Generated Narrative: StructureDefinition PatientSummary Name Flags Card. Type Description & Constraints PatientSummary 0..* Base A - Patient Summary #xD; header 1..1 BackboneElement A.1 Report header data elements #xD; subject 1..1 Subject A.1.1 A1.2 Patient/subject #xD; insuranceInfo 0..1 BackboneElement A.1.3 Insurance information #xD; insuranceNumber 0..* Identifier A.1.3.1 Insurance number #xD; documentData 1..1 BackboneElement A.1.4 Document data #xD; created 1..1 dateTime A.1.4.1 Date created #xD; lastUpdate 0..1 dateTime A.1.4.2 Date of last update #xD; natureOfIPS 1..1 BackboneElement A.1.4.3 Nature of the PS #xD; participant 1..* BackboneElement A.1.5 Author and Organisation #xD; <a href="StructureDefinition-PatientSummary-definitions.html#PatientSummary.header.participant.author" title="A.1.5.1 Author organization - At least one Author and Organisation shall be listed. In the event that there is no Author, at least one Organisation shall be listed This Author should be able to provide further information on the provenance of the data present in the patient summary. Different authors contributing to individual sections and/or entries could be provided at the relevant level.">author 1..* Identifier A.1.5.1 Author organization #xD; legalAuth 0..* CodeableConcept A.1.5.2 Legal authenticator #xD; additionalInfo 0..* BackboneElement A.1.6 Additional information / Knowledge resources #xD; <a href="StructureDefinition-PatientSummary-definitions.html#PatientSummary.header.additionalInfo.reference" title="A.1.6.1 External reference - A reference leading to Clinical Practice Guidelines (CPG), emergency and anesthesia guidelines or other clinical relevant guidelines. This should be used only for providing specific guidance which may not be readily available to the health professional caring for the patient.">reference 0..* Reference() A.1.6.1 External reference #xD; relatedWith 0..* Reference() A.1.6.2 Related with #xD; body 1..1 BackboneElement A.2 Patient summary body data elements #xD; alerts 1..1 BackboneElement A.2.1 Alerts #xD; allergy 0..* Allergy A.2.1.1 Allergy #xD; alert 0..* BackboneElement A.2.1.2 Medical alert information (other alerts not included in allergies) #xD; <a href="StructureDefinition-PatientSummary-definitions.html#PatientSummary.body.alerts.alert.description" title="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. #xA;Example 1: intolerance to aspirin due to gastrointestinal bleeding. #xA;Example 2: intolerance to captopril because of cough (the patient is not allergic but can't tolerate it because of persistent cough)#xA;Example 3: the patient has a rare disease that requires special treatment#xA;Example 4: Airway Alert / Difficult Intubation#xA;Example 5: Diagnoses such as malignant hyperthermia, porphyria, and bleeding disvaccinations; special treatments like anticoagulants or immunosuppressants; implanted devices.#xA;Example 6: transplanted organs illustrate other information that has to be taken into account in a healthcare contact.#xA;Example 7: participation in a clinical trial that has to be taken into account in a healthcare contact.">description 0..* string A.2.1.2.1 Healthcare alert description #xD; medicalHistory 1..1 BackboneElement A.2.2 Medical history #xD; vaccination 0..* Vaccination A.2.2.1 Vaccination/ prophylaxis information #xD; inactiveProblem 0..* ClosedProblem A.2.2.2 Resolved, closed or inactive problems #xD; anamnesis 0..1 BackboneElement A.2.2.3 Medical history #xD; <a href="StructureDefinition-PatientSummary-definitions.html#PatientSummary.body.medicalHistory.anamnesis.details" title="This section may provide both synthetic anamnesis (e.g. description of phases of the pathology as a chronological summary of clustered clinical information) and anecdotal evidence that clinicians can collect from the patient, and can read in a narrative form. See Section 2, Chapter III, Art 7, (c).">details 0..1 Narrative A.2.2.3.1 Medical history This profile does not constrain the narrative in regard to content, language, or traceability to data elements #xD; medicalProblems 0..1 BackboneElement A.2.3 Medical problems #xD; problems 0..1 Problem A.2.3.1 Current problems #xD; medicalDevices 1..1 BackboneElement A.2.3.2 Medical devices and implants #xD; procedures 1..1 BackboneElement A.2.3.3 Procedures #xD; functionalStatus 0..1 BackboneElement A.2.3.4 Functional status #xD; medicationSummary 1..1 BackboneElement A.2.4 Medication summary #xD; medication 1..* Medicine A.2.4.1 Current and relevant past medicines #xD; socialHistory 0..1 BackboneElement A.2.5 Social history #xD; observation 0..* BackboneElement A.2.5.1 Social history observations related to health #xD; referenceRange 0..* Range A.2.5.2 Reference date range #xD; pregnancyHistory 0..1 BackboneElement A.2.6 Pregnancy history #xD; patientData 0..1 BackboneElement A.2.7 Patient provided data #xD; travelHistory 0..1 BackboneElement A.2.7.1 Travel history #xD; country 0..* CodeableConcept A.2.7.1.1 Country #xD; period 0..* dateTime A.2.7.1.2 Period #xD; advanceDirective 0..1 BackboneElement A.2.7.2 Advance Directive #xD; documentation 0..* BackboneElement A.2.7.2.1 Documentation #xD; results 0..1 Result A.2.8 Results #xD; planOfCare 0..1 BackboneElement A.2.9 Plan of Care #xD; carePlan 0..* string A.2.9.1 Plan of care #xD; Documentation for this format
