Zestawienie danych pacjenta (patient summary) w FHIR
Zestawienie danych pacjenta (patient summary) to priorytetowa kategoria Europejskiej Przestrzeni Danych dotyczących Zdrowia (art. 14 ust. 1 lit. (a) rozporządzenia (UE) 2025/327). Stosuje się ją od 26 marca 2029. HL7 Europe obejmuje ją przewodnikami: eps 1.0.0-ballot.
- Rozporządzenie
- Regulation (EU) 2025/327, Article 14(1)(a), Annex I
- Stosuje się od
- 26 marca 2029
- Przewodniki HL7 Europe
- hl7.fhir.eu.eps 1.0.0-ballot, w ballocie
- Modele logiczne Xt-EHR
- EHDSPatientSummary
- Typ dokumentu
LOINC 60591-5Patient summary Document- Walidator
- Otwórz walidator profili EHDS
Co mówi rozporządzenie
Załącznik I do rozporządzenia opisuje główne cechy tej kategorii. Tekst jest angielskim oryginałem.
Patient summariesElectronic health data that include significant clinical facts related to an identified natural person and that are essential for the provision of safe and efficient healthcare to that person. The following information is part of a patient summary:
1. Personal details.
2. Contact information.
3. Information on insurance.
4. Allergies.
5. Medical alerts.
6. Vaccination/prophylaxis information, possibly in the form of a vaccination card.
7. Current, resolved, closed or inactive problems, including in an international classification coding.
8. Textual information related to medical history.
9. Medical devices and implants.
10. Medical or care procedures.
11. Functional status.
12. Current and relevant past medicines.
13. Social history observations related to health.
14. Pregnancy history.
15. Patient-provided data.
16. Observation results pertaining to the health condition.
17. Plan of care.
18. Information on a rare disease, such as details about the impact or characteristics of the disease.
Profile FHIR 23
Profile zdefiniowane przez powyższe przewodniki. Kolumna reguł liczy elementy, w których profil wykracza poza bazowy FHIR (wymagane, zakazane lub ograniczone) i które sprawdza walidator; spośród slice’ów sprawdzane są tylko wymagane, które odróżnia stała wartość lub typ zasobu.
| Profil | Zasób | Przewodnik HL7 Europe | Sprawdzane reguły | Slice’y sprawdzane / zdefiniowane |
|---|---|---|---|---|
AllergyIntolerance - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/allergyintolerance-obl-eu-eps | AllergyIntolerance | eps | 1 | 0 / 3 |
Bundle (EPS) http://hl7.eu/fhir/eps/StructureDefinition/bundle-eu-eps | Bundle | eps | 6 | 2 / 26 |
Composition (EPS) http://hl7.eu/fhir/eps/StructureDefinition/composition-eu-eps | Composition | eps | 8 | 5 / 61 |
Condition - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/condition-obl-eu-eps | Condition | eps | 1 | 0 / 5 |
Consent: Advance Directives (EPS) http://hl7.eu/fhir/eps/StructureDefinition/consent-eu-eps | Consent | eps | 0 | 0 / 2 |
Device (EPS) http://hl7.eu/fhir/eps/StructureDefinition/device-eu-eps | Device | eps | 0 | 0 / 0 |
DeviceUseStatement (EPS) http://hl7.eu/fhir/eps/StructureDefinition/deviceUseStatement-eu-eps | DeviceUseStatement | eps | 2 | 0 / 2 |
DiagnosticReport (EPS) http://hl7.eu/fhir/eps/StructureDefinition/diagnosticReport-eu-eps | DiagnosticReport | eps | 3 | 0 / 8 |
Flag : Alert - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/flag-alert-obl-eu-eps | Flag | eps | 0 | 0 / 3 |
Immunization - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/immunization-obl-eu-eps | Immunization | eps | 0 | 0 / 11 |
