HL7 Europe Patient Summary
1.0.0-xtehr - qa-preview 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-xtehr 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, Bundle (EPS)

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

Mapping Context

EHDSPatientSummary → Composition, Bundle (EPS)
EHDSPatientSummary (Logical Model) Relationship Composition, Bundle (EPS)
Element Description Relation Resource Element Description Notes
header Document header elements inherited through the base model. related-to Composition . Composition-level metadata.
header.subject Patient/subject information. equivalent Composition subject Who or what the composition is about.
header.identifier Unique identifier of the document. equivalent Composition identifier Version-independent identifier for the Patient Summary.
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.author[x] Author(s) responsible for the document content. equivalent Composition author Who and/or what authored the composition.
header.date Date and time when the document was created. equivalent Composition date Composition creation time.
header.status Status of the resource or document. equivalent Composition status The workflow/clinical status of this composition.
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 Type of document.
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.
header.attestation Document attestation details. related-to Composition attester Participants responsible for attesting the composition.
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.
header.legalAuthentication Document legal authentication details. related-to Composition attester Legal authenticator.
header.legalAuthentication.legalAuthenticator The person taking responsibility for the medical content of the document. related-to Composition attester.party Legal authenticator party.
header.legalAuthentication.datetime Date and time when the document was authorised. equivalent Composition attester.time When the composition was attested.
header.eventType Categorisation of the event covered by the document. related-to Composition event.code Codes describing the event(s) related to the composition. Not clear if it is a type of event - PCPR for Patient Summary - or a classification of the document.
header.serviceSpecialty Additional details about where the content was created (e.g. clinical specialty). source-is-narrower-than-target Composition category Categorizes the composition. Do not apply to Patient Summary.
header.custodian Organisation that is in charge of maintaining the document/report. equivalent Composition custodian Organization responsible for maintenance.
alerts Section: Alerts. equivalent Composition section:sectionAlerts Alert section Use LOINC 104605-1
alerts.generatedNarrative 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:sectionAlerts.entry:flag Alert entries. Reference to FlagPatientEuCore.
alerts.note Free text notes by the health professional. related-to Composition section:sectionAlerts.text Additional narrative note for Alerts section.
allergiesAndIntolerances Section: Allergies and intolerances. equivalent Composition section:sectionAllergies Allergy and intolerance section. Mandatory slice in CompositionEuEps.
allergiesAndIntolerances.generatedNarrative 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.
allergiesAndIntolerances.note Free text notes by the health professional. related-to Composition section:sectionAllergies.text Additional narrative note for Allergies section.
problems Medical problems. equivalent Composition section:sectionProblems Active problems section. Use LOINC 11450-4
problems.generatedNarrative 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.problem Health conditions affecting the patient. equivalent Composition section:sectionProblems.entry:problem Problem entries. Reference to ConditionEuCore.
problems.note Free text notes by the health professional. related-to Composition section:sectionProblems.text Additional narrative note for Problems section.
medicationSummary Section: Medication Summary. equivalent Composition section:sectionMedications Medication summary section. Use LOINC 10160-0
medicationSummary.generatedNarrative 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.medicationUse Medication treatment/prescription relevant for this patient summary. equivalent Composition section:sectionMedications.entry:medicationStatementOrRequest Medication entries. Reference to MedicationStatementEuEps.
medicationSummary.note Free text notes by the health professional. related-to Composition section:sectionMedications.text Additional narrative note for Medication section.
medicalDevicesAndImplants Section: Medical devices and implants. equivalent Composition section:sectionMedicalDevices Medical devices section. Use LOINC 46264-8
medicalDevicesAndImplants.generatedNarrative 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.deviceUse Implanted and external medical devices. equivalent Composition section:sectionMedicalDevices.entry:deviceStatement Device use entries. Reference to DeviceUseStatementEuEps.
medicalDevicesAndImplants.note Free text notes by the health professional. related-to Composition section:sectionMedicalDevices.text Additional narrative note for Medical Devices section.
procedures Section: Procedures. equivalent Composition section:sectionProceduresHx Procedures section. Use LOINC 47519-4
procedures.generatedNarrative 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.
procedures.note Free text notes by the health professional. related-to Composition section:sectionProceduresHx.text Additional narrative note for Procedures section.
immunisations Section: Vaccination/prophylaxis. equivalent Composition section:sectionImmunizations Immunizations section. Use LOINC 11369-6
