EHDS Logical Information Models
0.2.0 - ci-build

EHDS Logical Information Models, published by Xt-EHR. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Xt-EHR/xt-ehr-common/ and changes regularly. See the Directory of published versions

Logical Model: Patient summary model

Official URL: https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatientSummary Version: 0.2.0
Draft as of 2025-09-24 Computable Name: EHDSPatientSummary

EHDS refined base model for Patient Summary

Patient summary consists of several sections of which some are suggested to be mandatory to support. For each mandatory section, implementers should as a minimum be able to produce a generated narrative text of the content, as well as certain structured elements. There are only few elements that are suggested as required to support at this point.

While the overall use cases for exchanging a full Patient Summary (PS) remain consistent—typically aiming to support patients access to its own data, transfer of data between systems and cross-border care (both emergency access, and continuity of care)—it is acknowledged that, in practice, implementers will need to support multiple variants of these use cases, depending on the context. In some cases, only a subset of the PS (e.g. just medications, allergies, or vaccinations) will be relevant or exchanged. As such, each section of the Patient Summary is described and handled independently, with clear guidance on both the narrative and structured data elements expected for that section.

The information elements and value sets suggested are mainly taken from eHN Guideline, MyHealth@EU and HL7 FHIR IPS. Some additions or adjustments have been made, based on input from the working group of this deliverable. These are described in each section.

Usages:

  • This Logical Model is not used by any profiles in this Implementation Guide

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSPatientSummary 0..* EHDSDocument
Elements defined in Ancestors:header, header, presentedForm
Patient summary model
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 1..* Base Resource authoring details
..... author[x] 1..1 Author(s) by whom the resource was/were authored. Multiple authors could be provided.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... lastUpdate 0..1 dateTime Date and time of the last update to the resource (may be used for technical corrections).
.... status 1..1 CodeableConcept Status of the resource or document
.... statusReason[x] 0..1 Reason for the current status of the resource.
..... statusReasonCodeableConcept CodeableConcept
..... statusReasonString string
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester 1..1 EHDSHealthProfessional Attester who validated the document. Mulitple attesters could be provided.
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator 1..1 EHDSHealthProfessional The person taking responsibility for the medical content of the document
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... alerts 1..1 Base Section: Alerts.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
.... narrative 1..1 string Text summary of the content in section
.... allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances
.... emptyReason 0..1 CodeableConcept Use if no Allergies are listed
Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
... problems 1..1 Base Medical problems.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no conditions are listed
.... problems 0..* EHDSCondition !!Health conditions affecting the health of the patient.!!
... medicationSummary 1..1 Base Section: Medication Summary.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no medicines are listed
.... medicationTreatment 0..* EHDSMedicationStatement Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.
... medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalDevice 0..* EHDSDeviceUse Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.
... procedures 1..1 Base Section: Procedures
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... procedure 0..* EHDSProcedure List of procedures
... vaccination 0..1 Base Section: Vaccination/prophylaxis.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... vaccination 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care.
... functionalStatus 0..1 Base Section: Functional status
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
... socialHistory 0..1 Base Section: Social history.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... socialHistoryObservation 0..* EHDSSocialHistory Social history observations related to health
... pregnancyHistory 0..1 Base Section: Pregnancy history
.... generatedNarrative 0..1 string Generated text summary of the content in the section, for human interpretation
.... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
.... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
.... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
... travelHistory 0..1 Base Relevant information about the patient's recent travel history
.... narrative 0..1 string Text summary of the content in the section
.... travelHistory 0..* EHDSTravelHistory Travel history for one country
... patientStory 0..1 Base What the patient believes to be important for the attending clinician to know.
.... narrative 0..1 string Text summary of the content in the section
... advanceDirectives 0..1 Base Section: Advance Directives.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
... results 0..1 Base Section: Observation results.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
..... resultObservationEHDSObservation EHDSObservation
..... resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation
... carePlan 0..1 Base Section: Care plans.
.... narrative 0..1 string Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.
.... carePlanEntry 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
EHDSPatientSummary.header.languagepreferred
EHDSPatientSummary.header.documentTypepreferred
EHDSPatientSummary.header.eventTypepreferred
EHDSPatientSummary.header.serviceSpecialtypreferred
EHDSPatientSummary.header.confidentialitypreferred
EHDSPatientSummary.allergiesAndIntolerances.emptyReasonpreferred