Medication - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/medication-obl-eu-eps | Medication | eps | 0 | 0 / 12 |
MedicationRequest - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/medicationrequest-obl-eu-eps | MedicationRequest | eps | 0 | 0 / 4 |
MedicationStatement (EPS) http://hl7.eu/fhir/eps/StructureDefinition/MedicationStatement-eu-eps | MedicationStatement | eps | 2 | 0 / 5 |
Observation: Pregnancy - Expected Delivery Date (EPS) http://hl7.eu/fhir/eps/StructureDefinition/observation-pregnancy-edd-eu-eps | Observation | eps | 9 | 0 / 1 |
Observation: Pregnancy - Gestational Age (EPS) http://hl7.eu/fhir/eps/StructureDefinition/observation-pregnancy-gestationalAge-eu-eps | Observation | eps | 9 | 0 / 1 |
Observation: Pregnancy - Outcome (EPS) http://hl7.eu/fhir/eps/StructureDefinition/observation-pregnancy-outcome-eu-eps | Observation | eps | 8 | 0 / 1 |
Observation: Pregnancy - Status (EPS) http://hl7.eu/fhir/eps/StructureDefinition/observation-pregnancy-status-eu-ips | Observation | eps | 9 | 0 / 1 |
Observation: Country Visited (EPS) http://hl7.eu/fhir/eps/StructureDefinition/observation-travel-eu-eps | Observation | eps | 3 | 0 / 1 |
Organization - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/organization-obl-eu-eps | Organization | eps | 1 | 0 / 0 |
Patient (EPS) http://hl7.eu/fhir/eps/StructureDefinition/patient-eu-eps | Patient | eps | 2 | 0 / 7 |
Practitioner - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/practitioner-obl-eu-eps | Practitioner | eps | 1 | 0 / 0 |
PractitionerRole - Obligations (EPS) http://hl7.eu/fhir/eps/StructureDefinition/practitionerrole-obl-eu-eps | PractitionerRole | eps | 0 | 0 / 0 |
Procedure (EPS) http://hl7.eu/fhir/eps/StructureDefinition/procedure-eu-eps | Procedure | eps | 3 | 0 / 3 |
Struktura dokumentu
Profile dokumentów tej kategorii: sekcje, które może zawierać Composition, i wpisy, które może zawierać Bundle, tak jak określają je profile. Nazwy to nazwy slice’ów; kod sekcji to kod LOINC ustalony przez profil.
Bundle (EPS): wpisy Bundle 26
| Wpis | Licz. | Zasób FHIR | Profil |
|---|---|---|---|
composition | 1..1 | Composition | CompositionEuEps |
patient | 1..1 | Patient | PatientEuEps |
allergyintolerance | 0..* | AllergyIntolerance | AllergyIntoleranceOblEuEps |
careplan | 0..* | CarePlan | |
condition | 0..* | Condition | ConditionOblEuEps |
device | 0..* | Device | DeviceEuEps |
deviceusestatement | 0..* | DeviceUseStatement | DeviceUseStatementEuEps |
diagnosticreport | 0..* | DiagnosticReport | DiagnosticReportEuEps |
flag | 0..* | Flag | FlagAlertOblEuEps |
imagingstudy | 0..* | ImagingStudy | ImagingStudy-uv-ips |
immunization | 0..* | Immunization | ImmunizationOblEuEps |
medication | 0..* | Medication | MedicationOblEuEps |
medicationrequest | 0..* | MedicationRequest | MedicationRequestOblEuEps |
medicationstatement | 0..* | MedicationStatement | MedicationStatementEuEps |
practitioner | 0..* | Practitioner | PractitionerOblEuEps |
practitionerrole | 0..* | PractitionerRole | PractitionerRoleOblEuEps |
procedure | 0..* | Procedure | ProcedureEuEps |
observation-pregnancy-edd | 0..* | Observation | ObservationPregnancyEddEuEps |
observation-pregnancy-outcome | 0..* | Observation | ObservationPregnancyOutcomeEuEps |
