
"section" : [
{
"title" : "Allergies",
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"text" : {
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the Allergies section</div>"
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{
"title" : "History of Medication use Narrative",
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"coding" : [
{
"system" : "http://loinc.org",
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"display" : "Hx of Medication use"
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the History of Medication section</div>"
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{
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{
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the History of Procedures section</div>"
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{
"title" : "Relevant diagnostic tests/laboratory data Narrative",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "30954-2",
"display" : "Relevant Dx tests/lab data"
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the laboratory section section</div>"
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"entry" : [
{
🔗 "reference" : "Observation/1"
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},
{
"title" : "Social history",
"code" : {
"coding" : [
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"system" : "http://loinc.org",
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the Social History section</div>"
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{
"title" : "Vital signs",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8716-3",
"display" : "Vital signs"
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]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the Vital Signs section</div>"
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{
"title" : "Advance directives",
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"text" : {
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{
"title" : "History of Hospitalizations+Outpatient visits Narrative",
"code" : {
"coding" : [
{
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the History of Hospitalizations+Outpatient visits section</div>"
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},
{
"title" : "History of family member diseases Narrative",
"code" : {
"coding" : [
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"code" : "10157-6",
"display" : "Family member diseases Hx"
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]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the History of family disease section</div>"
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},
{
"title" : "Functional status assessment note",
"code" : {
"coding" : [
{
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the Functional status section</div>"
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{
"title" : "History of Immunization Narrative",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
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]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the history of immunization section</div>"
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},
{
"title" : "Mental status Narrative",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10190-7",
"display" : "Mental status"
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},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the mental status section</div>"
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{
"title" : "History of medical device use",
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the medical device history section</div>"
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{
"title" : "Diet and nutrition Narrative",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
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"display" : "Diet+nutrition"
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the diet and nutrition section</div>"
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{
"title" : "Payment sources Document",
"code" : {
"coding" : [
{
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]
},
"text" : {
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the payment document section</div>"
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{
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"code" : {
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">This is the plan of care section</div>"