This structure is derived from EHDSDocument

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSPatientSummary 0..* EHDSDocument
Elements defined in Ancestors:header, header, presentedForm
Patient summary model
Instances of this logical model can be the target of a Reference
... alerts 1..1 Base Section: Alerts.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
... allergiesAndIntolerances 1..1 Base Section: Allergies and intolerances
.... narrative 1..1 string Text summary of the content in section
.... allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances
.... emptyReason 0..1 CodeableConcept Use if no Allergies are listed
Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
... problems 1..1 Base Medical problems.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no conditions are listed
.... problems 0..* EHDSCondition !!Health conditions affecting the health of the patient.!!
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no medicines are listed
.... medicationTreatment 0..* EHDSMedicationStatement Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.
... medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalDevice 0..* EHDSDeviceUse Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.
... procedures 1..1 Base Section: Procedures
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... procedure 0..* EHDSProcedure List of procedures
... vaccination 0..1 Base Section: Vaccination/prophylaxis.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... vaccination 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care.
... functionalStatus 0..1 Base Section: Functional status
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
... socialHistory 0..1 Base Section: Social history.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... socialHistoryObservation 0..* EHDSSocialHistory Social history observations related to health
... pregnancyHistory 0..1 Base Section: Pregnancy history
.... generatedNarrative 0..1 string Generated text summary of the content in the section, for human interpretation
.... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
.... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
.... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
... travelHistory 0..1 Base Relevant information about the patient's recent travel history
.... narrative 0..1 string Text summary of the content in the section
.... travelHistory 0..* EHDSTravelHistory Travel history for one country
... patientStory 0..1 Base What the patient believes to be important for the attending clinician to know.
.... narrative 0..1 string Text summary of the content in the section
... advanceDirectives 0..1 Base Section: Advance Directives.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
... results 0..1 Base Section: Observation results.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
..... resultObservationEHDSObservation EHDSObservation
..... resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation
... carePlan 0..1 Base Section: Care plans.
.... narrative 0..1 string Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.
.... carePlanEntry 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
EHDSPatientSummary.allergiesAndIntolerances.emptyReasonpreferred
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSPatientSummary 0..* EHDSDocument
Elements defined in Ancestors:header, header, presentedForm
Patient summary model
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 1..* Base Resource authoring details
..... author[x] 1..1 Author(s) by whom the resource was/were authored. Multiple authors could be provided.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... lastUpdate 0..1 dateTime Date and time of the last update to the resource (may be used for technical corrections).
.... status 1..1 CodeableConcept Status of the resource or document
.... statusReason[x] 0..1 Reason for the current status of the resource.
..... statusReasonCodeableConcept CodeableConcept
..... statusReasonString string
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester 1..1 EHDSHealthProfessional Attester who validated the document. Mulitple attesters could be provided.
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator 1..1 EHDSHealthProfessional The person taking responsibility for the medical content of the document
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... alerts 1..1 Base Section: Alerts.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
.... narrative 1..1 string Text summary of the content in section
.... allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances
.... emptyReason 0..1 CodeableConcept Use if no Allergies are listed
Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
... problems 1..1 Base Medical problems.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no conditions are listed
.... problems 0..* EHDSCondition !!Health conditions affecting the health of the patient.!!
... medicationSummary 1..1 Base Section: Medication Summary.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no medicines are listed
.... medicationTreatment 0..* EHDSMedicationStatement Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.
... medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalDevice 0..* EHDSDeviceUse Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.
... procedures 1..1 Base Section: Procedures
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... procedure 0..* EHDSProcedure List of procedures
... vaccination 0..1 Base Section: Vaccination/prophylaxis.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... vaccination 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care.
... functionalStatus 0..1 Base Section: Functional status
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
... socialHistory 0..1 Base Section: Social history.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... socialHistoryObservation 0..* EHDSSocialHistory Social history observations related to health
... pregnancyHistory 0..1 Base Section: Pregnancy history
.... generatedNarrative 0..1 string Generated text summary of the content in the section, for human interpretation
.... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
.... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
.... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
... travelHistory 0..1 Base Relevant information about the patient's recent travel history
.... narrative 0..1 string Text summary of the content in the section
.... travelHistory 0..* EHDSTravelHistory Travel history for one country
... patientStory 0..1 Base What the patient believes to be important for the attending clinician to know.
.... narrative 0..1 string Text summary of the content in the section
... advanceDirectives 0..1 Base Section: Advance Directives.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
... results 0..1 Base Section: Observation results.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
..... resultObservationEHDSObservation EHDSObservation
..... resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation
... carePlan 0..1 Base Section: Care plans.
.... narrative 0..1 string Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.
.... carePlanEntry 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
EHDSPatientSummary.header.languagepreferred
EHDSPatientSummary.header.documentTypepreferred
EHDSPatientSummary.header.eventTypepreferred
EHDSPatientSummary.header.serviceSpecialtypreferred
EHDSPatientSummary.header.confidentialitypreferred
EHDSPatientSummary.allergiesAndIntolerances.emptyReasonpreferred

