HL7 Europe Patient Summary
1.0.0-ci-build - ci-build 150

HL7 Europe Patient Summary, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/eps/ and changes regularly. See the Directory of published versions

## EHDSPatientSummary to Composition (EPS)

EHDSPatientSummary → Composition (EPS)
Ongoing alignment: The Xt-EHR logical models are under active revision and continuous refinement. Updates from Xt-EHR will be progressively incorporated into this Implementation Guide to maintain alignment with the evolving EHDS specifications.

### EHDSPatientSummary → Composition (EPS)

This page explains how conceptual elements from the EHDSPatientSummary logical model are expressed in the corresponding FHIR CompositionEuEps profile used by this Implementation Guide.

Mapping Context

- Source logical model: EHDSPatientSummary
- Target FHIR profile: CompositionEuEps

EHDSPatientSummary → Composition (EPS)
EHDSPatientSummary (Logical Model) | Relationship | Composition (EPS)
--- | --- | ---
Element | Description | Relation | Resource | Element | Description | Notes
header | Document header elements. | related-to | Composition | . | Composition-level metadata. | CompositionEuEps constrains cardinalities and section slices for Patient Summary.
header.subject | Patient/subject information. | equivalent | Composition | subject | Who or what the composition is about. | Reference to PatientEuEps.
header.identifier | Unique identifier of the document. | equivalent | Composition | identifier | Version-independent identifier for the Patient Summary. | Multiple identifiers allowed through profiling; Composition R4 is 0..1.
header.identifier | Unique identifier of the document. | equivalent | Bundle | identifier | Persistent identifier for the Patient Summary document bundle. | Represents a specific rendition/version of the document.
header.authorship | Resource authoring details. | related-to | Composition | author | Authors of the Patient Summary. | Composition.date captures the authoring timestamp.
header.authorship.author[x] | Author(s) by whom the resource was/were authored. | equivalent | Composition | author | Logical authors list. | Reference to Practitioner / PractitionerRole / Organization / Device per profile.
header.authorship.datetime | Date and time of authoring/issuing. | equivalent | Composition | date | Composition creation time. |
header.lastUpdate | Date and time of the last update to the resource. | equivalent | Composition | meta.lastUpdated | System-level modification time. | Only applicable when representing the system update instant (YYYY-MM-DDThh:mm:ss.sss+zz:zz).
header.status | Status of the resource or document. | equivalent | Composition | status | The workflow/clinical status of this composition. |
header.statusReason[x] | Reason for the current status of the resource. | no-map | Composition |  |  | No native element.
header.language | Language of the resource (IETF BCP-47). | equivalent | Composition | language | Language of the narrative. |
header.documentType | Type of document at hand (e.g., LOINC 60591-5 Patient summary document). | equivalent | Composition | type | Kind of composition. |
header.documentTitle | Human readable document title. | equivalent | Composition | title | Official human-readable label. |
header.period | Time of service that is being documented. | related-to | Composition | event.period | Period covered by the composition content. | Map to the primary Composition.event entry.
header.version | Business version of the document. | related-to | Composition | extension:version | Document business version. | Use composition.version (R5) or the pre-adopted extension for R4.
header.attestation | Document attestation details. | related-to | Composition | attester | Participants responsible for attesting the composition. | Use attester.mode to distinguish assertions.
header.attestation.attester | Attester who validated the document. | equivalent | Composition | attester.party | Who attested the composition. |
header.attestation.datetime | Date and time of the approval of the document by Attester. | equivalent | Composition | attester.time | When the composition was attested. | Set attester.mode as appropriate (e.g., professional).
header.legalAuthentication | Document legal authentication details. | related-to | Composition | attester | Legal authenticator. | Use attester.mode = "legal".
header.legalAuthentication.legalAuthenticator | The person taking responsibility for the medical content of the document. | related-to | Composition | attester.party | Legal authenticator party. | Use attester.mode = "legal".
header.legalAuthentication.datetime | Date and time when the document was authorised. | equivalent | Composition | attester.time | When the composition was attested. | Use attester.mode = "legal".
header.eventType | Categorisation of the event covered by the document. | related-to | Composition | event.code | Codes describing the event(s) related to the composition. | Clarify whether codes reflect event tags or document classification.
header.serviceSpecialty | Additional details about where the content was created (e.g. clinical specialty). | source-is-narrower-than-target | Composition | category | Categorizes the composition. | Service Speciality is out of scope for a Patient Summary. Give feedback to Xt-EHR.
