EHDS Logical Information Models
0.4.0 - draft

EHDS Logical Information Models, published by Xt-EHR. This guide is not an authorized publication; it is the continuous build for version 0.4.0 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: EHDSPatientSummary - Detailed Descriptions

Draft as of 2026-03-03

Definitions for the EHDSPatientSummary logical model.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. EHDSPatientSummary
Definition | The model is a structured document designed to provide an overview of a patient’s most important health information. The model aims to be compatible with the ISO International Patient Summary standard. Base definition for all types defined in FHIR type system.
Short | Patient summary modelBase for all types and resources
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSPatientSummary.header
Definition | Basic metadata for this information
Short | Document header
Control | 1..1
Type | Base
4. EHDSPatientSummary.header.subject
Definition | Patient/subject information
Short | Patient/subject information
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient
6. EHDSPatientSummary.header.identifier
Definition | Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Short | Unique identifier of the document
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSPatientSummary.header.author[x]
Definition | Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.
Short | Author(s) of the document
Control | 1..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
10. EHDSPatientSummary.header.date
Definition | Date and optionally time of authoring/issuing
Short | Date of finalising/issuing the document
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. EHDSPatientSummary.header.status
Definition | Status of the resource or document
Short | Status of the document
Control | 1..1
Type | CodeableConcept
14. EHDSPatientSummary.header.source
Definition | 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.
Short | 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.
Control | 0..0
Type | CodeableConcept
16. EHDSPatientSummary.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language in which the resource is written. Language is expressed by the IETF language tag.
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
18. EHDSPatientSummary.header.documentType
Definition | Type of document at hand, e.g. 60591-5 Patient summary document.
Short | Type of document at hand, e.g. 60591-5 Patient summary document.
Control | 1..1
Binding | LOINC
Type | CodeableConcept
20. EHDSPatientSummary.header.documentTitle
Definition | 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'
Short | 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'
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. EHDSPatientSummary.header.period
Definition | Time period of information covered in the document
Short | Time period of information covered in the document
Control | 0..1
Type | Period
24. EHDSPatientSummary.header.version
Definition | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian
Short | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. EHDSPatientSummary.header.attestation
Definition | Document attestation details
Short | Document attestation details
Control | 0..*
Type | Base
28. EHDSPatientSummary.header.attestation.attester[x]
Definition | Attester who validated the document
Short | Attester who validated the document
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
30. EHDSPatientSummary.header.attestation.datetime
Definition | Date and time of the approval of the document by Attester
Short | Date and time of the approval of the document by Attester
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
32. EHDSPatientSummary.header.legalAuthentication
Definition | Document legal authentication details
Short | Document legal authentication details
Control | 0..*
Type | Base
34. EHDSPatientSummary.header.legalAuthentication.legalAuthenticator[x]
Definition | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Short | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
36. EHDSPatientSummary.header.legalAuthentication.datetime
Definition | Date and time when the document was authorised
Short | Date and time when the document was authorised
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSPatientSummary.header.eventType
Definition | 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.
Short | 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.
Control | 0..*
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
40. EHDSPatientSummary.header.serviceSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Additional details about where the content was created (e.g. clinical specialty)
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
42. EHDSPatientSummary.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Organisation that is in charge of maintaining the document/report.
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
44. EHDSPatientSummary.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment
46. EHDSPatientSummary.alerts
Definition | Substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
48. EHDSPatientSummary.alerts.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
50. EHDSPatientSummary.alerts.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
52. EHDSPatientSummary.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert
Requirements | ISO IPS
54. EHDSPatientSummary.alerts.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
56. EHDSPatientSummary.allergiesAndIntolerances
Definition | Section: Allergies and intolerances
Short | Section: Allergies and intolerances
Control | 1..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
58. EHDSPatientSummary.allergiesAndIntolerances.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
60. EHDSPatientSummary.allergiesAndIntolerances.allergyIntolerance
Definition | List of structured allergies and intolerances
Short | List of structured allergies and intolerances
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
62. EHDSPatientSummary.allergiesAndIntolerances.emptyReason
Definition | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Short | Use if no Allergies are listed
Control | 0..1
Binding | 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
Type | CodeableConcept
Requirements | 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.
64. EHDSPatientSummary.allergiesAndIntolerances.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.problems
Definition | Conditions and symptoms affecting the health of the patient.