immunisations.generatedNarrative Narrative content of the section. equivalent Composition section.text Narrative for Immunizations section.
immunisations.immunisation Immunisations given to the patient and their status. equivalent Composition section:sectionImmunizations.entry:immunization Immunization entries. Reference to ImmunizationEuCore.
immunisations.note Free text notes by the health professional. related-to Composition section:sectionImmunizations.text Additional narrative note for Immunizations section.
functionalStatus Section: Functional status. equivalent Composition section:sectionFunctionalStatus Functional status section. Use LOINC 47420-5
functionalStatus.generatedNarrative Narrative content of the section. equivalent Composition section.text Narrative for Functional Status section.
functionalStatus.condition Condition information describing functional status or disability. related-to Composition section:sectionFunctionalStatus.entry Functional status condition entries. Target slice/profile alignment may need clarification.
functionalStatus.assessment Functional status assessments. equivalent Composition section:sectionFunctionalStatus.entry:functionalStatus Functional status entries. The actual content maps better into an Observation profile, not allowed in this section
functionalStatus.note Free text notes by the health professional. related-to Composition section:sectionFunctionalStatus.text Additional narrative note for Functional Status section.
socialHistory Section: Social history. equivalent Composition section:sectionSocialHistory Social history section.
socialHistory.generatedNarrative Narrative content of the section. equivalent Composition section.text Narrative for Social History section.
socialHistory.observation Social history observations related to health. equivalent Composition section:sectionSocialHistory.entry Social history entries.
socialHistory.note Free text notes by the health professional. related-to Composition section:sectionSocialHistory.text Additional narrative note for Social History section.
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.
pregnancyHistory.note Free text notes by the health professional. related-to Composition section:sectionPregnancyHx.text Additional narrative note for pregnancy history. Narrative text used when no structured mapping is needed.
pregnancyHistory.previousPregnancies History of previous pregnancies. equivalent Composition section:sectionPregnancyHx.entry:pregnancyOutcome Pregnancy outcome entries.
travelHistory Relevant information about the patient's recent travel history. equivalent Composition section:sectionTravelHx Travel history section. Uses LOINC 10182-4.
travelHistory.generatedNarrative Text summary of the content in the section. equivalent Composition section.text Narrative for Travel History section.
travelHistory.travelHistory Travel history for one country. equivalent Composition section:sectionTravelHx.entry Travel history entries. Reference to ObservationTravelEuEps.
travelHistory.note Free text notes by the health professional. related-to Composition section:sectionTravelHx.text Additional narrative note for Travel History section.
patientStory What the patient believes to be important for the attending clinician to know. equivalent Composition section:sectionPatientHx Patient story section. check if the propoer loinc code is used and the patient history section is added.
patientStory.note Free text notes by the health professional. equivalent Composition section:sectionPatientHx.text Additional narrative note for Patient Story.
advanceDirectives Section: Advance Directives. equivalent Composition section:sectionAdvanceDirectives Advance directives section. Use LOINC 42348-3
advanceDirectives.generatedNarrative 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.
advanceDirectives.note Free text notes by the health professional. related-to Composition section:sectionAdvanceDirectives.text Additional narrative note for Advance Directives section.
observationResults Section: Observation results. source-is-broader-than-target Composition section:sectionResults Results section. When the result is a diagnostic result.
observationResults Section: Observation results. source-is-broader-than-target Composition section:sectionVitalSigns Vital Signs section. When the result is a vital sign
observationResults.generatedNarrative Narrative content of the section. equivalent Composition section.text Narrative for Results section.
observationResults.result Observation results pertaining to the subject of care. equivalent Composition section:sectionResults.entry Result observation entries. When the result is a diagnostic result.
observationResults.result Observation results pertaining to the subject of care. equivalent Composition section:sectionVitalSigns.entry Result observation entries. When the result is a vital sign, target profile is http://hl7.org/fhir/StructureDefinition/vitalsigns.
observationResults.note Free text notes by the health professional. related-to Composition section.text Additional narrative note for Results section.
carePlans Section: Care plans. equivalent Composition section:sectionPlanOfCare Care plan section.
carePlans.generatedNarrative Narrative containing the plan including proposals, goals, and order requests. equivalent Composition section.text Narrative for Care Plan section.
carePlans.carePlan Describes the intention of how care will be delivered. equivalent Composition section:sectionPlanOfCare.entry Care plan entries.
carePlans.note Free text notes by the health professional. related-to Composition section:sectionPlanOfCare.text Additional narrative note for Care Plans section.

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