This structure is derived from EHDSDocument

Summary

Mandatory: 0 element(7 nested mandatory elements)

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSPatientSummary 0..* EHDSDocument
Elements defined in Ancestors:header, header, presentedForm
Patient summary model
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 1..* Base Resource authoring details
..... author[x] 1..1 Author(s) by whom the resource was/were authored. Multiple authors could be provided.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... lastUpdate 0..1 dateTime Date and time of the last update to the resource (may be used for technical corrections).
.... status 1..1 CodeableConcept Status of the resource or document
.... statusReason[x] 0..1 Reason for the current status of the resource.
..... statusReasonCodeableConcept CodeableConcept
..... statusReasonString string
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester 1..1 EHDSHealthProfessional Attester who validated the document. Mulitple attesters could be provided.
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator 1..1 EHDSHealthProfessional The person taking responsibility for the medical content of the document
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... alerts 1..1 Base Section: Alerts.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
.... narrative 1..1 string Text summary of the content in section
.... allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances
.... emptyReason 0..1 CodeableConcept Use if no Allergies are listed
Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
... problems 1..1 Base Medical problems.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no conditions are listed
.... problems 0..* EHDSCondition !!Health conditions affecting the health of the patient.!!
... medicationSummary 1..1 Base Section: Medication Summary.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no medicines are listed
.... medicationTreatment 0..* EHDSMedicationStatement Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.
... medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalDevice 0..* EHDSDeviceUse Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.
... procedures 1..1 Base Section: Procedures
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... procedure 0..* EHDSProcedure List of procedures
... vaccination 0..1 Base Section: Vaccination/prophylaxis.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... vaccination 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care.
... functionalStatus 0..1 Base Section: Functional status
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
... socialHistory 0..1 Base Section: Social history.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... socialHistoryObservation 0..* EHDSSocialHistory Social history observations related to health
... pregnancyHistory 0..1 Base Section: Pregnancy history
.... generatedNarrative 0..1 string Generated text summary of the content in the section, for human interpretation
.... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
.... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
.... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
... travelHistory 0..1 Base Relevant information about the patient's recent travel history
.... narrative 0..1 string Text summary of the content in the section
.... travelHistory 0..* EHDSTravelHistory Travel history for one country
... patientStory 0..1 Base What the patient believes to be important for the attending clinician to know.
.... narrative 0..1 string Text summary of the content in the section
... advanceDirectives 0..1 Base Section: Advance Directives.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
... results 0..1 Base Section: Observation results.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
..... resultObservationEHDSObservation EHDSObservation
..... resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation
... carePlan 0..1 Base Section: Care plans.
.... narrative 0..1 string Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.
.... carePlanEntry 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
EHDSPatientSummary.header.languagepreferred
EHDSPatientSummary.header.documentTypepreferred
EHDSPatientSummary.header.eventTypepreferred
EHDSPatientSummary.header.serviceSpecialtypreferred
EHDSPatientSummary.header.confidentialitypreferred
EHDSPatientSummary.allergiesAndIntolerances.emptyReasonpreferred

