Cross Border Data Exchange IG
1.0.0 - CI Build
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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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Composition_1"> </a><p><b>Generated Narrative: Composition</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 Composition "1" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-Composition-VisitReport-IEHR.html">VisitReport-IEHR</a></p></div><p><b>ProvenanceExtension-IEHR</b>: <a href="Provenance-38.html">Provenance/38</a></p><p><b>status</b>: final</p><p><b>type</b>: Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#81214-9)</span></p><p><b>encounter</b>: See on this page: Encounter/1</p><p><b>date</b>: 2022-07-05 09:49:37+0200</p><p><b>author</b>: See on this page: Practitioner/21</p><p><b>title</b>: Medical visit</p></div>
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<valueReference>🔗
<reference value="Provenance/38"/>
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<status value="final"/>
<type>
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<system value="http://loinc.org"/>
<code value="81214-9"/>
<display
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</coding>
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<encounter>🔗
<reference value="Encounter/1"/>
</encounter>
<date value="2022-07-05T09:49:37+02:00"/>
<author>🔗
<reference value="Practitioner/21"/>
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<title value="Medical visit"/>
<section>
<title value="Allergies"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
<display value="Allergies and adverse reactions Document"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the Allergies section</div>
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</section>
<section>
<title value="History of Medication use Narrative"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10160-0"/>
<display value="Hx of Medication use"/>
</coding>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the History of Medication section</div>
</text>
<entry>🔗
<reference value="MedicationRequest/2"/>
</entry>
</section>
<section>
<title value="Problem list - Reported"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11450-4"/>
<display value="Problem list - Reported"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the Problem list section</div>
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<section>
<title value="History of Procedures Document"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47519-4"/>
<display value="History of Procedures Document"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the History of Procedures section</div>
</text>
</section>
<section>
<title value="Relevant diagnostic tests/laboratory data Narrative"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="30954-2"/>
<display value="Relevant Dx tests/lab data"/>
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</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the laboratory section section</div>
</text>
<entry>🔗
<reference value="Observation/1"/>
</entry>
</section>
<section>
<title value="Social history"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29762-2"/>
<display value="Social Hx"/>
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</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the Social History section</div>
</text>
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<section>
<title value="Vital signs"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8716-3"/>
<display value="Vital signs"/>
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</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the Vital Signs section</div>
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<section>
<title value="Advance directives"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42348-3"/>
<display value="Advance directives"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the Advance directives section</div>
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</section>
<section>
<title
value="History of Hospitalizations+Outpatient visits Narrative"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46240-8"/>
<display value="Hx of Hospitalizations+OP visits"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the History of Hospitalizations+Outpatient visits section</div>
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<section>
<title value="History of family member diseases Narrative"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10157-6"/>
<display value="Family member diseases Hx"/>
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</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the History of family disease section</div>
</text>
</section>
<section>
<title value="Functional status assessment note"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47420-5"/>
<display value="Functional status note"/>
</coding>
</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the Functional status section</div>
</text>
</section>
<section>
<title value="History of Immunization Narrative"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11369-6"/>
<display value="Hx of Immunization"/>
</coding>
</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the history of immunization section</div>
</text>
</section>
<section>
<title value="Mental status Narrative"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10190-7"/>
<display value="Mental status"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the mental status section</div>
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</section>
<section>
<title value="History of medical device use"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46264-8"/>
<display value="Hx medical device use"/>
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</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the medical device history section</div>
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<section>
<title value="Diet and nutrition Narrative"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61144-2"/>
<display value="Diet+nutrition"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the diet and nutrition section</div>
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</section>
<section>
<title value="Payment sources Document"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48768-6"/>
<display value="Payment sources Doc"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the payment document section</div>
</text>
</section>
<section>
<title value="Plan of care note"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
<display value="Plan of care note"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">This is the plan of care section</div>
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<entry>