observation-pregnancy-status | 0..* | Observation | ObservationPregnancyStatusEuEps |
observation-alcohol-use | 0..* | Observation | Observation-alcoholuse-uv-ips |
observation-tobacco-use | 0..* | Observation | Observation-tobaccouse-uv-ips |
observation-vital-signs | 0..* | Observation | vitalsigns |
organization | 0..* | Organization | OrganizationOblEuEps |
specimen | 0..* | Specimen | Specimen-uv-ips |
observation-pregnancy-age | 0..* | Observation | ObservationPregnancyGestationalAgeEuEps |
Composition (EPS): sekcje 17
| Sekcja | Licz. | Kod sekcji | Opis |
|---|---|---|---|
sectionProblems | 1..1 | LOINC 11450-4 | EPS Problems Section |
sectionAllergies | 1..1 | LOINC 48765-2 | EPS Allergies and Intolerances Section |
sectionMedications | 1..1 | LOINC 10160-0 | EPS Medication Summary Section |
sectionImmunizations | 0..1 | LOINC 11369-6 | EPS Immunizations Section |
sectionResults | 0..1 | LOINC 30954-2 | EPS Results Section |
sectionProceduresHx | 1..1 | LOINC 47519-4 | EPS History of Procedures Section |
sectionMedicalDevices | 1..1 | LOINC 46264-8 | EPS Medical Devices Section |
sectionAdvanceDirectives | 0..1 | LOINC 42348-3 | EPS Advance Directives Section |
sectionAlert | 0..1 | LOINC 104605-1 | EPS Alerts Section |
sectionFunctionalStatus | 0..1 | LOINC 47420-5 | EPS Functional Status |
sectionPregnancyHx | 0..1 | LOINC 10162-6 | EPS History of Pregnancy Section |
sectionPatientStory | 0..1 | LOINC 81338-6 | EPS Patient Story Section |
sectionPlanOfCare | 0..1 | LOINC 18776-5 | EPS Plan of Care Section |
sectionSocialHistory | 0..1 | LOINC 29762-2 | EPS Social History Section |
sectionVitalSigns | 0..1 | LOINC 8716-3 | EPS Vital Signs Section |
sectionTravelHx | 0..1 | LOINC 10182-4 | EPS Travel History Section |
sectionPatientHx | 0..1 | LOINC 11329-0 | EPS Patient History Section |
Powiązania terminologiczne 6
Value sets, z którymi profile tej kategorii wiążą elementy powiązaniem required lub extensible. Powiązanie required dopuszcza tylko kody z value set; extensible oczekuje ich, chyba że żaden nie pasuje. Value sets definiowane w pakietach HL7 Europe są wypisane z kodami w wykazie value sets.
Profile określają też powiązania: preferred – 14, example – 6.
| Value set | Powiązanie | Używany przez | Kody |
|---|---|---|---|
Gestational Age (LOINC) http://hl7.eu/fhir/eps/ValueSet/gestational-age-loinc | required | ObservationPregnancyGestationalAgeEuEps code | zdefiniowany regułami |
edd-method-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/edd-method-uv-ips | required | ObservationPregnancyEddEuEps code | zdefiniowany poza pakietami HL7 Europe |
pregnancies-summary-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/pregnancies-summary-uv-ips | required | ObservationPregnancyOutcomeEuEps code | zdefiniowany poza pakietami HL7 Europe |
condition-clinical http://hl7.org/fhir/ValueSet/condition-clinical | required | ConditionOblEuEps clinicalStatus | zdefiniowany poza pakietami HL7 Europe |
condition-ver-status http://hl7.org/fhir/ValueSet/condition-ver-status | required | ConditionOblEuEps verificationStatus | zdefiniowany poza pakietami HL7 Europe |
iso3166-1-2 http://hl7.org/fhir/ValueSet/iso3166-1-2 | required | ObservationTravelEuEps value[x] | zdefiniowany poza pakietami HL7 Europe |
Rozszerzenia 5
Rozszerzenia HL7 Europe, które zawierają profile tej kategorii, z elementem, który je przechowuje.
