NOT International Patient Summary Implementation Guide
2.0.0-ballot - STU 2 Ballot International flag

NOT International Patient Summary Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/costateixeira/fhir-ips/ and changes regularly. See the Directory of published versions

Example Bundle: IPS Bundle example with Immunization

Document Subject

Generated Narrative: Patient 2b90dd2b-2dab-4c75-9bb9-a355e07401e1-with-immunization

Martha DeLarosa Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)

Active:true
Contact Detail
mother:

Document Content

Active Problems

Hot flushes

Medication

MedicationStrengthFormDosageComment
Anastrozole1 mgtabletonce dailytreatment for breast cancer
Black Cohosh Extractpilherbal supplement

Allergies and Intolerances

Allergy to penicillin, high criticality, active No known food allergies

History of Past Illness

Breast cancer Stage II with no evidence of recurrence following treatment

Plan of Treatment

Continue hormone medication with Anastrozole for total of 5 years and monitor for potential breast cancer recurrence

Results

Blood typing
Blood groupA+
C Ab [Presence] in Serum or PlasmaPositive
E Ab [Presence] in Serum or PlasmaPositive
Little c Ab [Presence] in Serum or PlasmaNegative
Hemoglobin A1c monitoring
Hemoglobin A1c/Hemoglobin.total in Blood by HPLC7.5 %
Bacteriology
Methicillin resistant Staphylococcus aureus
Healthy carrier of MRSA

Immunizations

Marie Lux-Brennard (Apr 17, 1998)

Vaccin anti diphtérie-coqueluche-tétanos-poliomyélite, Jun 3, 1998, 10:00:00 PM

Voie intramusculaire, Cuisse droite

Additional Resources Included in Document

Entry 1 - fullUrl = urn:uuid:30551ce1-5a28-4356-b684-1e639094ad4d

Resource Composition:

Generated Narrative: Composition 30551ce1-5a28-4356-b684-1e639094ad4d

identifier: urn:oid:2.16.724.4.8.10.200.10/3f69e0a5-2177-4540-baab-7a5d0877428f

status: Final

type: Patient summary Document

date: 2017-12-11 14:30:00+0100

author: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

title: Patient Summary as of December 11, 2017 14:30

attester

mode: Legal

time: 2017-12-11 14:30:00+0100

party: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

attester

mode: Legal

time: 2017-12-11 14:30:00+0100

party: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

custodian: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

relatesTo

No display for RelatedArtifact (type: appends)

Events

-PeriodDetail
*?? --> 2017-12-11 14:30:00+0100No display for Composition.event.detail (concept: care provision)

Entry 2 - fullUrl = urn:uuid:2b90dd2b-2dab-4c75-9bb9-a355e07401e1

Resource Patient:

Generated Narrative: Patient 2b90dd2b-2dab-4c75-9bb9-a355e07401e1-with-immunization

Martha DeLarosa Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)

Active:true
Contact Detail
mother:

Entry 3 - fullUrl = urn:uuid:1c616b24-3895-48c4-9a02-9a64110351ef

Resource Practitioner:

Generated Narrative: Practitioner 1c616b24-3895-48c4-9a02-9a64110351ef-with-immunization

identifier: urn:oid:2.16.528.1.1007.3.1/129854633

active: true

name: Beetje van Hulp

Qualifications

-Code
*Doctor of Medicine

Entry 4 - fullUrl = urn:uuid:890751f4-2924-4636-bab7-efffc7f3cf15

Resource Organization:

Generated Narrative: Organization 890751f4-2924-4636-bab7-efffc7f3cf15-with-immunization

identifier: urn:oid:2.16.528.1.1007.3.3/564738757

active: true

name: Anorg Aniza Tion BV / The best custodian ever

Contacts

-TelecomAddress
*+31-51-34343400Houttuinen 27 Dordrecht 3311 CE NL (work)

Entry 5 - fullUrl = urn:uuid:c64139e7-f02d-409c-bf34-75e8bf23bc80

Resource Condition:

Generated Narrative: Condition c64139e7-f02d-409c-bf34-75e8bf23bc80-with-immunization

identifier: urn:oid:1.2.3.999/c87bf51c-e53c-4bfe-b8b7-aa62bdd93002

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem

severity: Moderate severity

code: Menopausal flushing (finding)

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

onset: 2015

recordedDate: 2016-10

Entry 6 - fullUrl = urn:uuid:c220e36c-eb67-4fc4-9ba1-2fabc52acec6

Resource MedicationStatement:

Generated Narrative: MedicationStatement c220e36c-eb67-4fc4-9ba1-2fabc52acec6-with-immunization

identifier: urn:oid:1.2.3.999/b75f92cb-61d4-469a-9387-df5ef70d25f0

status: recorded

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2015-03 --> (ongoing)

dosage

Entry 7 - fullUrl = urn:uuid:47524493-846a-4a26-bae2-4ab03e60f02e

Resource MedicationStatement:

Generated Narrative: MedicationStatement 47524493-846a-4a26-bae2-4ab03e60f02e-with-immunization

identifier: urn:oid:1.2.3.999/9e312d6b-c6b6-439a-a730-6efaa5dcf8bc

status: recorded

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2016-01 --> (ongoing)

Dosages

-Route
*Oral use

Entry 8 - fullUrl = urn:uuid:976d0804-cae0-45ae-afe3-a19f3ceba6bc

Resource Medication:

Generated Narrative: Medication 976d0804-cae0-45ae-afe3-a19f3ceba6bc-with-immunization

code: Product containing anastrozole (medicinal product)

Entry 9 - fullUrl = urn:uuid:8adc0999-9468-4ac9-9557-680fa133d626

Resource Medication:

Generated Narrative: Medication 8adc0999-9468-4ac9-9557-680fa133d626-with-immunization

code: Black Cohosh Extract herbal supplement

Entry 10 - fullUrl = urn:uuid:72884cad-ebe6-4f43-a51a-2f978275f132

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance 72884cad-ebe6-4f43-a51a-2f978275f132-with-immunization

identifier: urn:oid:1.2.3.999/3a462598-009c-484a-965c-d6b24a821424

clinicalStatus: Active

verificationStatus: Confirmed

type: Allergy

category: Medication

criticality: High Risk

code: Substance with penicillin structure and antibacterial mechanism of action (substance)

patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

onset: 2010

Entry 11 - fullUrl = urn:uuid:c4597aa2-688a-401b-a658-70acc6de28c6

Resource Condition:

Generated Narrative: Condition c4597aa2-688a-401b-a658-70acc6de28c6-with-immunization

identifier: urn:oid:1.2.3.999/66d4a8c7-9081-43e0-a63f-489c2ae6edd6

clinicalStatus: Remission

verificationStatus: Confirmed

category: Problem

severity: Severe

code: Malignant tumor of breast

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

onset: 2015-01

abatement: 2015-03

Entry 12 - fullUrl = urn:uuid:45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

Resource Organization:

Generated Narrative: Organization 45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7-with-immunization

active: true

type: Other

name: Laboratoire de charme

Entry 13 - fullUrl = urn:uuid:aa11a2be-3e36-4be7-b58a-6fc3dace2741

Resource Observation:

Generated Narrative: Observation aa11a2be-3e36-4be7-b58a-6fc3dace2741-with-immunization

status: Final

category: Laboratory

code: ABO and Rh group [Type] in Blood

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2015-10-10 09:15:00+0100

performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

value: Blood group A Rh(D) positive

Entry 14 - fullUrl = urn:uuid:6e39ccf3-f997-4a2b-8f28-b4b71c778c70

Resource Observation:

Generated Narrative: Observation 6e39ccf3-f997-4a2b-8f28-b4b71c778c70-with-immunization

status: Final

category: Laboratory

code: C Ab [Presence] in Serum or Plasma

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2015-10-10 09:35:00+0100

performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

value: Positive

Entry 15 - fullUrl = urn:uuid:b4916505-a06b-460c-9be8-011609282457

Resource Observation:

Generated Narrative: Observation b4916505-a06b-460c-9be8-011609282457-with-immunization

status: Final

category: Laboratory

code: E Ab [Presence] in Serum or Plasma

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2015-10-10 09:35:00+0100

performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

value: Positive

Entry 16 - fullUrl = urn:uuid:a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4

Resource Observation:

Generated Narrative: Observation a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4-with-immunization

status: Final

category: Laboratory

code: little c Ab [Presence] in Serum or Plasma

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2015-10-10 09:35:00+0100

performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

value: Negative

Entry 17 - fullUrl = urn:uuid:2639657a-c19a-48e2-82cc-471e13b8ad94

Resource Observation:

Generated Narrative: Observation 2639657a-c19a-48e2-82cc-471e13b8ad94-with-immunization

status: Final

category: Laboratory

code: Blood typing

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2015-10-10

performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

hasMember:

Entry 18 - fullUrl = urn:uuid:cc354e00-a419-47ea-8b6c-1768b2a01646

Resource Observation:

Generated Narrative: Observation cc354e00-a419-47ea-8b6c-1768b2a01646-with-immunization

status: Final

category: Laboratory

code: Hemoglobin A1c/Hemoglobin.total in Blood by HPLC

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2017-11-10 08:20:00+0100

performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

value: 7.5 % (Details: UCUM code% = '%')

note: Above stated goal of 7.0 %

Entry 19 - fullUrl = urn:uuid:26bee0a9-5997-4557-ab9d-c6adbb05b572

Resource Observation:

Generated Narrative: Observation 26bee0a9-5997-4557-ab9d-c6adbb05b572-with-immunization

status: Final

category: Laboratory

code: Bacteria identified in Isolate

subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

effective: 2017-12-10 08:20:00+0100

performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

value: Methicillin resistant Staphylococcus aureus

note: Healthy carrier of MRSA

Entry 20 - fullUrl = urn:uuid:c7781f44-6df8-4a8b-9e06-0b34263a47c5

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance c7781f44-6df8-4a8b-9e06-0b34263a47c5-with-immunization

clinicalStatus: Active

code: No known food allergy (situation)

patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

Entry 21 - fullUrl = urn:uuid:40b7b6a0-c043-423a-9959-be3707e728b2

Resource Immunization:

Generated Narrative: Immunization 40b7b6a0-c043-423a-9959-be3707e728b2

Language: fr-LU

status: Completed

vaccineCode: Vaccin anti diphtérie-coqueluche-tétanos-poliomyélite

lotNumber: AXK23RWERS

expirationDate: 2000-06-01

patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

occurrence: 1998-06-04 00:00:00+0200

primarySource: true

site: Cuisse droite

route: Voie intramusculaire

ProtocolApplieds

-TargetDisease
*Pertussis