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_1\"> </a><p><b>Generated Narrative: Encounter</b><a name=\"1\"> </a><a name=\"hc1\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Encounter "1" </p></div><p><b>ProvenanceExtension-IEHR</b>: <a href=\"Provenance-38.html\">Provenance/38</a></p><p><b>identifier</b>: <code>http://interopEHRate.eu/fhir-resource/</code>/E1</p><p><b>status</b>: finished</p><p><b>class</b>: ambulatory (Details: http://terminology.hl7.org/CodeSystem/v3-ActCode code AMB = 'ambulatory', stated as 'ambulatory')</p><p><b>priority</b>: routine <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-v3-ActPriority.html\">ActPriority</a>#R)</span></p><p><b>subject</b>: See on this page: Patient/3466</p><h3>Participants</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Period</b></td><td><b>Individual</b></td></tr><tr><td style=\"display: none\">*</td><td>primary performer <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-v3-ParticipationType.html\">ParticipationType</a>#PPRF)</span></td><td>2021-03-03 11:30:00+0000 --> 2021-03-03 11:55:00+0000</td><td>See on this page: Practitioner/21</td></tr></table><p><b>period</b>: 2021-03-03 11:30:00+0000 --> 2021-03-03 11:55:00+0000</p></div>"
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"code" : "AMB",
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"priority" : {
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"code" : "R",
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"participant" : [
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🔗 "reference" : "Practitioner/21"
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"period" : {
"start" : "2021-03-03T11:30:00Z",
"end" : "2021-03-03T11:55:00Z"
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}
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{
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"resource" : {
"resourceType" : "Observation",
"id" : "1",
"meta" : {
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"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_1\"> </a><p><b>Generated Narrative: Observation</b><a name=\"1\"> </a><a name=\"hc1\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Observation "1" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"http://hl7.org/fhir/uv/ips/STU1/StructureDefinition-Observation-results-uv-ips.html\">Observation Results (IPS)</a></p></div><p><b>identifier</b>: <code>http://interopEHRate.eu/fhir-resource/</code>/O1</p><p><b>status</b>: final</p><p><b>category</b>: Imaging <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-observation-category.html\">Observation Category Codes</a>#imaging)</span></p><p><b>code</b>: Radiology studies (set) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#18726-0)</span></p><p><b>subject</b>: See on this page: Patient/3466</p><p><b>encounter</b>: See on this page: Encounter/1</p><p><b>effective</b>: 2011-06-25 06:30:00+0000</p><p><b>performer</b>: See on this page: Organization/34432</p><p><b>value</b>: Radiology</p><p><b>interpretation</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-v3-ObservationInterpretation.html\">ObservationInterpretation</a>#N)</span></p></div>"
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🔗 "reference" : "Patient/3466"
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"encounter" : {
🔗 "reference" : "Encounter/1"
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}
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"id" : "2",
"meta" : {
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"MedicationRequest_2\"> </a><p><b>Generated Narrative: MedicationRequest</b><a name=\"2\"> </a><a name=\"hc2\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource MedicationRequest "2" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-MedicationRequest-prescription-IEHR.html\">MedicationRequestPrescription-IEHR</a></p></div><p><b>ProvenanceExtension-IEHR</b>: <a href=\"Provenance-38.html\">Provenance/38</a></p><p><b>identifier</b>: <code>http://interopEHRate.eu/fhir-resource/</code>/MR1</p><p><b>status</b>: active</p><p><b>intent</b>: plan</p><p><b>category</b>: Outpatient <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-medicationrequest-category.html\">MedicationRequest Category Codes</a>#outpatient)</span></p><p><b>medication</b>: Azacyclonol <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#3142009)</span></p><p><b>subject</b>: See on this page: Patient/3466</p><p><b>encounter</b>: See on this page: Encounter/1</p><p><b>authoredOn</b>: 2022-07-05 09:49:36+0200</p><p><b>requester</b>: See on this page: Practitioner/21</p><blockquote><p><b>dosageInstruction</b></p><p><b>timing</b>: Code: BID, 2 per 1 days</p><blockquote><p><b>doseAndRate</b></p></blockquote><blockquote><p><b>doseAndRate</b></p></blockquote></blockquote></div>"
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🔗 "reference" : "Provenance/38"
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"identifier" : [
{
"system" : "http://interopEHRate.eu/fhir-resource/",
"value" : "MR1"
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"status" : "active",
"intent" : "plan",
"category" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/medicationrequest-category",
"code" : "outpatient",
"display" : "Outpatient"
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]
}
],
"medicationCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "3142009",
"display" : "Azacyclonol"
}
]
},
"subject" : {
🔗 "reference" : "Patient/3466"
},
"encounter" : {
🔗 "reference" : "Encounter/1"
},
"authoredOn" : "2022-07-05T09:49:36+02:00",