| Rozszerzenie | Kontekst | Wartość | Użyte w |
|---|---|---|---|
Consent: Related Condition http://hl7.eu/fhir/StructureDefinition/consent-relatedCondition | Consent | Reference | ConsentEuEps extension:relatedCondition 0..* |
Document DiagnosticReport Reference http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference | Composition | Reference | CompositionEuEps extension:diagnosticReport 0..1 |
Composition: Information recipient http://hl7.eu/fhir/StructureDefinition/information-recipient | Composition | Reference | CompositionEuEps extension:informationRecipient 0..* |
Medication: Package type http://hl7.eu/fhir/StructureDefinition/medication-package-type | Medication | CodeableConcept | MedicationOblEuEps extension:packageType 0..1 |
Many: Periods of Life http://hl7.eu/fhir/extensions/StructureDefinition/periods-of-life | AgePeriodRangeRange.lowRange.highdateTime | CodeableConcept | ImmunizationOblEuEps occurrence[x]:occurrenceDateTime.extension:periodOfLife 0..1 |
Model logiczny EHDSPatientSummary 87
Elementy modelu logicznego Xt-EHR z licznością i obowiązkami. Obowiązki mówią producentom i odbiorcom danych, co system MUSI lub POWINIEN robić z każdym elementem.
Obowiązki według uczestnika
Ile elementów EHDSPatientSummary niesie dany obowiązek dla danego uczestnika.
| Obowiązek | Uczestnik | Elementy |
|---|---|---|
SHALL:able-to-populate | producent | 27 |
SHALL:process | odbiorca | 27 |
SHOULD:able-to-populate | producent | 21 |
SHOULD:display | odbiorca | 7 |
SHOULD:process | odbiorca | 16 |
Elementy 87
| Element | Licz. | Obowiązki | Opis |
|---|---|---|---|
header | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Document header |
subject | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Patient/subject information |
identifier | 1..* | SHALL:able-to-populate producentSHALL:process odbiorca | Unique identifier of the document |
author[x] | 1..* | SHALL:able-to-populate producentSHALL:process odbiorca | Author(s) of the document |
date | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Date of finalising/issuing the document |
status | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Status of the document |
source | 0..0 | Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information. | |
language | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Language in which the resource is written. Language is expressed by the IETF language tag. |
documentType | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Type of document at hand, e.g. 60591-5 Patient summary document. |
documentTitle | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024' |
period | 0..1 | Time period of information covered in the document | |
version | 0..1 | Business version of the document. The exact algorithm for versioning is decided by the producer/custodian | |
attestation | 0..* | Document attestation details | |
attester[x] | 1..1 | Attester who validated the document | |
datetime | 1..1 | Date and time of the approval of the document by Attester | |
legalAuthentication | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | Document legal authentication details |
legalAuthenticator[x] | 1..1 | The person or organisation taking responsibility for the content of the document. | |
datetime | 1..1 | Date and time when the document was authorised | |
eventType | 0..* | Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes. | |
serviceSpecialty | 0..* | Additional details about where the content was created (e.g. clinical specialty) | |
custodian | 0..1 | Organisation that is in charge of maintaining the document/report. | |
presentedForm | 0..* | SHOULD:able-to-populate producentSHOULD:display odbiorca | A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document |
alerts | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Section: Alerts |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSystem shall be able to populate generatedNarrative if the structured content is not supported by the system. SHOULD:display odbiorcaSystem shall display generatedNarrative if the structured content is not supported by the system. | Narrative, potentially formatted, content of the whole section. |
medicalAlert | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | 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. |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:display odbiorca | Free text notes by the health professional |
allergiesAndIntolerances | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Section: Allergies and intolerances |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSHOULD:display odbiorca | Narrative, potentially formatted, content of the whole section. |
allergyIntolerance | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | List of structured allergies and intolerances |
emptyReason | 0..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Use if no Allergies are listed |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:display odbiorca | Free text notes by the health professional |
problems | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Section: Medical problems |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Narrative, potentially formatted, content of the whole section. |
