Model for common document data elements, including the common header. Data relevant to document type and its content for administrative and searching purposes.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.

Date and optionally time of authoring/issuing

Status of the resource or document

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian

Document attestation details

Attester who validated the document

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)

Date and time when the document was authorised

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Model for common document data elements, including the common header. Data relevant to document type and its content for administrative and searching purposes.

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian

Document attestation details

Attester who validated the document

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)

Date and time when the document was authorised

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Model for common document data elements, including the common header. Data relevant to document type and its content for administrative and searching purposes.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.

Date and optionally time of authoring/issuing

Status of the resource or document

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian

Document attestation details

Attester who validated the document

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)

Date and time when the document was authorised

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document