Generated Narrative: StructureDefinition EHDSPatientSummaryObligations Name Flags Card. Type Description & Constraints EHDSPatientSummaryObligations 0..* EHDSPatientSummary Patient summary obligations Elements defined in Ancestors:header, header, presentedForm, alerts, allergiesAndIntolerances, problems, medicationSummary, medicalDevicesAndImplants, procedures, immunisations, functionalStatus, socialHistory, pregnancyHistory, <a href="StructureDefinition-EHDSPatientSummary.html" title="Captures relevant information about the patient's recent travel history that may be of clinical relevance — particularly in relation to exposure to infectious diseases, epidemiological risks, or environmental factors. The intent is to support clinical decision-making and risk assessment, especially in contexts such as outbreaks or endemic disease regions.">travelHistory, patientStory, advanceDirectives, observationResults, carePlans #xD; header O 1..1 Base Document header Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; subject O 1..1 EHDSPatient Patient/subject information Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; identifier O 1..* Identifier Unique identifier of the document Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; author[x] O 1..* EHDSHealthProfessional, EHDSOrganisation, EHDSDevice Author(s) of the document Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; date O 1..1 dateTime Date of finalising/issuing the document Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; status O 1..1 CodeableConcept Status of the document Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; language O 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; documentType O 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document. Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; documentTitle O 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' Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; legalAuthentication O 0..* Base Document legal authentication details Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; presentedForm O 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document Obligations Actor SHOULD:able-to-populate Producer SHOULD:display Consumer #xD; alerts O 0..1 Base Section: Alerts Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:display Consumer #xD; medicalAlert O 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. Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:display Consumer #xD; allergiesAndIntolerances O 1..1 Base Section: Allergies and intolerances Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:display Consumer #xD; allergyIntolerance O 0..* EHDSAllergyIntolerance List of structured allergies and intolerances Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; emptyReason O 0..1 CodeableConcept Use if no Allergies are listed Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:display Consumer #xD; problems O 1..1 Base Section: Medical problems Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; emptyReason O 0..1 CodeableConcept Use if no conditions are listed Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; problem O 0..* EHDSCondition Health conditions affecting the health of the patient. Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; medicationSummary O 1..1 Base Section: Medication summary Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:display Consumer #xD; emptyReason O 0..1 CodeableConcept Use if no medicines are listed Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; medicationUse O 0..* EHDSMedicationUse 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. Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:display Consumer #xD; medicalDevicesAndImplants O 1..1 Base Section: Medical devices and implants Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; emptyReason O 0..1 CodeableConcept Use if no conditions are listed Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; deviceUse O 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. Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; procedures O 1..1 Base Section: Procedures Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; emptyReason O 0..1 CodeableConcept Reason for absence of data Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; procedure O 0..* EHDSProcedure List of procedures Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; immunisations O 0..1 Base Section: Immunisations Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; immunisation O 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care. Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; pregnancyHistory O 0..1 Base Section: Pregnancy history Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; generatedNarrative O 0..1 string Narrative, potentially formatted, content of the whole section. Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; currentPregnancyStatus O 0..1 EHDSCurrentPregnancy Current pregnancy status Obligations Actor SHALL:able-to-populate Producer SHALL:process Consumer #xD; note O 0..1 string Free text notes by the health professional Obligations Actor SHOULD:able-to-populate Producer SHOULD:process Consumer #xD; patientStory O 0..1 Base Section: Patient story Obligations Actor SHOULD:process Consumer #xD; advanceDirectives O 0..1 Base Section: Advance Directives Obligations Actor SHOULD:process Consumer #xD; Documentation for this format
Obligations for the logical model for patient summary.
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
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.
Type of document at hand, e.g. 60591-5 Patient summary document.
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 period of information covered in the document
Business version of the document. The exact algorithm for versioning is decided by the producer/custodian
Date and time of the approval of the document by Attester
The person or organisation taking responsibility for the 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.
Additional details about where the content was created (e.g. clinical specialty)
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
Substantial alerts or warnings that health professionals should be aware of.
System shall be able to populate generatedNarrative if the structured content is not supported by the system.
System shall display generatedNarrative if the structured content is not supported by the system.
Narrative, potentially formatted, content of the whole section.
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.
Free text notes by the health professional
List of structured allergies and intolerances
Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
This element is present in MyHealth@EU specifications and ISO IPS. The proposed way of modelling is identical to the newest version of FHIR IPS IG. See general description of Patient summary modelling for more information about this element. MH@EU has a similar concept, but it is modelled in slightly different way.
Conditions and symptoms affecting the health of the patient.
Health conditions affecting the health of the patient.
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.
The devices that are implanted in the patient and external medical devices and equipment that the health status depends on.
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.
Significant procedures performed on the patient.
A patient's immunisation status (vaccination and other prophylaxis). The section should include current immunisation status and may contain the entire history that is relevant to the period of time being summarised. Adverse reactions against vaccines should be documented in the allergy section.
Immunisations given to the patient and their status at the point of care.
An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being.
Condition information describing patient's functional status or disability.
Assessment results regarding functional status.
Observations on social factors such as alcohol consumption or smoking. From the healthcare perspective, life-style factors relate to well-being but can also provide a source of risk factors.
Social history observations related to health
Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Captures relevant information about the patient's recent travel history that may be of clinical relevance — particularly in relation to exposure to infectious diseases, epidemiological risks, or environmental factors. The intent is to support clinical decision-making and risk assessment, especially in contexts such as outbreaks or endemic disease regions.
A concise narrative from the patient’s perspective about their present health state. This is a record of things that a person feels are important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
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.