header.custodian | Organisation that is in charge of maintaining the document/report. | equivalent | Composition | custodian | Organization responsible for maintenance. | Reference to Organization.
header.confidentiality | Level of confidentiality of the document. | equivalent | Composition | confidentiality | As defined by confidentiality codes. | Implicit value is normal.
presentedForm | A narrative easy-to-read representation of the full data set (e.g. PDF). | related-to | DocumentReference | content.attachment | Embedded or referenced rendition of the Patient Summary. | Include a DocumentReference in the bundle linked from Composition via event/relatesTo if provided.
alerts | Section: Alerts. | equivalent | Composition | section:sectionAlerts | Alert section | Use LOINC 104605-1
alerts.narrative | Narrative content of the section. | equivalent | Composition | section:sectionAlerts.text | Narrative for Alerts section. |
alerts.emptyReason | Reason for absence of data. | equivalent | Composition | section:sectionAlerts.emptyReason | Why no alerts are present. |
alerts.medicalAlert | Description of medical alerts. | equivalent | Composition | section:sectionAlert.entry:flag | Alert entries. | Reference to `FlagEuCore.`
allergiesAndIntolerances | Section: Allergies and intolerances. | equivalent | Composition | section:sectionAllergies | Allergy and intolerance section. | Mandatory slice in CompositionEuEps.
allergiesAndIntolerances.narrative | Text summary of the content in section. | equivalent | Composition | section:sectionAllergies.text | Narrative for Allergies section. |
allergiesAndIntolerances.allergyIntolerance | List of structured allergies and intolerances. | equivalent | Composition | section:sectionAllergies.entry:allergyOrIntolerance | Allergy intolerance entries. | Reference to AllergyIntoleranceEuCore.
allergiesAndIntolerances.emptyReason | Use if no Allergies are listed. | equivalent | Composition | section:sectionAllergies.emptyReason | Reason for missing allergy data. |
problems | Medical problems. | equivalent | Composition | section:sectionProblems | Active problems section. | Use LOINC 11450-4
problems.narrative | Text summary of the content in the section. | equivalent | Composition | section:sectionProblems.text | Narrative for Problems section. |
problems.emptyReason | Reason for absence of data. | equivalent | Composition | section:sectionProblems.emptyReason | Why no problems are listed. |
problems.problems | Health conditions affecting the patient. | equivalent | Composition | section:sectionProblems.entry:problem | Problem entries. | Reference to ConditionEuCore.
medicationSummary | Section: Medication Summary. | equivalent | Composition | section:sectionMedications | Medication summary section. | Use LOINC 10160-0
medicationSummary.narrative | Text summary of the content in the section. | equivalent | Composition | section:sectionMedications.text | Narrative for Medication section. |
medicationSummary.emptyReason | Use if no medicines are listed. | equivalent | Composition | section:sectionMedications.emptyReason | Reason for missing medication data. |
medicationSummary.medicationTreatment | Medication treatment/prescription relevant for this patient summary. | equivalent | Composition | section:sectionMedications.entry:medicationStatementOrRequest | Medication entries. | Reference to MedicationStatementEuCore (or MedicationRequest/Administration/Dispense per profile).
medicalDevicesAndImplants | Section: Medical devices and implants. | equivalent | Composition | section:sectionMedicalDevices | Medical devices section. | Use LOINC 46264-8
medicalDevicesAndImplants.narrative | Narrative content of the section. | equivalent | Composition | section.text | Narrative for devices and implants. |
medicalDevicesAndImplants.emptyReason | Reason for absence of data. | equivalent | Composition | section.emptyReason | Why no devices are listed. |
medicalDevicesAndImplants.medicalDevice | Implanted and external medical devices. | equivalent | Composition | section:sectionMedicalDevices.entry:deviceStatement | Device use entries. | Reference to DeviceUseStatementEuEps.
procedures | Section: Procedures. | equivalent | Composition | section:sectionProceduresHx | Procedures section. | Use LOINC 47519-4
procedures.narrative | Narrative content of the section. | equivalent | Composition | section.text | Narrative for Procedures section. |
procedures.emptyReason | Reason for absence of data. | equivalent | Composition | section.emptyReason | Why no procedures are listed. |
procedures.procedure | List of procedures. | equivalent | Composition | section:sectionProceduresHx.entry:procedure | Procedure entries. | Reference to ProcedureEuCore.
vaccination | Section: Vaccination/prophylaxis. | equivalent | Composition | section:sectionImmunizations | Immunizations section. | Use LOINC 11369-6
vaccination.narrative | Narrative content of the section. | equivalent | Composition | section.text | Narrative for Immunizations section. |
vaccination.vaccination | Immunisations given to the patient and their status. | equivalent | Composition | section:sectionImmunizations.entry:immunization | Immunization entries. | Reference to ImmunizationEuCore.
functionalStatus | Section: Functional status. | equivalent | Composition | section:sectionFunctionalStatus | Functional status section. | Use LOINC 47420-5