Differential View

This structure is derived from EHDSDocument

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSPatientSummary 0..* EHDSDocument
Elements defined in Ancestors:header, header, presentedForm
Patient summary model
Instances of this logical model can be the target of a Reference
... alerts 1..1 Base Section: Alerts.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
... allergiesAndIntolerances 1..1 Base Section: Allergies and intolerances
.... narrative 1..1 string Text summary of the content in section
.... allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances
.... emptyReason 0..1 CodeableConcept Use if no Allergies are listed
Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
... problems 1..1 Base Medical problems.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no conditions are listed
.... problems 0..* EHDSCondition !!Health conditions affecting the health of the patient.!!
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no medicines are listed
.... medicationTreatment 0..* EHDSMedicationStatement Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.
... medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalDevice 0..* EHDSDeviceUse Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.
... procedures 1..1 Base Section: Procedures
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... procedure 0..* EHDSProcedure List of procedures
... vaccination 0..1 Base Section: Vaccination/prophylaxis.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... vaccination 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care.
... functionalStatus 0..1 Base Section: Functional status
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
... socialHistory 0..1 Base Section: Social history.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... socialHistoryObservation 0..* EHDSSocialHistory Social history observations related to health
... pregnancyHistory 0..1 Base Section: Pregnancy history
.... generatedNarrative 0..1 string Generated text summary of the content in the section, for human interpretation
.... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
.... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
.... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
... travelHistory 0..1 Base Relevant information about the patient's recent travel history
.... narrative 0..1 string Text summary of the content in the section
.... travelHistory 0..* EHDSTravelHistory Travel history for one country
... patientStory 0..1 Base What the patient believes to be important for the attending clinician to know.
.... narrative 0..1 string Text summary of the content in the section
... advanceDirectives 0..1 Base Section: Advance Directives.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
... results 0..1 Base Section: Observation results.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
..... resultObservationEHDSObservation EHDSObservation
..... resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation
... carePlan 0..1 Base Section: Care plans.
.... narrative 0..1 string Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.
.... carePlanEntry 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
EHDSPatientSummary.allergiesAndIntolerances.emptyReasonpreferred