emptyReason | 0..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Use if no conditions are listed |
problem | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | Health conditions affecting the health of the patient. |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Free text notes by the health professional |
medicationSummary | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Section: Medication summary |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSHOULD:display odbiorca | Narrative, potentially formatted, content of the whole section. |
emptyReason | 0..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Use if no medicines are listed |
medicationUse | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not. |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:display odbiorca | Free text notes by the health professional |
medicalDevicesAndImplants | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Section: Medical devices and implants |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Narrative, potentially formatted, content of the whole section. |
emptyReason | 0..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Use if no conditions are listed |
deviceUse | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP. |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Free text notes by the health professional |
procedures | 1..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Section: Procedures |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Narrative, potentially formatted, content of the whole section. |
emptyReason | 0..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Reason for absence of data |
procedure | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | List of procedures |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Free text notes by the health professional |
immunisations | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Section: Immunisations |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Narrative, potentially formatted, content of the whole section. |
immunisation | 0..* | SHALL:able-to-populate producentSHALL:process odbiorca | Immunisations given to the patient and their status at the point of care. |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Free text notes by the health professional |
functionalStatus | 0..1 | Section: Functional status | |
generatedNarrative | 0..1 | Narrative, potentially formatted, content of the whole section. | |
condition | 0..* | Condition information describing patient's functional status or disability. | |
assessment | 0..* | Assessment results regarding functional status. | |
note | 0..1 | Free text notes by the health professional | |
socialHistory | 0..1 | Section: Social history | |
generatedNarrative | 0..1 | Narrative, potentially formatted, content of the whole section. | |
observation | 0..* | Social history observations related to health | |
note | 0..1 | Free text notes by the health professional | |
pregnancyHistory | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Section: Pregnancy history |
generatedNarrative | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Narrative, potentially formatted, content of the whole section. |
currentPregnancyStatus | 0..1 | SHALL:able-to-populate producentSHALL:process odbiorca | Current pregnancy status |
previousPregnancies | 0..* | History of previous pregnancies | |
note | 0..1 | SHOULD:able-to-populate producentSHOULD:process odbiorca | Free text notes by the health professional |
travelHistory | 0..1 | Section: Travel history | |
generatedNarrative | 0..1 | Narrative, potentially formatted, content of the whole section. | |
travelHistory | 0..* | Travel history for one country | |
note | 0..1 | Free text notes by the health professional | |
patientStory | 0..1 | SHOULD:process odbiorca | Section: Patient story |
note | 0..1 | Free text notes by the health professional | |
advanceDirectives | 0..1 | SHOULD:process odbiorca | Section: Advance Directives |
generatedNarrative | 0..1 | Narrative, potentially formatted, content of the whole section. | |
advanceDirective | 0..* | Provision for healthcare decisions if, in the future, a person is unable to make those decisions | |
note | 0..1 | Free text notes by the health professional | |
observationResults | 0..1 | Section: Observation results | |
generatedNarrative | 0..1 | Narrative, potentially formatted, content of the whole section. | |
result | 0..* | Observation results pertaining to the subject of care's health condition and which might have impact on future treatments | |
note | 0..1 | Free text notes by the health professional | |
carePlans | 0..1 | Section: Care plans | |
generatedNarrative | 0..1 | Narrative, potentially formatted, content of the whole section. | |
carePlan | 0..* | 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. | |
note | 0..1 | Free text notes by the health professional |
Odwzorowanie EHDSPatientSummary na FHIR 89
Jak każdy element logiczny trafia do FHIR, według przewodnika HL7 Europe. Odwzorowane na: BundleEuEps, CompositionEuEps.