Short | Section: Medical problems
Control | 1..1
Type | Base
68. EHDSPatientSummary.problems.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSPatientSummary.problems.emptyReason
Definition | Use if no conditions are listed
Short | Use if no conditions are listed
Control | 0..1
Type | CodeableConcept
72. EHDSPatientSummary.problems.problem
Definition | Health conditions affecting the health of the patient.
Short | Health conditions affecting the health of the patient.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
74. EHDSPatientSummary.problems.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
76. EHDSPatientSummary.medicationSummary
Definition | Current and relevant past medicines.
Short | Section: Medication summary
Control | 1..1
Type | Base
78. EHDSPatientSummary.medicationSummary.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSPatientSummary.medicationSummary.emptyReason
Definition | Use if no medicines are listed
Short | Use if no medicines are listed
Control | 0..1
Type | CodeableConcept
82. EHDSPatientSummary.medicationSummary.medicationUse
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationUse
84. EHDSPatientSummary.medicationSummary.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
86. EHDSPatientSummary.medicalDevicesAndImplants
Definition | The devices that are implanted in the patient and external medical devices and equipment that the health status depends on.
Short | Section: Medical devices and implants
Control | 1..1
Type | Base
88. EHDSPatientSummary.medicalDevicesAndImplants.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
92. EHDSPatientSummary.medicalDevicesAndImplants.deviceUse
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse
94. EHDSPatientSummary.medicalDevicesAndImplants.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.procedures
Definition | Significant procedures performed on the patient.
Short | Section: Procedures
Control | 1..1
Type | Base
98. EHDSPatientSummary.procedures.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSPatientSummary.procedures.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
102. EHDSPatientSummary.procedures.procedure
Definition | List of procedures
Short | List of procedures
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure
104. EHDSPatientSummary.procedures.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSPatientSummary.immunisations
Definition | 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.
Short | Section: Immunisations
Control | 0..1
Type | Base
108. EHDSPatientSummary.immunisations.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSPatientSummary.immunisations.immunisation
Definition | Immunisations given to the patient and their status at the point of care.
Short | Immunisations given to the patient and their status at the point of care.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSImmunisation
Requirements | eHN PS Guideline
112. EHDSPatientSummary.immunisations.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. EHDSPatientSummary.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being.
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
116. EHDSPatientSummary.functionalStatus.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
118. EHDSPatientSummary.functionalStatus.condition
Definition | Condition information describing patient's functional status or disability.
Short | Condition information describing patient's functional status or disability.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
120. EHDSPatientSummary.functionalStatus.assessment
Definition | Assessment results regarding functional status.
Short | Assessment results regarding functional status.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
122. EHDSPatientSummary.functionalStatus.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
124. EHDSPatientSummary.socialHistory
Definition | 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.
Short | Section: Social history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
126. EHDSPatientSummary.socialHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
128. EHDSPatientSummary.socialHistory.observation
Definition | Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
Short | Social history observations related to health
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
130. EHDSPatientSummary.socialHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
132. EHDSPatientSummary.pregnancyHistory
Definition | To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Short | Section: Pregnancy history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, ISO IPS
134. EHDSPatientSummary.pregnancyHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
136. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition | Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Short | Current pregnancy status
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCurrentPregnancy
Requirements | eHN PS Guideline, ISO IPS
138. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition | Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Short | History of previous pregnancies
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPregnancyHistory
140. EHDSPatientSummary.pregnancyHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
142. EHDSPatientSummary.travelHistory
Definition | 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.
Short | Section: Travel history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, ISO IPS
144. EHDSPatientSummary.travelHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
146. EHDSPatientSummary.travelHistory.travelHistory
Definition | Travel history for one country
Short | Travel history for one country
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSTravelHistory
Requirements | eHN PS Guideline, ISO IPS
148. EHDSPatientSummary.travelHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
150. EHDSPatientSummary.patientStory
Definition | 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.
Short | Section: Patient story
Control | 0..1
Type | Base
Requirements | ISO IPS
152. EHDSPatientSummary.patientStory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
154. EHDSPatientSummary.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives
Control | 0..1
Type | Base
156. EHDSPatientSummary.advanceDirectives.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
158. EHDSPatientSummary.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAdvanceDirective
160. EHDSPatientSummary.advanceDirectives.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
162. EHDSPatientSummary.observationResults
Definition | Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Short | Section: Observation results
Control | 0..1
Type | Base
164. EHDSPatientSummary.observationResults.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
166. EHDSPatientSummary.observationResults.result
Definition | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Short | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
168. EHDSPatientSummary.observationResults.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
170. EHDSPatientSummary.carePlans
Definition | Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
Short | Section: Care plans
Control | 0..1
Type | Base
172. EHDSPatientSummary.carePlans.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
174. EHDSPatientSummary.carePlans.carePlan
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan
176. EHDSPatientSummary.carePlans.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. EHDSPatientSummary
Definition | The model is a structured document designed to provide an overview of a patient’s most important health information. The model aims to be compatible with the ISO International Patient Summary standard.