<fullUrl value="http://interopEHRate.eu/fhir-resource/Encounter/1"/>
<resource>
<Encounter>
<id value="1"/>
<text>
<status value="extensions"/>
<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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<extension
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<valueReference>🔗
<reference value="Provenance/38"/>
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<identifier>
<system value="http://interopEHRate.eu/fhir-resource/"/>
<value value="E1"/>
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<status value="finished"/>
<class>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="AMB"/>
<display value="ambulatory"/>
</class>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActPriority"/>
<code value="R"/>
<display value="routine"/>
</coding>
</priority>
<subject>🔗
<reference value="Patient/3466"/>
</subject>
<participant>
<type>
<coding>
<system
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<code value="PPRF"/>
<display value="primary performer"/>
</coding>
</type>
<period>
<start value="2021-03-03T11:30:00Z"/>
<end value="2021-03-03T11:55:00Z"/>
</period>
<individual>🔗
<reference value="Practitioner/21"/>
</individual>
</participant>
<period>
<start value="2021-03-03T11:30:00Z"/>
<end value="2021-03-03T11:55:00Z"/>
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</Encounter>
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<entry>
<fullUrl value="http://interopEHRate.eu/fhir-resource/Observation/1"/>
<resource>
<Observation>
<id value="1"/>
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<text>
<status value="generated"/>
<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>
</text>
<identifier>
<system value="http://interopEHRate.eu/fhir-resource/"/>
<value value="O1"/>
</identifier>
<status value="final"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/observation-category"/>
<code value="imaging"/>
<display value="Imaging"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18726-0"/>
<display value="Radiology studies (set)"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/3466"/>
</subject>
<encounter>🔗
<reference value="Encounter/1"/>
</encounter>
<effectiveDateTime value="2011-06-25T06:30:00Z"/>
<performer>🔗
<reference value="Organization/34432"/>
</performer>
<valueString value="Radiology"/>
<interpretation>
<coding>
<system
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<code value="N"/>
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</interpretation>
</Observation>
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</entry>
<entry>
<fullUrl
value="http://interopEHRate.eu/fhir-resource/MedicationRequest/2"/>
<resource>
<MedicationRequest>
<id value="2"/>
<meta>
<profile
value="http://interopehrate.eu/fhir/StructureDefinition/MedicationRequest-prescription-IEHR"/>
</meta>
<text>
<status value="extensions"/>
<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>
</text>
<extension
url="http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR">
<valueReference>🔗
<reference value="Provenance/38"/>
</valueReference>
</extension>
<identifier>
<system value="http://interopEHRate.eu/fhir-resource/"/>
<value value="MR1"/>
</identifier>
<status value="active"/>
<intent value="plan"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/medicationrequest-category"/>
<code value="outpatient"/>
<display value="Outpatient"/>
</coding>
</category>
<medicationCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="3142009"/>
<display value="Azacyclonol"/>
</coding>
</medicationCodeableConcept>
<subject>🔗
<reference value="Patient/3466"/>
</subject>
<encounter>🔗
<reference value="Encounter/1"/>
</encounter>
<authoredOn value="2022-07-05T09:49:36+02:00"/>
<requester>🔗
<reference value="Practitioner/21"/>
</requester>
<dosageInstruction>
<timing>
<repeat>
<frequency value="2"/>
<period value="1"/>
<periodUnit value="d"/>
<timeOfDay value="08:00:00"/>
<timeOfDay value="16:00:00"/>
</repeat>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-GTSAbbreviation"/>
<code value="BID"/>
<display value="BID"/>
</coding>
</code>
</timing>
<doseAndRate>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/dose-rate-type"/>
<code value="ordered"/>
<display value="Ordered"/>
</coding>
</type>
<doseQuantity>
<value value="3"/>
<unit value="milliliter"/>
<system value="http://unitsofmeasure.org"/>
<code value="mL"/>
</doseQuantity>
</doseAndRate>
<doseAndRate>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/dose-rate-type"/>
<code value="ordered"/>
<display value="Ordered"/>
</coding>
</type>
</doseAndRate>
</dosageInstruction>
</MedicationRequest>
</resource>
</entry>
<entry>
<fullUrl value="http://interopEHRate.eu/fhir-resource/Patient/3466"/>
<resource>
<Patient>
<id value="3466"/>
<meta>
<profile
value="http://interopehrate.eu/fhir/StructureDefinition/Patient-IEHR"/>
</meta>
<language value="it-IT"/>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<system value="http://interopEHRate.eu/fhir-resource/"/>
<value value="Patient/MS01"/>
</identifier>
<name>
<family value="Smith"/>
<given value="Markus"/>
</name>
<gender value="male"/>
<birthDate value="2013-12-05"/>
<address>
<use value="home"/>
<type value="physical"/>
<city value="Rome"/>
<country value="ITA"/>
</address>
<generalPractitioner>🔗
<reference value="Practitioner/21"/>
</generalPractitioner>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://interopEHRate.eu/fhir-resource/Organization/34432"/>
<resource>
<Organization>
<id value="34432"/>
<meta>
<profile
value="http://hl7.org/fhir/uv/ips/StructureDefinition/Organization-uv-ips"/>
</meta>
<language value="it-IT"/>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<system value="http://interopEHRate.eu/fhir-resource/"/>
<value value="Organization/FTGM01"/>
</identifier>
<name value="Fondazione Gabriele Monasterio"/>
<address>
<line value="Via Giuseppe Moruzzi 1"/>
<city value="Pisa"/>
<country value="IT"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://interopEHRate.eu/fhir-resource/Practitioner/21"/>
<resource>
<Practitioner>
<id value="21"/>
<meta>
<profile
value="http://hl7.org/fhir/uv/ips/StructureDefinition/Practitioner-uv-ips"/>
</meta>
<language value="it-IT"/>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<system value="http://interopEHRate.eu/fhir-resource/"/>
<value value="Practitioner/MA01"/>
</identifier>
<name>
<family value="Antonio"/>
<given value="Mark"/>
</name>
</Practitioner>
</resource>
</entry>
<signature id="Signature/04012022">
<type>
<system value="urn:iso-astm:E1762-95:2013"/>
<code value="1.2.840.10065.1.12.1.5"/>
<display value="Verification Signature"/>
</type>
<when value="2022-07-05T09:49:41.264+02:00"/>
<who>🔗
<reference value="Practitioner/21"/>
</who>
<targetFormat value="json"/>
<sigFormat value="application/jose"/>
<data value="ZW1wdHk="/>
</signature>
</Bundle>