Used by permission of the XpanDH project, all rights reserved Creative Commons License
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
A.1.1 Identification of the patient/subject and A.1.2 Patient/subject related contact information
A.1.4.1 Date created - Date on which PS was generated
A.1.4.2 Date of last update - Date on which PS was updated (date of most recent version) Preferred system: ISO 8601
A.1.4.3 Nature of the PS - Defines the context in which it was generated. Distinguishes between three methodological approaches for generating the PS: direct human intervention by an HP, automatically generated approach and mixed approach
A.1.5.1 Author organization - At least one Author and Organisation shall be listed. In the event that there is no Author, at least one Organisation shall be listed This Author should be able to provide further information on the provenance of the data present in the patient summary. Different authors contributing to individual sections and/or entries could be provided at the relevant level.
A.1.5.2 Legal authenticator - Legal entity (Health Professional or Health Care Provider) who authenticated the Patient Summary
A.1.6 Additional information / Knowledge resources
A.1.6 Additional information / Knowledge resources -
A.1.6.1 External reference - A reference leading to Clinical Practice Guidelines (CPG), emergency and anesthesia guidelines or other clinical relevant guidelines. This should be used only for providing specific guidance which may not be readily available to the health professional caring for the patient.
A.1.6.2 Related with - Identify the entry or entries of this Patient Summary for which this additional information relates with, for example a link between a rare disease problem (section A.2.3.1) and guidelines for that particular rare disease (this section).
A.2 - Patient summary body data elements
A.2.1.2 Medical alert information (other alerts not included in allergies)
A.2.1.2 - Medical alert information (other alerts not included in allergies)
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. Example 1: intolerance to aspirin due to gastrointestinal bleeding. Example 2: intolerance to captopril because of cough (the patient is not allergic but can't tolerate it because of persistent cough) Example 3: the patient has a rare disease that requires special treatment Example 4: Airway Alert / Difficult Intubation Example 5: Diagnoses such as malignant hyperthermia, porphyria, and bleeding disvaccinations; special treatments like anticoagulants or immunosuppressants; implanted devices. Example 6: transplanted organs illustrate other information that has to be taken into account in a healthcare contact. Example 7: participation in a clinical trial that has to be taken into account in a healthcare contact.
A.2.2.1 Vaccination/ prophylaxis information
A.2.2.1 - Vaccination/ prophylaxis information
A.2.2.2 Resolved, closed or inactive problems
A.2.2.2 - Resolved, closed or inactive problems
This section may provide both synthetic anamnesis (e.g. description of phases of the pathology as a chronological summary of clustered clinical information) and anecdotal evidence that clinicians can collect from the patient, and can read in a narrative form. See Section 2, Chapter III, Art 7, (c).
A.2.4.1 Current and relevant past medicines
Relevant prescribed medicines whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not, or medicines that influence current health status or are relevant to a clinical decision
A.2.5.1 Social history observations related to health
Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption. - Preferred System: SNOMED CT GPS
A.1.4.1 Country(s) visited - Preferred System: ISO 3166
A.1.4.2 Date of entry and departure - Preferred System: ISO 8601
Existence of documentation on living will. Preferred system: SNOMED CT GPS
(Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries)
Narrative containing the plan including proposals, goals, and vaccination requests for monitoring, tracking, or improving the condition of the patient. In the future it is expected that this Section could be provided in a structured and coded format.