"requester" : {
🔗 "reference" : "Practitioner/21"
},
"dosageInstruction" : [
{
"timing" : {
"repeat" : {
"frequency" : 2,
"period" : 1,
"periodUnit" : "d",
"timeOfDay" : [
"08:00:00",
"16:00:00"
]
},
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-GTSAbbreviation",
"code" : "BID",
"display" : "BID"
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]
}
},
"doseAndRate" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/dose-rate-type",
"code" : "ordered",
"display" : "Ordered"
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]
},
"doseQuantity" : {
"value" : 3,
"unit" : "milliliter",
"system" : "http://unitsofmeasure.org",
"code" : "mL"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/dose-rate-type",
"code" : "ordered",
"display" : "Ordered"
}
]
}
}
]
}
]
}
},
{
"fullUrl" : "http://interopEHRate.eu/fhir-resource/Patient/3466",
"resource" : {
"resourceType" : "Patient",
"id" : "3466",
"meta" : {
"profile" : [
🔗 "http://interopehrate.eu/fhir/StructureDefinition/Patient-IEHR"
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},
"language" : "it-IT",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"it-IT\" lang=\"it-IT\"><a name=\"Patient_3466\"> </a><p><b>Generated Narrative: Patient</b><a name=\"3466\"> </a><a name=\"hc3466\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Patient "3466" (Language "it-IT") </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-Patient-IEHR.html\">Patient-IEHR</a></p></div><p><b>identifier</b>: <code>http://interopEHRate.eu/fhir-resource/</code>/Patient/MS01</p><p><b>name</b>: Markus Smith </p><p><b>gender</b>: male</p><p><b>birthDate</b>: 2013-12-05</p><p><b>address</b>: Rome ITA (home)</p><p><b>generalPractitioner</b>: See on this page: Practitioner/21</p></div>"
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"identifier" : [
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],
"name" : [
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"family" : "Smith",
"given" : [
"Markus"
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}
],
"gender" : "male",
"birthDate" : "2013-12-05",
"address" : [
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"use" : "home",
"type" : "physical",
"city" : "Rome",
"country" : "ITA"
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{
🔗 "reference" : "Practitioner/21"
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]
}
},
{
"fullUrl" : "http://interopEHRate.eu/fhir-resource/Organization/34432",
"resource" : {
"resourceType" : "Organization",
"id" : "34432",
"meta" : {
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🔗 "http://hl7.org/fhir/uv/ips/StructureDefinition/Organization-uv-ips"
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"language" : "it-IT",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"it-IT\" lang=\"it-IT\"><a name=\"Organization_34432\"> </a><p><b>Generated Narrative: Organization</b><a name=\"34432\"> </a><a name=\"hc34432\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Organization "34432" (Language "it-IT") </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"http://hl7.org/fhir/uv/ips/STU1/StructureDefinition-Organization-uv-ips.html\">Organization (IPS)</a></p></div><p><b>identifier</b>: <code>http://interopEHRate.eu/fhir-resource/</code>/Organization/FTGM01</p><p><b>name</b>: Fondazione Gabriele Monasterio</p><p><b>address</b>: Via Giuseppe Moruzzi 1 Pisa IT </p></div>"
},
"identifier" : [
{
"system" : "http://interopEHRate.eu/fhir-resource/",
"value" : "Organization/FTGM01"
}
],
"name" : "Fondazione Gabriele Monasterio",
"address" : [
{
"line" : [
"Via Giuseppe Moruzzi 1"
],
"city" : "Pisa",
"country" : "IT"
}
]
}
},
{
"fullUrl" : "http://interopEHRate.eu/fhir-resource/Practitioner/21",
"resource" : {
"resourceType" : "Practitioner",
"id" : "21",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/uv/ips/StructureDefinition/Practitioner-uv-ips"
]
},
"language" : "it-IT",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"it-IT\" lang=\"it-IT\"><a name=\"Practitioner_21\"> </a><p><b>Generated Narrative: Practitioner</b><a name=\"21\"> </a><a name=\"hc21\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Practitioner "21" (Language "it-IT") </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"http://hl7.org/fhir/uv/ips/STU1/StructureDefinition-Practitioner-uv-ips.html\">Practitioner (IPS)</a></p></div><p><b>identifier</b>: <code>http://interopEHRate.eu/fhir-resource/</code>/Practitioner/MA01</p><p><b>name</b>: Mark Antonio </p></div>"
},
"identifier" : [
{
"system" : "http://interopEHRate.eu/fhir-resource/",
"value" : "Practitioner/MA01"
}
],
"name" : [
{
"family" : "Antonio",
"given" : [
"Mark"
]
}
]
}
}
],
"signature" : {
"id" : "Signature/04012022",
"type" : [
{
"system" : "urn:iso-astm:E1762-95:2013",
"code" : "1.2.840.10065.1.12.1.5",
"display" : "Verification Signature"
}
],
"when" : "2022-07-05T09:49:41.264+02:00",
"who" : {
🔗 "reference" : "Practitioner/21"
},
"targetFormat" : "json",
"sigFormat" : "application/jose",
"data" : "ZW1wdHk="
}
}