| Element | Relacja | Zasób FHIR | Element FHIR | Uwagi |
|---|---|---|---|---|
header | powiązany z | Composition | . | |
subject | równoważny | Composition | subject | |
identifier | równoważny | Composition | identifier | |
identifier | równoważny | Bundle | identifier | Represents a specific rendition/version of the document. |
author[x] | równoważny | Composition | author | |
date | równoważny | Composition | date | |
status | równoważny | Composition | status | |
language | równoważny | Composition | language | |
documentType | równoważny | Composition | type | |
documentTitle | równoważny | Composition | title | |
period | powiązany z | Composition | event.period | Map to the primary Composition.event entry. |
version | powiązany z | Composition | extension:version | |
attestation | powiązany z | Composition | attester | |
attester | równoważny | Composition | attester.party | |
datetime | równoważny | Composition | attester.time | |
legalAuthentication | powiązany z | Composition | attester | |
legalAuthenticator | powiązany z | Composition | attester.party | |
datetime | równoważny | Composition | attester.time | |
eventType | powiązany z | Composition | event.code | Not clear if it is a type of event - PCPR for Patient Summary - or a classification of the document. |
serviceSpecialty | węższy niż cel | Composition | category | Do not apply to Patient Summary. |
custodian | równoważny | Composition | custodian | |
alerts | równoważny | Composition | section:sectionAlerts | Use LOINC 104605-1 |
generatedNarrative | równoważny | Composition | section:sectionAlerts.text | |
emptyReason | równoważny | Composition | section:sectionAlerts.emptyReason | |
medicalAlert | równoważny | Composition | section:sectionAlerts.entry:flag | Reference to FlagPatientEuCore. |
note | powiązany z | Composition | section:sectionAlerts.text | |
allergiesAndIntolerances | równoważny | Composition | section:sectionAllergies | Mandatory slice in CompositionEuEps. |
generatedNarrative | równoważny | Composition | section:sectionAllergies.text | |
allergyIntolerance | równoważny | Composition | section:sectionAllergies.entry:allergyOrIntolerance | Reference to AllergyIntoleranceEuCore. |
emptyReason | równoważny | Composition | section:sectionAllergies.emptyReason | |
note | powiązany z | Composition | section:sectionAllergies.text | |
problems | równoważny | Composition | section:sectionProblems | Use LOINC 11450-4 |
generatedNarrative | równoważny | Composition | section:sectionProblems.text | |
emptyReason | równoważny | Composition | section:sectionProblems.emptyReason | |
problem | równoważny | Composition | section:sectionProblems.entry:problem | Reference to ConditionEuCore. |
note | powiązany z | Composition | section:sectionProblems.text | |
medicationSummary | równoważny | Composition | section:sectionMedications | Use LOINC 10160-0 |
generatedNarrative | równoważny | Composition | section:sectionMedications.text | |
emptyReason | równoważny | Composition | section:sectionMedications.emptyReason | |
medicationUse | równoważny | Composition | section:sectionMedications.entry:medicationStatementOrRequest | Reference to MedicationStatementEuEps. |
note | powiązany z | Composition | section:sectionMedications.text | |
medicalDevicesAndImplants | równoważny | Composition | section:sectionMedicalDevices | Use LOINC 46264-8 |
generatedNarrative | równoważny | Composition | section.text | |
emptyReason | równoważny | Composition | section.emptyReason | |
deviceUse | równoważny | Composition | section:sectionMedicalDevices.entry:deviceStatement | Reference to DeviceUseStatementEuEps. |
note | powiązany z | Composition | section:sectionMedicalDevices.text | |
procedures | równoważny | Composition | section:sectionProceduresHx | Use LOINC 47519-4 |
generatedNarrative | równoważny | Composition | section.text | |
emptyReason | równoważny | Composition | section.emptyReason | |
procedure | równoważny | Composition | section:sectionProceduresHx.entry:procedure | Reference to ProcedureEuCore. |
