Generated Narrative: StructureDefinition EHDSPatientSummary Name Flags Card. Type Description & Constraints EHDSPatientSummary 0..* EHDSDocument Patient summary model Elements defined in Ancestors:header, header, presentedForm #xD; header #xD; period 0..1 Period Time period of information covered in the document #xD; alerts 0..1 Base Section: Alerts #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; emptyReason 0..1 CodeableConcept Reason for absence of data #xD; medicalAlert 0..* EHDSAlert Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat. #xD; note 0..1 string Free text notes by the health professional #xD; allergiesAndIntolerances 1..1 Base Section: Allergies and intolerances #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; allergyIntolerance 0..* EHDSAllergyIntolerance List of structured allergies and intolerances #xD; emptyReason 0..1 CodeableConcept Use if no Allergies are listed Binding Description: (preferred): 1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason #xD; note 0..1 string Free text notes by the health professional #xD; problems 1..1 Base Section: Medical problems #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; emptyReason 0..1 CodeableConcept Use if no conditions are listed #xD; problem 0..* EHDSCondition Health conditions affecting the health of the patient. #xD; note 0..1 string Free text notes by the health professional #xD; medicationSummary 1..1 Base Section: Medication summary #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; emptyReason 0..1 CodeableConcept Use if no medicines are listed #xD; medicationUse 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. #xD; note 0..1 string Free text notes by the health professional #xD; medicalDevicesAndImplants 1..1 Base Section: Medical devices and implants #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; emptyReason 0..1 CodeableConcept Reason for absence of data #xD; deviceUse 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. #xD; note 0..1 string Free text notes by the health professional #xD; procedures 1..1 Base Section: Procedures #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; emptyReason 0..1 CodeableConcept Reason for absence of data #xD; procedure 0..* EHDSProcedure List of procedures #xD; note 0..1 string Free text notes by the health professional #xD; immunisations 0..1 Base Section: Immunisations #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; immunisation 0..* EHDSImmunisation Immunisations given to the patient and their status at the point of care. #xD; note 0..1 string Free text notes by the health professional #xD; functionalStatus 0..1 Base Section: Functional status #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; condition 0..* EHDSCondition Condition information describing patient's functional status or disability. #xD; assessment 0..* EHDSObservation Assessment results regarding functional status. #xD; note 0..1 string Free text notes by the health professional #xD; socialHistory 0..1 Base Section: Social history #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; observation 0..* EHDSObservation Social history observations related to health #xD; note 0..1 string Free text notes by the health professional #xD; pregnancyHistory 0..1 Base Section: Pregnancy history #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; currentPregnancyStatus 0..1 EHDSCurrentPregnancy Current pregnancy status #xD; previousPregnancies 0..* EHDSPregnancyHistory History of previous pregnancies #xD; note 0..1 string Free text notes by the health professional #xD; <a href="StructureDefinition-EHDSPatientSummary-definitions.html#EHDSPatientSummary.travelHistory" 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 0..1 Base Section: Travel history #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; travelHistory 0..* EHDSTravelHistory Travel history for one country #xD; note 0..1 string Free text notes by the health professional #xD; patientStory 0..1 Base Section: Patient story #xD; note 0..1 string Free text notes by the health professional #xD; advanceDirectives 0..1 Base Section: Advance Directives #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; advanceDirective 0..* EHDSAdvanceDirective Provision for healthcare decisions if, in the future, a person is unable to make those decisions #xD; note 0..1 string Free text notes by the health professional #xD; observationResults 0..1 Base Section: Observation results #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; result 0..* EHDSObservation Observation results pertaining to the subject of care's health condition and which might have impact on future treatments #xD; note 0..1 string Free text notes by the health professional #xD; carePlans 0..1 Base Section: Care plans #xD; generatedNarrative 0..1 string Narrative, potentially formatted, content of the whole section. #xD; carePlan 0..* EHDSCarePlan Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions. #xD; note 0..1 string Free text notes by the health professional #xD; Documentation for this format
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.
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 medical content of the document (typically the person who signs it)
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.
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.
1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason
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.