Short | Patient summary model
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSPatientSummary.header
4. EHDSPatientSummary.header.period
Definition | Time period of information covered in the document
Short | Time period of information covered in the document
6. EHDSPatientSummary.alerts
Definition | Substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
8. EHDSPatientSummary.alerts.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
10. EHDSPatientSummary.alerts.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
12. EHDSPatientSummary.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert
Requirements | ISO IPS
14. EHDSPatientSummary.alerts.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. EHDSPatientSummary.allergiesAndIntolerances
Definition | Section: Allergies and intolerances
Short | Section: Allergies and intolerances
Control | 1..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
18. EHDSPatientSummary.allergiesAndIntolerances.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
20. EHDSPatientSummary.allergiesAndIntolerances.allergyIntolerance
Definition | List of structured allergies and intolerances
Short | List of structured allergies and intolerances
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
22. EHDSPatientSummary.allergiesAndIntolerances.emptyReason
Definition | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Short | Use if no Allergies are listed
Control | 0..1
Binding | 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
Type | CodeableConcept
Requirements | 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.
24. EHDSPatientSummary.allergiesAndIntolerances.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. EHDSPatientSummary.problems
Definition | Conditions and symptoms affecting the health of the patient.
Short | Section: Medical problems
Control | 1..1
Type | Base
28. EHDSPatientSummary.problems.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
30. EHDSPatientSummary.problems.emptyReason
Definition | Use if no conditions are listed
Short | Use if no conditions are listed
Control | 0..1
Type | CodeableConcept
32. EHDSPatientSummary.problems.problem
Definition | Health conditions affecting the health of the patient.
Short | Health conditions affecting the health of the patient.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
34. EHDSPatientSummary.problems.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
36. EHDSPatientSummary.medicationSummary
Definition | Current and relevant past medicines.
Short | Section: Medication summary
Control | 1..1
Type | Base
38. EHDSPatientSummary.medicationSummary.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
40. EHDSPatientSummary.medicationSummary.emptyReason
Definition | Use if no medicines are listed
Short | Use if no medicines are listed
Control | 0..1
Type | CodeableConcept
42. EHDSPatientSummary.medicationSummary.medicationUse
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationUse
44. EHDSPatientSummary.medicationSummary.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
46. EHDSPatientSummary.medicalDevicesAndImplants
Definition | The devices that are implanted in the patient and external medical devices and equipment that the health status depends on.
Short | Section: Medical devices and implants
Control | 1..1
Type | Base
48. EHDSPatientSummary.medicalDevicesAndImplants.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
50. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
52. EHDSPatientSummary.medicalDevicesAndImplants.deviceUse
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse
54. EHDSPatientSummary.medicalDevicesAndImplants.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
56. EHDSPatientSummary.procedures
Definition | Significant procedures performed on the patient.
Short | Section: Procedures
Control | 1..1
Type | Base
58. EHDSPatientSummary.procedures.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
60. EHDSPatientSummary.procedures.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
62. EHDSPatientSummary.procedures.procedure
Definition | List of procedures
Short | List of procedures
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure
64. EHDSPatientSummary.procedures.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.immunisations
Definition | 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.
Short | Section: Immunisations
Control | 0..1
Type | Base
68. EHDSPatientSummary.immunisations.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSPatientSummary.immunisations.immunisation
Definition | Immunisations given to the patient and their status at the point of care.
Short | Immunisations given to the patient and their status at the point of care.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSImmunisation
Requirements | eHN PS Guideline
72. EHDSPatientSummary.immunisations.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
74. EHDSPatientSummary.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being.
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
76. EHDSPatientSummary.functionalStatus.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
78. EHDSPatientSummary.functionalStatus.condition
Definition | Condition information describing patient's functional status or disability.
Short | Condition information describing patient's functional status or disability.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
80. EHDSPatientSummary.functionalStatus.assessment
Definition | Assessment results regarding functional status.