note | powiązany z | Composition | section:sectionProceduresHx.text | |
immunisations | równoważny | Composition | section:sectionImmunizations | Use LOINC 11369-6 |
generatedNarrative | równoważny | Composition | section.text | |
immunisation | równoważny | Composition | section:sectionImmunizations.entry:immunization | Reference to ImmunizationEuCore. |
note | powiązany z | Composition | section:sectionImmunizations.text | |
functionalStatus | równoważny | Composition | section:sectionFunctionalStatus | Use LOINC 47420-5 |
generatedNarrative | równoważny | Composition | section.text | |
condition | powiązany z | Composition | section:sectionFunctionalStatus.entry | Target slice/profile alignment may need clarification. |
assessment | równoważny | Composition | section:sectionFunctionalStatus.entry:functionalStatus | The actual content maps better into an Observation profile, not allowed in this section |
note | powiązany z | Composition | section:sectionFunctionalStatus.text | |
socialHistory | równoważny | Composition | section:sectionSocialHistory | |
generatedNarrative | równoważny | Composition | section.text | |
observation | równoważny | Composition | section:sectionSocialHistory.entry | |
note | powiązany z | Composition | section:sectionSocialHistory.text | |
pregnancyHistory | równoważny | Composition | section:sectionPregnancyHx | Use LOINC 10162-6 |
generatedNarrative | równoważny | Composition | section.text | |
currentPregnancyStatus | równoważny | Composition | section:sectionPregnancyHx.entry:pregnancyStatus | |
note | powiązany z | Composition | section:sectionPregnancyHx.text | Narrative text used when no structured mapping is needed. |
previousPregnancies | równoważny | Composition | section:sectionPregnancyHx.entry:pregnancyOutcome | |
travelHistory | równoważny | Composition | section:sectionTravelHx | Uses LOINC 10182-4. |
generatedNarrative | równoważny | Composition | section.text | |
travelHistory | równoważny | Composition | section:sectionTravelHx.entry | Reference to ObservationTravelEuEps. |
note | powiązany z | Composition | section:sectionTravelHx.text | |
patientStory | równoważny | Composition | section:sectionPatientHx | check if the propoer loinc code is used and the patient history section is added. |
note | równoważny | Composition | section:sectionPatientHx.text | |
advanceDirectives | równoważny | Composition | section:sectionAdvanceDirectives | Use LOINC 42348-3 |
generatedNarrative | równoważny | Composition | section.text | |
advanceDirective | równoważny | Composition | section:sectionAdvanceDirectives.entry | Reference to ConsentEuEps or DocumentReference. |
note | powiązany z | Composition | section:sectionAdvanceDirectives.text | |
observationResults | szerszy niż cel | Composition | section:sectionResults | When the result is a diagnostic result. |
observationResults | szerszy niż cel | Composition | section:sectionVitalSigns | When the result is a vital sign |
generatedNarrative | równoważny | Composition | section.text | |
result | równoważny | Composition | section:sectionResults.entry | When the result is a diagnostic result. |
result | równoważny | Composition | section:sectionVitalSigns.entry | When the result is a vital sign, target profile is http://hl7.org/fhir/StructureDefinition/vitalsigns. |
note | powiązany z | Composition | section.text | |
carePlans | równoważny | Composition | section:sectionPlanOfCare | |
generatedNarrative | równoważny | Composition | section.text | |
carePlan | równoważny | Composition | section:sectionPlanOfCare.entry | |
note | powiązany z | Composition | section:sectionPlanOfCare.text |
Dokumenty CDA (eHDSI)
Tę samą kategorię niosą w CDA te szablony dokumentów eHDSI. Ich struktura, zbiory wartości i walidator dokumentów CDA są w przewodniku CDA.
Źródła
Rozporządzenie (UE) 2025/327, Dziennik Urzędowy Unii Europejskiej; przewodniki wdrożeniowe FHIR HL7 Europe; modele logiczne Xt-EHR (xtehr.eu.ehds.models). Przewodniki w ballocie mogą się jeszcze zmienić. Ten przewodnik ma charakter informacyjny: nie jest poradą prawną ani certyfikacją zgodności.