B.1 - EHDS refined base model for Patient Summary body data elements

Alert section includes information about allergies, intolerances and other substantial alerts or warnings that health professionals should be aware of.

Narative content of the section. This narative shell containing either narative description of both allergy and alerts, or similar narative sub-section elements shell be provided.

A record of allergies and intolerances.

Medical alert information (other alerts not included in allergies).

Medical history section.

Narative content of the section. This narative shell containing either narative description of al subsections, or similar narative sub-section elements shell be provided. This will be the preferred way.

Vaccination history subsection.

Narative content of the section.

Vaccination / prophylaxis information.

Problems history subsection.

Narative content of the subsection.

Resolved, closed or inactive problems.

Medical history section.

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).

Current medical problems section.

Narative content of the section.

Current problems section

Narative content of the subsection.

Health conditions affecting the health of the patient and are important to be known for a health professional during a health encounter.

Devices that are implanted in the patient and external medical devices and equipment that the health status depends on.

Narative content of the subsection.

Includes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

Procedures section

Narative content of the subsection.

Major procedures.

Funtional assessment section

Narative content of the subsection.

A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition.

Medication summary section.

Narative content of the section.

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.

Social history section.

Textual description of the socialhistory.

Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption

Clinically relevant time or time period for the observation.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Full name of the observation according to the used test coding standard.

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Device (e.g. analyser) that generates the measurements

SNOMED CT, EMDN

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

SNOMED CT (for ordinal or nominal scale results and result interpretation), UCUM (for units)

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT

The patient, or group of patients, location, device, organization, procedure or practitioner this observation is about.

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

The status of the result value.

HL7 Observation status

Example: from 1974 to 2004

Pregnancy history section

Narative content of the section.

Current pregnancy status section

Date on which the observation of the pregnancy state was made

Provides the woman's current state at the date the observation was made: e.g. pregnant, not pregnant, unknown

Date on which the woman is due to give birth.

History of previous pregnancies section

Information on the woman's previous pregnancies:Yes, previous pregnancies; No, previous pregnancies; Unknown

Details of the previous pregnancies

Date referred to the previous pregnancies outcome

Outcome of the previous pregnancies

Number of children/fetus in this specific pregnancy

Patient provided data section

Narative content of the section.

Visited country

Country code

ISO 3166

Date of entry and departure

Advance directive section

Existence of documentation on living will

SNOMED CT

Results section

Narative content of the section.

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

Narrative containing the plan including proposals, goals, and order 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.

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.

B.1 - EHDS refined base model for Patient Summary body data elements

Alert section includes information about allergies, intolerances and other substantial alerts or warnings that health professionals should be aware of.

Narative content of the section. This narative shell containing either narative description of both allergy and alerts, or similar narative sub-section elements shell be provided.

A record of allergies and intolerances.

Medical alert information (other alerts not included in allergies).

Medical history section.

Narative content of the section. This narative shell containing either narative description of al subsections, or similar narative sub-section elements shell be provided. This will be the preferred way.

Vaccination history subsection.

Narative content of the section.

Vaccination / prophylaxis information.

Problems history subsection.

Narative content of the subsection.

Resolved, closed or inactive problems.

Medical history section.

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).

Current medical problems section.

Narative content of the section.

Current problems section

Narative content of the subsection.

Health conditions affecting the health of the patient and are important to be known for a health professional during a health encounter.

Devices that are implanted in the patient and external medical devices and equipment that the health status depends on.

Narative content of the subsection.

Includes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

Procedures section

Narative content of the subsection.

Major procedures.

Funtional assessment section

Narative content of the subsection.

A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition.

Medication summary section.

Narative content of the section.

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.

Social history section.

Textual description of the socialhistory.

Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption

Example: from 1974 to 2004

Pregnancy history section

Narative content of the section.

Current pregnancy status section

Date on which the observation of the pregnancy state was made

Provides the woman's current state at the date the observation was made: e.g. pregnant, not pregnant, unknown

Date on which the woman is due to give birth.

History of previous pregnancies section

Information on the woman's previous pregnancies:Yes, previous pregnancies; No, previous pregnancies; Unknown

Details of the previous pregnancies

Date referred to the previous pregnancies outcome

Outcome of the previous pregnancies

Number of children/fetus in this specific pregnancy

Patient provided data section

Narative content of the section.

Visited country

Country code

ISO 3166

Date of entry and departure

Advance directive section

Existence of documentation on living will

SNOMED CT

Results section

Narative content of the section.

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

Narrative containing the plan including proposals, goals, and order 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.

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.

B.1 - EHDS refined base model for Patient Summary body data elements

Alert section includes information about allergies, intolerances and other substantial alerts or warnings that health professionals should be aware of.

Narative content of the section. This narative shell containing either narative description of both allergy and alerts, or similar narative sub-section elements shell be provided.

A record of allergies and intolerances.

Medical alert information (other alerts not included in allergies).

Medical history section.

Narative content of the section. This narative shell containing either narative description of al subsections, or similar narative sub-section elements shell be provided. This will be the preferred way.

Vaccination history subsection.

Narative content of the section.

Vaccination / prophylaxis information.

Problems history subsection.

Narative content of the subsection.

Resolved, closed or inactive problems.

Medical history section.

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).

Current medical problems section.

Narative content of the section.

Current problems section

Narative content of the subsection.

Health conditions affecting the health of the patient and are important to be known for a health professional during a health encounter.

Devices that are implanted in the patient and external medical devices and equipment that the health status depends on.

Narative content of the subsection.

Includes the patient's implanted and external medical devices and equipment upon which their health status depends. Includes devices such as cardiac pacemakers, implantable fibrillator, prosthesis, ferromagnetic bone implants, etc. of which the HP needs to be aware.

Procedures section

Narative content of the subsection.

Major procedures.

Funtional assessment section

Narative content of the subsection.

A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition.

Medication summary section.

Narative content of the section.

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.

Social history section.

Textual description of the socialhistory.

Health related lifestyle factors or lifestyle observations and social determinants of health. Example: cigarette smoker, alcohol consumption

Clinically relevant time or time period for the observation.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Full name of the observation according to the used test coding standard.

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Device (e.g. analyser) that generates the measurements

SNOMED CT, EMDN

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

SNOMED CT (for ordinal or nominal scale results and result interpretation), UCUM (for units)

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT

The patient, or group of patients, location, device, organization, procedure or practitioner this observation is about.

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

The status of the result value.

HL7 Observation status

Example: from 1974 to 2004

Pregnancy history section

Narative content of the section.

Current pregnancy status section

Date on which the observation of the pregnancy state was made

Provides the woman's current state at the date the observation was made: e.g. pregnant, not pregnant, unknown

Date on which the woman is due to give birth.

History of previous pregnancies section

Information on the woman's previous pregnancies:Yes, previous pregnancies; No, previous pregnancies; Unknown

Details of the previous pregnancies

Date referred to the previous pregnancies outcome

Outcome of the previous pregnancies

Number of children/fetus in this specific pregnancy

Patient provided data section

Narative content of the section.

Visited country

Country code

ISO 3166

Date of entry and departure

Advance directive section

Existence of documentation on living will

SNOMED CT

Results section

Narative content of the section.

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

Narrative containing the plan including proposals, goals, and order 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.

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.