Short | Assessment results regarding functional status.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
82. EHDSPatientSummary.functionalStatus.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
84. EHDSPatientSummary.socialHistory
Definition | 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.
Short | Section: Social history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
86. EHDSPatientSummary.socialHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
88. EHDSPatientSummary.socialHistory.observation
Definition | Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
Short | Social history observations related to health
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
90. EHDSPatientSummary.socialHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
92. EHDSPatientSummary.pregnancyHistory
Definition | To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Short | Section: Pregnancy history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, ISO IPS
94. EHDSPatientSummary.pregnancyHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition | Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Short | Current pregnancy status
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCurrentPregnancy
Requirements | eHN PS Guideline, ISO IPS
98. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition | Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Short | History of previous pregnancies
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPregnancyHistory
100. EHDSPatientSummary.pregnancyHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
102. EHDSPatientSummary.travelHistory
Definition | 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.
Short | Section: Travel history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, ISO IPS
104. EHDSPatientSummary.travelHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSPatientSummary.travelHistory.travelHistory
Definition | Travel history for one country
Short | Travel history for one country
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSTravelHistory
Requirements | eHN PS Guideline, ISO IPS
108. EHDSPatientSummary.travelHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSPatientSummary.patientStory
Definition | 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.
Short | Section: Patient story
Control | 0..1
Type | Base
Requirements | ISO IPS
112. EHDSPatientSummary.patientStory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. EHDSPatientSummary.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives
Control | 0..1
Type | Base
116. EHDSPatientSummary.advanceDirectives.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
118. EHDSPatientSummary.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAdvanceDirective
120. EHDSPatientSummary.advanceDirectives.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
122. EHDSPatientSummary.observationResults
Definition | Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Short | Section: Observation results
Control | 0..1
Type | Base
124. EHDSPatientSummary.observationResults.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
126. EHDSPatientSummary.observationResults.result
Definition | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Short | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
128. EHDSPatientSummary.observationResults.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
130. EHDSPatientSummary.carePlans
Definition | Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
Short | Section: Care plans
Control | 0..1
Type | Base
132. EHDSPatientSummary.carePlans.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
134. EHDSPatientSummary.carePlans.carePlan
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan
136. EHDSPatientSummary.carePlans.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension

Guidance on how to interpret the contents of this table can be foundhere

0. EHDSPatientSummary
Definition | The model is a structured document designed to provide an overview of a patient’s most important health information. The model aims to be compatible with the ISO International Patient Summary standard.
Short | Patient summary model
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. EHDSPatientSummary.header
Definition | Basic metadata for this information
Short | Document header
Control | 1..1
Type | Base
4. EHDSPatientSummary.header.subject
Definition | Patient/subject information
Short | Patient/subject information
Control | 1..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPatient
6. EHDSPatientSummary.header.identifier
Definition | Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Short | Unique identifier of the document
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
8. EHDSPatientSummary.header.author[x]
Definition | Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.
Short | Author(s) of the document
Control | 1..*
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
10. EHDSPatientSummary.header.date
Definition | Date and optionally time of authoring/issuing
Short | Date of finalising/issuing the document
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
12. EHDSPatientSummary.header.status
Definition | Status of the resource or document
Short | Status of the document
Control | 1..1
Type | CodeableConcept
14. EHDSPatientSummary.header.source
Definition | 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.
Short | 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.
Control | 0..0
Type | CodeableConcept
16. EHDSPatientSummary.header.language
Definition | Language in which the resource is written. Language is expressed by the IETF language tag.
Short | Language in which the resource is written. Language is expressed by the IETF language tag.
Control | 0..1
Binding | BCP 47
Type | CodeableConcept
18. EHDSPatientSummary.header.documentType
Definition | Type of document at hand, e.g. 60591-5 Patient summary document.
Short | Type of document at hand, e.g. 60591-5 Patient summary document.