functionalStatus.narrative | Narrative content of the section. | equivalent | Composition | section.text | Narrative for Functional Status section. |
functionalStatus.functionalStatusAssessment | Functional status assessments. | equivalent | Composition | section:sectionFunctionalStatus.entry:functionalStatus | Functional status entries. | Reference to Observation/Condition representing functional status (per profile guidance).
socialHistory | Section: Social history. | equivalent | Composition | section:sectionSocialHistory | Social history section. | Uses slice defined in CompositionEuEps.
socialHistory.narrative | Narrative content of the section. | equivalent | Composition | section.text | Narrative for Social History section. |
socialHistory.socialHistoryObservation | Social history observations related to health. | equivalent | Composition | section:sectionSocialHistory.entry | Social history entries. | check the target profiles to be used.
pregnancyHistory | Section: Pregnancy history. | equivalent | Composition | section:sectionPregnancyHx | Pregnancy history section. | Use LOINC 10162-6
pregnancyHistory.generatedNarrative | Generated text summary of the section. | equivalent | Composition | section.text | Narrative for Pregnancy section. |
pregnancyHistory.currentPregnancyStatus | Current pregnancy status. | equivalent | Composition | section:sectionPregnancyHx.entry:pregnancyStatus | Pregnancy status entry. | Reference to ObservationPregnancyStatusUvIps.
pregnancyHistory.previousPregnanciesStatus | Overall status of previous pregnancies. | related-to | Composition | section:sectionPregnancyHx.entry:pregnancyOutcome | Summary of prior pregnancies. | Check target profiles. Use ObservationPregnancyOutcomeUvIps or equivalent summary observation.
pregnancyHistory.previousPregnancies | History of previous pregnancies. | equivalent | Composition | section:sectionPregnancyHx.entry:pregnancyOutcome | Pregnancy outcome entries. | Check target profiles. Reference to ObservationPregnancyOutcomeUvIps.
travelHistory | Relevant information about the patient's recent travel history. | equivalent | Composition | section:sectionTravelHx | Travel history section. | Uses LOINC 10182-4. MISSING to be added
travelHistory.narrative | Text summary of the content in the section. | equivalent | Composition | section.text | Narrative for Travel History section. MISSING to be added |
travelHistory.travelHistory | Travel history for one country. | equivalent | Composition | section:sectionTravelHx.entry | Travel history entries. | Reference to ObservationTravelEuHdr. MISSING to be added
patientStory | What the patient believes to be important for the attending clinician to know. | equivalent | Composition | section:sectionPatientHx | Patient story section. | Uses slice defined in CompositionEuEps. check if the propoer loinc code is used and the patient history section is added.
patientStory.narrative | Text summary of the content in the section. | equivalent | Composition | section.text | Narrative for Patient Story section. |
advanceDirectives | Section: Advance Directives. | equivalent | Composition | section:sectionAdvanceDirectives | Advance directives section. | Use LOINC 42348-3
advanceDirectives.narrative | Narrative content of the section. | equivalent | Composition | section.text | Narrative for Advance Directives section. |
advanceDirectives.advanceDirective | Provision for healthcare decisions. | equivalent | Composition | section:sectionAdvanceDirectives.entry | Advance directive entries. | Reference to ConsentEuEps or DocumentReference.
results | Section: Observation results. | source-is-broader-than-target | Composition | section:sectionResults | Results section. | Slice defined for coded results. CHECK IF THIS MAPS TO BOTH DIANGOSTIC RESULTS AND VITAL SIGNS. Section to be refined
results | Section: Observation results. | source-is-broader-than-target | Composition | section:sectionVitalSigns | Vital Signs section. | Slice defined for coded results. CHECK IF THIS MAPS TO BOTH DIANGOSTIC RESULTS AND VITAL SIGNS. Section to be refined
results.narrative | Narrative content of the section. | equivalent | Composition | section.text | Narrative for Results section. |
results.resultObservation[x] | Observation results pertaining to the subject of care. | equivalent | Composition | section:sectionResults.entry | Result observation entries. | Reference to Observation. Target profiles to be defined.
results.resultObservation[x] | Observation results pertaining to the subject of care. | equivalent | Composition | section:sectionVitalSigns.entry | Result observation entries. | Reference to Observation. Target profiles to be defined.
carePlan | Section: Care plans. | equivalent | Composition | section:sectionPlanOfCare | Care plan section. | Slice for plan of care in CompositionEuEps.
carePlan.narrative | Narrative containing the plan including proposals, goals, and order requests. | equivalent | Composition | section.text | Narrative for Care Plan section. |
carePlan.carePlanEntry | Describes the intention of how care will be delivered. | equivalent | Composition | section:sectionPlanOfCare.entry | Care plan entries. | taget profile to be defined

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