EHDS refined base model for Report header data elements. Common for hospital discharge, laboratory and medical imaging reports.

Patient/subject information

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Unique health insurance company identification code

Full, official name of the healthcare insurance provider.

Number or code under which the insured person is registered at the insurance provider.

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Document authoring details

Author by whom the document was/were authored. Multiple authors could be provided.

Date and time of the last modification of the document by its Author.

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

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Data relevent to document type and its content for administrative and searching purposes.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Date and time of the report creation.

Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.

Categorization of an ""event"" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

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 report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

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

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

ISO 639

Version of the document

Entire report as issued pdf format recommended

Media attachments.

EHDS refined base model for Report header data elements. Common for hospital discharge, laboratory and medical imaging reports.

Patient/subject information

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Unique health insurance company identification code

Full, official name of the healthcare insurance provider.

Number or code under which the insured person is registered at the insurance provider.

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Document authoring details

Author by whom the document was/were authored. Multiple authors could be provided.

Date and time of the last modification of the document by its Author.

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

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Data relevent to document type and its content for administrative and searching purposes.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Date and time of the report creation.

Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.

Categorization of an ""event"" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

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 report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

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

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

ISO 639

Version of the document

Entire report as issued pdf format recommended

Media attachments.

EHDS refined base model for Report header data elements. Common for hospital discharge, laboratory and medical imaging reports.

Patient/subject information

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Unique health insurance company identification code

Full, official name of the healthcare insurance provider.

Number or code under which the insured person is registered at the insurance provider.

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Document authoring details

Author by whom the document was/were authored. Multiple authors could be provided.

Date and time of the last modification of the document by its Author.

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

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Data relevent to document type and its content for administrative and searching purposes.

Unique identifier of the document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Date and time of the report creation.

Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.

Categorization of an ""event"" covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of event types depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

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 report [this element will include organisation ID, name, address etc., as other elements describing organisations].

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

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

hl7:Confidentiality

Language in which the document is written. Language is expressed by the ISO language code.

ISO 639

Version of the document

Entire report as issued pdf format recommended

Media attachments.