Control | 1..1
Binding | LOINC
Type | CodeableConcept
20. EHDSPatientSummary.header.documentTitle
Definition | 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'
Short | 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'
Control | 1..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. EHDSPatientSummary.header.period
Definition | Time period of information covered in the document
Short | Time period of information covered in the document
Control | 0..1
Type | Period
24. EHDSPatientSummary.header.version
Definition | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian
Short | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. EHDSPatientSummary.header.attestation
Definition | Document attestation details
Short | Document attestation details
Control | 0..*
Type | Base
28. EHDSPatientSummary.header.attestation.attester[x]
Definition | Attester who validated the document
Short | Attester who validated the document
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDevice
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
30. EHDSPatientSummary.header.attestation.datetime
Definition | Date and time of the approval of the document by Attester
Short | Date and time of the approval of the document by Attester
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
32. EHDSPatientSummary.header.legalAuthentication
Definition | Document legal authentication details
Short | Document legal authentication details
Control | 0..*
Type | Base
34. EHDSPatientSummary.header.legalAuthentication.legalAuthenticator[x]
Definition | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Short | The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
Control | 1..1
Type | Choice of: http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSHealthProfessional, http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
36. EHDSPatientSummary.header.legalAuthentication.datetime
Definition | Date and time when the document was authorised
Short | Date and time when the document was authorised
Control | 1..1
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
38. EHDSPatientSummary.header.eventType
Definition | 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.
Short | 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.
Control | 0..*
Binding | LOINC, SNOMED CT, dicom-cid-33-Modality
Type | CodeableConcept
40. EHDSPatientSummary.header.serviceSpecialty
Definition | Additional details about where the content was created (e.g. clinical specialty)
Short | Additional details about where the content was created (e.g. clinical specialty)
Control | 0..*
Binding | SNOMED CT
Type | CodeableConcept
42. EHDSPatientSummary.header.custodian
Definition | Organisation that is in charge of maintaining the document/report.
Short | Organisation that is in charge of maintaining the document/report.
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSOrganisation
44. EHDSPatientSummary.presentedForm
Definition | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Short | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAttachment
46. EHDSPatientSummary.alerts
Definition | Substantial alerts or warnings that health professionals should be aware of.
Short | Section: Alerts
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
48. EHDSPatientSummary.alerts.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
50. EHDSPatientSummary.alerts.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
52. EHDSPatientSummary.alerts.medicalAlert
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAlert
Requirements | ISO IPS
54. EHDSPatientSummary.alerts.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
56. EHDSPatientSummary.allergiesAndIntolerances
Definition | Section: Allergies and intolerances
Short | Section: Allergies and intolerances
Control | 1..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
58. EHDSPatientSummary.allergiesAndIntolerances.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
60. EHDSPatientSummary.allergiesAndIntolerances.allergyIntolerance
Definition | List of structured allergies and intolerances
Short | List of structured allergies and intolerances
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAllergyIntolerance
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
62. EHDSPatientSummary.allergiesAndIntolerances.emptyReason
Definition | Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)
Short | Use if no Allergies are listed
Control | 0..1
Binding | 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
Type | CodeableConcept
Requirements | 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.
64. EHDSPatientSummary.allergiesAndIntolerances.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
66. EHDSPatientSummary.problems
Definition | Conditions and symptoms affecting the health of the patient.
Short | Section: Medical problems
Control | 1..1
Type | Base
68. EHDSPatientSummary.problems.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
70. EHDSPatientSummary.problems.emptyReason
Definition | Use if no conditions are listed
Short | Use if no conditions are listed
Control | 0..1
Type | CodeableConcept
72. EHDSPatientSummary.problems.problem
Definition | Health conditions affecting the health of the patient.
Short | Health conditions affecting the health of the patient.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
74. EHDSPatientSummary.problems.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
76. EHDSPatientSummary.medicationSummary
Definition | Current and relevant past medicines.
Short | Section: Medication summary
Control | 1..1
Type | Base
78. EHDSPatientSummary.medicationSummary.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
80. EHDSPatientSummary.medicationSummary.emptyReason
Definition | Use if no medicines are listed
Short | Use if no medicines are listed
Control | 0..1
Type | CodeableConcept
82. EHDSPatientSummary.medicationSummary.medicationUse
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSMedicationUse
84. EHDSPatientSummary.medicationSummary.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
86. EHDSPatientSummary.medicalDevicesAndImplants
Definition | The devices that are implanted in the patient and external medical devices and equipment that the health status depends on.
Short | Section: Medical devices and implants
Control | 1..1
Type | Base
88. EHDSPatientSummary.medicalDevicesAndImplants.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
90. EHDSPatientSummary.medicalDevicesAndImplants.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
92. EHDSPatientSummary.medicalDevicesAndImplants.deviceUse
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSDeviceUse
94. EHDSPatientSummary.medicalDevicesAndImplants.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
96. EHDSPatientSummary.procedures
Definition | Significant procedures performed on the patient.
