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

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of authoring/issuing

Date and time of the last update to the resource (may be used for technical corrections).

Status of the resource or document

Reason for the current status of the resource.

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.

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication details

The person taking responsibility for the medical content of the document

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.

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

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

EHDS refined base 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.

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication details

The person taking responsibility for the medical content of the document

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.

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

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

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

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of authoring/issuing

Date and time of the last update to the resource (may be used for technical corrections).

Status of the resource or document

Reason for the current status of the resource.

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.

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication details

The person taking responsibility for the medical content of the document

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.

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

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