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. EHDSPatientSummary 0..* EHDSDocument
Elements defined in Ancestors:header, header, presentedForm
Patient summary model
Instances of this logical model can be the target of a Reference
... header 1..1 Base Document header elements
.... subject 1..1 EHDSPatient Patient/subject information
.... identifier 1..* Identifier Unique identifier of the document
.... authorship 1..* Base Resource authoring details
..... author[x] 1..1 Author(s) by whom the resource was/were authored. Multiple authors could be provided.
...... authorEHDSHealthProfessional EHDSHealthProfessional
...... authorEHDSOrganisation EHDSOrganisation
...... authorEHDSDevice EHDSDevice
..... datetime 1..1 dateTime Date and time of authoring/issuing
.... lastUpdate 0..1 dateTime Date and time of the last update to the resource (may be used for technical corrections).
.... status 1..1 CodeableConcept Status of the resource or document
.... statusReason[x] 0..1 Reason for the current status of the resource.
..... statusReasonCodeableConcept CodeableConcept
..... statusReasonString string
.... language 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag.
Binding Description: (preferred): BCP 47
.... documentType 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document.
Binding Description: (preferred): LOINC
.... documentTitle 1..1 string 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'
.... period 0..1 Period Time of service that is being documented
.... version 0..1 string Business version of the document.
.... attestation 0..* Base Document attestation details
..... attester 1..1 EHDSHealthProfessional Attester who validated the document. Mulitple attesters could be provided.
..... datetime 1..1 dateTime Date and time of the approval of the document by Attester.
.... legalAuthentication 0..1 Base Document legal authentication details
..... legalAuthenticator 1..1 EHDSHealthProfessional The person taking responsibility for the medical content of the document
..... datetime 1..1 dateTime Date and time when the document was authorised.
.... eventType 0..* CodeableConcept 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.
Binding Description: (preferred): LOINC, SNOMED CT, dicom-cid-33-Modality
.... serviceSpecialty 0..* CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding Description: (preferred): SNOMED CT
.... custodian 0..1 EHDSOrganisation Organisation that is in charge of maintaining the document/report.
.... confidentiality 0..1 CodeableConcept Level of confidentiality of the document. Implicit value is normal.
Binding Description: (preferred): hl7:Confidentiality
... presentedForm 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
... alerts 1..1 Base Section: Alerts.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.
.... narrative 1..1 string Text summary of the content in section
.... allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances
.... emptyReason 0..1 CodeableConcept Use if no Allergies are listed
Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
... problems 1..1 Base Medical problems.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no conditions are listed
.... problems 0..* EHDSCondition !!Health conditions affecting the health of the patient.!!
... medicationSummary 1..1 Base Section: Medication Summary.
.... narrative 0..1 string Text summary of the content in the section
.... emptyReason 0..1 CodeableConcept Use if no medicines are listed
.... medicationTreatment 0..* EHDSMedicationStatement Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.
... medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... medicalDevice 0..* EHDSDeviceUse Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.
... procedures 1..1 Base Section: Procedures
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... emptyReason 0..1 CodeableConcept Reason for absence of data
.... procedure 0..* EHDSProcedure List of procedures
... vaccination 0..1 Base Section: Vaccination/prophylaxis.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... vaccination 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care.
... functionalStatus 0..1 Base Section: Functional status
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... functionalStatusAssessment 0..* EHDSFunctionalStatus An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being
... socialHistory 0..1 Base Section: Social history.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... socialHistoryObservation 0..* EHDSSocialHistory Social history observations related to health
... pregnancyHistory 0..1 Base Section: Pregnancy history
.... generatedNarrative 0..1 string Generated text summary of the content in the section, for human interpretation
.... currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status
.... previousPregnanciesStatus 0..1 CodeableConcept Overall status of previous pregnancies
.... previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies
... travelHistory 0..1 Base Relevant information about the patient's recent travel history
.... narrative 0..1 string Text summary of the content in the section
.... travelHistory 0..* EHDSTravelHistory Travel history for one country
... patientStory 0..1 Base What the patient believes to be important for the attending clinician to know.
.... narrative 0..1 string Text summary of the content in the section
... advanceDirectives 0..1 Base Section: Advance Directives.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions
... results 0..1 Base Section: Observation results.
.... narrative 0..1 string Narrative, potentially formatted, content of the section
.... resultObservation[x] 0..* Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
..... resultObservationEHDSObservation EHDSObservation
..... resultObservationEHDSLaboratoryObservation EHDSLaboratoryObservation
... carePlan 0..1 Base Section: Care plans.
.... narrative 0..1 string Narrative containing the plan including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.
.... carePlanEntry 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
EHDSPatientSummary.header.languagepreferred
EHDSPatientSummary.header.documentTypepreferred
EHDSPatientSummary.header.eventTypepreferred
EHDSPatientSummary.header.serviceSpecialtypreferred
EHDSPatientSummary.header.confidentialitypreferred
EHDSPatientSummary.allergiesAndIntolerances.emptyReasonpreferred

This structure is derived from EHDSDocument

Summary

Mandatory: 0 element(7 nested mandatory elements)

 

Other representations of profile: CSV, Excel

Notes:

Differences and relationship to eHN Guidelines

The main proposed changes of the proposed EEHRxF logical model, compared with the eHN Guideline are:

  • The structure has been flattened to facilitate implementation of only parts of the Patient summary and better support a data centric approach. The result is that all sections are at the same level, not having the grouper-sections "Alerts", "Medical problems", "Medical history", and "Patient provided data" that the eHN GL does.

  • All content sections are kept the same as in the Guideline. However, we do suggest that the two problem sections are combined into one. This is to better support different use cases and current available data. See under the section "Problems" for more information.

  • In line with the International Patient Summary and MyHealth@EU specifications, there is an empty list reason elements for all sections that are suggested to be mandatory

  • Each section has a Generated narrative text element. This is in line with the FHIR International Patient Summary implementation guide, and supports the right for natural persons to get the content in an easily readable format (Article 3 in the EHDS regulation).

  • Instead of top level preferred code systems, which in many cases are not meant to be implemented in full, we have added value sets that are in use in the MyHealth@EU and HL7 Europe specifications as examples. We also include some value sets based on suggestions from participating Member states.

  • The logical models have cardinality, and repeatable elements are split into their own models, which is often reused between different priority categories (e.g. problems, procedures). The individual information elements in these reusable models are based on the eHN Guideline, unless otherwise stated.