Short | Section: Procedures
Control | 1..1
Type | Base
98. EHDSPatientSummary.procedures.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
100. EHDSPatientSummary.procedures.emptyReason
Definition | Reason for absence of data
Short | Reason for absence of data
Control | 0..1
Type | CodeableConcept
102. EHDSPatientSummary.procedures.procedure
Definition | List of procedures
Short | List of procedures
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSProcedure
104. EHDSPatientSummary.procedures.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
106. EHDSPatientSummary.immunisations
Definition | 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.
Short | Section: Immunisations
Control | 0..1
Type | Base
108. EHDSPatientSummary.immunisations.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
110. EHDSPatientSummary.immunisations.immunisation
Definition | Immunisations given to the patient and their status at the point of care.
Short | Immunisations given to the patient and their status at the point of care.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSImmunisation
Requirements | eHN PS Guideline
112. EHDSPatientSummary.immunisations.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
114. EHDSPatientSummary.functionalStatus
Definition | An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being.
Short | Section: Functional status
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
116. EHDSPatientSummary.functionalStatus.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
118. EHDSPatientSummary.functionalStatus.condition
Definition | Condition information describing patient's functional status or disability.
Short | Condition information describing patient's functional status or disability.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCondition
120. EHDSPatientSummary.functionalStatus.assessment
Definition | Assessment results regarding functional status.
Short | Assessment results regarding functional status.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
122. EHDSPatientSummary.functionalStatus.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
124. EHDSPatientSummary.socialHistory
Definition | 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.
Short | Section: Social history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
126. EHDSPatientSummary.socialHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
128. EHDSPatientSummary.socialHistory.observation
Definition | Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption
Short | Social history observations related to health
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
Requirements | eHN PS Guideline, MyHealth@EU, ISO IPS
130. EHDSPatientSummary.socialHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
132. EHDSPatientSummary.pregnancyHistory
Definition | To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.
Short | Section: Pregnancy history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, ISO IPS
134. EHDSPatientSummary.pregnancyHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
136. EHDSPatientSummary.pregnancyHistory.currentPregnancyStatus
Definition | Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.
Short | Current pregnancy status
Control | 0..1
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCurrentPregnancy
Requirements | eHN PS Guideline, ISO IPS
138. EHDSPatientSummary.pregnancyHistory.previousPregnancies
Definition | Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.
Short | History of previous pregnancies
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSPregnancyHistory
140. EHDSPatientSummary.pregnancyHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
142. EHDSPatientSummary.travelHistory
Definition | 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.
Short | Section: Travel history
Control | 0..1
Type | Base
Requirements | eHN PS Guideline, ISO IPS
144. EHDSPatientSummary.travelHistory.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
146. EHDSPatientSummary.travelHistory.travelHistory
Definition | Travel history for one country
Short | Travel history for one country
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSTravelHistory
Requirements | eHN PS Guideline, ISO IPS
148. EHDSPatientSummary.travelHistory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
150. EHDSPatientSummary.patientStory
Definition | 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.
Short | Section: Patient story
Control | 0..1
Type | Base
Requirements | ISO IPS
152. EHDSPatientSummary.patientStory.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
154. EHDSPatientSummary.advanceDirectives
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions.
Short | Section: Advance Directives
Control | 0..1
Type | Base
156. EHDSPatientSummary.advanceDirectives.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
158. EHDSPatientSummary.advanceDirectives.advanceDirective
Definition | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Short | Provision for healthcare decisions if, in the future, a person is unable to make those decisions
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSAdvanceDirective
160. EHDSPatientSummary.advanceDirectives.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
162. EHDSPatientSummary.observationResults
Definition | Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.
Short | Section: Observation results
Control | 0..1
Type | Base
164. EHDSPatientSummary.observationResults.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
166. EHDSPatientSummary.observationResults.result
Definition | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Short | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSObservation
168. EHDSPatientSummary.observationResults.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
170. EHDSPatientSummary.carePlans
Definition | Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries
Short | Section: Care plans
Control | 0..1
Type | Base
172. EHDSPatientSummary.carePlans.generatedNarrative
Definition | Narrative, potentially formatted, content of the whole section.
Short | Narrative, potentially formatted, content of the whole section.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
174. EHDSPatientSummary.carePlans.carePlan
Definition | 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.
Short | 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.
Control | 0..*
Type | http://www.xt-ehr.eu/fhir/models/StructureDefinition/EHDSCarePlan
176. EHDSPatientSummary.carePlans.note
Definition | Free text notes by the health professional
Short | Free text notes by the health professional
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension