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Questionnaire for IPS Created

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Collection of data used for identification and assurance of identity within a patient summary.Every PS conformant to IPS must contain ’Patient’s Name’ from this IPS collection.Insurance information is necessary in some countries 

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Collection of data used for identification and assurance of identity within a patient summary.

Every PS conformant to IPS must contain ’Patient’s Name’ from this IPS collection.

Insurance information is necessary in some countries

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It requires family and given name components.

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It requires family and given name components.

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The name of a person is a familiar, cross-sector idea, independent of a particular use case. It is explained in the Primitive Values clause.

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The name of a person is a familiar, cross-sector idea, independent of a particular use case. It is explained in the Primitive Values clause.

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This Label Concept positions the nested attributes. However, it is useful to note that the patient’s address is administrative but can also be used in the clinical process to assist with the verification of the patient’s identification.

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This Label Concept positions the nested attributes. However, it is useful to note that the patient’s address is administrative but can also be used in the clinical process to assist with the verification of the patient’s identification.

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Some countries require ‘gender’ as part of their identification of the patient. Administrative gender SHALL be specified from a value set including, ‘Male’, ‘Female’, ‘Unknown’, ‘Neutral’

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Some countries require ‘gender’ as part of their identification of the patient. Administrative gender SHALL be specified from a value set including, ‘Male’, ‘Female’, ‘Unknown’, ‘Neutral’

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A list of patient identifiers.Notes: Arguably a national health number would be of more use locally than for cross-border purposes. It is also possible, even probable, that a person will have several numbers, each one related to one or more healthcare providers. In an international context, a national healthcare identifier may be useful.
However not all countries have such a registration scheme in place.

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A list of patient identifiers.

Notes: Arguably a national health number would be of more use locally than for cross-border purposes. It is also possible, even probable, that a person will have several numbers, each one related to one or more healthcare providers. In an international context, a national healthcare identifier may be useful. However not all countries have such a registration scheme in place.

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Note, Patient Number is often used as a synonym, albeit that the identifier is not necessarily numeric; some jurisdictions use the Social Security Number as a healthcare identifier.

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Note, Patient Number is often used as a synonym, albeit that the identifier is not necessarily numeric; some jurisdictions use the Social Security Number as a healthcare identifier.

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Insurance information is not always required in a patient summary. However, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care. In those countries that require such information, it must be present.

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Insurance information is not always required in a patient summary. However, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care. In those countries that require such information, it must be present.

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People and organizations address details relevant for the planned and unplanned care.Considered to be generic to the English language and not specific to this standard.Notes: A list relating to people or organisations details who might need to be contacted for this care event; it is not to do with previous care events
involving this patient. These entities can be considered as providers (person or organisation) who are wholly or partially responsible for the safety and well-being of the subject of care.

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People and organizations address details relevant for the planned and unplanned care.
Considered to be generic to the English language and not specific to this standard.
Notes: A list relating to people or organisations details who might need to be contacted for this care event; it is not to do with previous care events involving this patient. These entities can be considered as providers (person or organisation) who are wholly or partially responsible for the safety and well-being of the subject of care.

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If known, this information shall be provided. Note it is not necessarily the case that Preferred Healthcare Provider is the same party as the source of the patient summary; the latter is given by the Provenance meta data. ‘Preferred’ indicates the most relevant entity to be contacted for use in this patient summary.

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If known, this information shall be provided. Note it is not necessarily the case that Preferred Healthcare Provider is the same party as the source of the patient summary; the latter is given by the Provenance meta data. ‘Preferred’ indicates the most relevant entity to be contacted for use in this patient summary.

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It requires family and given name components.

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The urgency of the scenario suggests that the contact details will be minimised to the most likely means of getting in touch. The role distinguishes between individuals (and organisations) by means of their function with respect to the patient’s care to enable the relevant person to be contacted by the healthcare provider at the point of care. The role
can be both functional (e.g. doctor) and a specialisation (e.g. specialist).

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The urgency of the scenario suggests that the contact details will be minimised to the most likely means of getting in touch. The role distinguishes between individuals (and organisations) by means of their function with respect to the patient’s care to enable the relevant person to be contacted by the healthcare provider at the point of care. The role
can be both functional (e.g. doctor) and a specialisation (e.g. specialist).

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It requires family and given name components.

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Provision for healthcare decisions in the event that, in the future, a person is unable to make those decisions.A conformant IPS document may not include this section.Healthcare directives concerning life or after life wishes of the patient

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Provision for healthcare decisions in the event that, in the future, a person is unable to make those decisions.
A conformant IPS document may not include this section.

Healthcare directives concerning life or after life wishes of the patient

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A list comprising one or more advance directivesNote: Although not in this version of the standard, future versions of the Advanced Directives IPS Section might also include definitions and descriptions regarding ‘CONSENT practices’ as directives and mandates from particular jurisdictions

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A list comprising one or more advance directives

Note: Although not in this version of the standard, future versions of the Advanced Directives IPS Section might also include definitions and descriptions regarding ‘CONSENT practices’ as directives and mandates from particular jurisdictions

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The source of each directive if known; the decision maker is usually the patient and/or a delegated person such as a Legal Guardian. If the authority is not the patient, then it will be someone to contact for further information and clarification of the patient’s wishes. The postal address elements are not included reflecting the urgency for the
contact; however, full details should be consistent and available from the Patient’s Address Book.

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The source of each directive if known; the decision maker is usually the patient and/or a delegated person such as a Legal Guardian. If the authority is not the patient, then it will be someone to contact for further information and clarification of the patient’s wishes. The postal address elements are not included reflecting the urgency for the
contact; however, full details should be consistent and available from the Patient’s Address Book.

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It requires family and given name components.

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There are Directives related to decisions prior and after death. For example, directives prior to death might relate to Blood transfusions, and Non-Resuscitation and post death directives might relate to organ donation.

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There are Directives related to decisions prior and after death. For example, directives prior to death might relate to Blood transfusions, and Non-Resuscitation and post death directives might relate to organ donation.

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Textual description of the directive.Derived models may choose to use distinct elements for each narrative directive or to collect them into a single section level narrative block.

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Textual description of the directive.

Derived models may choose to use distinct elements for each narrative directive or to collect them into a single section level narrative block.

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The Directives may take the form of a reference to a legal document (e.g. Living Will) or an external textual description.

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The Directives may take the form of a reference to a legal document (e.g. Living Will) or an external textual description.

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Relevant patient’s allergies and/or intolerance conditions. NOTE 1 to entry: At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. NOTE 2 to entry: ‘Alerts’ was used to describe this Section in the eHN guidance -lines, but ‘Alerts’ are far more general and are not
regarded here as a synonym.Every PS conformant to IPS must contain this IPS section.Allergies and Intolerances affecting the Patient.

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Relevant patient’s allergies and/or intolerance conditions.
NOTE 1 to entry: At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
NOTE 2 to entry: ‘Alerts’ was used to describe this Section in the eHN guidance -lines, but ‘Alerts’ are far more general and are not regarded here as a synonym.

Every PS conformant to IPS must contain this IPS section.

Allergies and Intolerances affecting the Patient.

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As this IPS Section is mandatory for conformance, information about “known absence of allergies” or no information about allergies is required to be stated. Known Content will be accompanied by the conditional list of Allergies and intolerances.

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As this IPS Section is mandatory for conformance, information about “known absence of allergies” or no information about allergies is required to be stated. Known Content will be accompanied by the conditional list of Allergies and intolerances.

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If allergies present then they shall be listed else give explicit reasons for why none are recorded. An ordered list comprising the name, code, a description of the Allergy/intolerance and Agent details for each Allergy/intolerance.

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If allergies present then they shall be listed else give explicit reasons for why none are recorded. An ordered list comprising the name, code, a description of the Allergy/intolerance and Agent details for each Allergy/intolerance.

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Textual description of the allergy or intolerance.Derived models may choose to use distinct elements for each narrative statement or to collect them into a single section level narrative block.

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Textual description of the allergy or intolerance.

Derived models may choose to use distinct elements for each narrative statement or to collect them into a single section level narrative block.

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Provides the current status of the allergy or intolerance, for example, whether it is active, in remission, resolved, and so on.

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Provides the current status of the allergy or intolerance, for example, whether it is active, in remission, resolved, and so on.

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It shall be provided with the highest known precision, at least year

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It shall be provided with the highest known precision, at least year

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If Clinical Status is non-active then an exception can be raised to indicate inconsistency.It shall be provided with the highest known precision, at least year.

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If Clinical Status is non-active then an exception can be raised to indicate inconsistency.

It shall be provided with the highest known precision, at least year.

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This attribute represents the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual. When the ‘worst case’ result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high
criticality.Notes: In some contexts, the severity is used as a synonym of the criticality.

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This attribute represents the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual. When the ‘worst case’ result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.

Notes: In some contexts, the severity is used as a synonym of the criticality.

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Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance

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Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance

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A code indicating the type of reaction and the agent; an alternative option for describing an allergy to the agent. Described with Textual information if coded data are unavailable.Example: lactose intolerance

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A code indicating the type of reaction and the agent; an alternative option for describing an allergy to the agent. Described with Textual information if coded data are unavailable.

Example: lactose intolerance

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A Label Concept recognising that other data concerning the reaction may be made available in later versions of this standard.

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A Label Concept recognising that other data concerning the reaction may be made available in later versions of this standard.

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Description of the clinical manifestation of the allergic reaction. Example: anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction).Textual information if coded/quantified data are not available. This is typically a more complex structure than simple
text.Example: “intestinal discomfort” is the manifestation of the reaction.

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Description of the clinical manifestation of the allergic reaction. Example: anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction).

Textual information if coded/quantified data are not available. This is typically a more complex structure than simple text.

Example: “intestinal discomfort” is the manifestation of the reaction.

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Coded element that described the subjective assessment of the severity of the condition as evaluated by the clinician, in the case of an allergy it is used as attribute of a manifestation of a reaction. For example, a person may have a severe rash as reaction, that it is not however critical.

# item[].item[].item[].item[].item[].item[]._text.extension[].valueString
Coded element that described the subjective assessment of the severity of the condition as evaluated by the clinician, in the case of an allergy it is used as attribute of a manifestation of a reaction. For example, a person may have a severe rash as reaction, that it is not however critical.

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A specific allergen or other agent/substance to which the patient has an adverse reaction propensity. This will be taken from a list of agents and the associated code from a value set.

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A specific allergen or other agent/substance to which the patient has an adverse reaction propensity. This will be taken from a list of agents and the associated code from a value set.

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Textual description of the functional assessment.Derived models may choose to use distinct elements for each narrative statement or to collect them into a single section level narrative block

# item[].item[].item[].item[].item[]._text.extension[].valueString
Textual description of the functional assessment.

Derived models may choose to use distinct elements for each narrative statement or to collect them into a single section level narrative block

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Past health conditions and problems list

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Coded element that described the subjective assessment of the severity of the condition as evaluated by the clinician, in the case of an allergy it is used as attribute of a manifestation of a reaction. For example, a person may have a severe rash as reaction, that it is not however critical.

# item[].item[].item[].item[].item[]._text.extension[].valueString
Coded element that described the subjective assessment of the severity of the condition as evaluated by the clinician, in the case of an allergy it is used as attribute of a manifestation of a reaction. For example, a person may have a severe rash as reaction, that it is not however critical.

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Date of the first observation of adverse reactions

# item[].item[].item[].item[].item[]._text.extension[].valueString
Date of the first observation of adverse reactions

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History of procedures informing whether there is no information about procedures or no known procedure 

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History of procedures informing whether there is no information about procedures or no known procedure

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A list of procedures performed on the subject of care

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A list of procedures performed on the subject of care

# item[].item[].item[].item[].text
Each member of the list describes the type of procedure and identifies the actual procedure performed and when it happened.

# item[].item[].item[].item[]._text.extension[].valueString
Each member of the list describes the type of procedure and identifies the actual procedure performed and when it happened.

# item[].item[].item[].item[].item[].text
Textual description of the procedure. Derived models may choose to use distinct elements for each narrative statement or to collect them into a single section level narrative block.

# item[].item[].item[].item[].item[]._text.extension[].valueString
Textual description of the procedure.

Derived models may choose to use distinct elements for each narrative statement or to collect them into a single section level narrative block.

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Period or Date Time

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A container for information related to information of the vaccine and its administration.

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A container for information related to information of the vaccine and its administration.

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Records whether there is no information about devices or no known devices

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Records whether there is no information about devices or no known devices

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Note, this was not part of the eHN dataset; the device identifier (e.g. UDI) has been added in the HL7 IPS as optional data.Unique and normalized identifier of the device

# item[].item[].item[].item[].item[]._text.extension[].valueString
Note, this was not part of the eHN dataset; the device identifier (e.g. UDI) has been added in the HL7 IPS as optional data.

Unique and normalized identifier of the device

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Date when the device was implantable to the patient or the external device was first in use. This field may contain only the year if the day and month are not available (ex: 01/01/2017). 

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Date when the device was implantable to the patient or the external device was first in use. This field may contain only the year if the day and month are not available (ex: 01/01/2017). 

# item[].item[].item[].item[].item[].item[].text
Physical manifestation of a Medicinal Product that contains the active ingredient(s) and/or inactive ingredient(s)that are intended to be delivered to the patientNOTE 1 Dose form, dosage form and pharmaceutical dose form are synonymous.NOTE 2 “Pharmaceutical dose form” can refer to the administered dose form or the manufactured dose form.

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Physical manifestation of a Medicinal Product that contains the active ingredient(s) and/or inactive ingredient(s)

that are intended to be delivered to the patient

NOTE 1 Dose form, dosage form and pharmaceutical dose form are synonymous.

NOTE 2 “Pharmaceutical dose form” can refer to the administered dose form or the manufactured dose form.

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This information may be expressed using start and end date times OR indicating the duration. The first is used to indicate a specified interval (e.g. from March 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks). In case of unbounded period (continuous therapy) the end element will be valued with an exceptional
value.

# item[].item[].item[].item[].item[].item[]._text.extension[].valueString
This information may be expressed using start and end date times OR indicating the duration. The first is used to indicate a specified interval (e.g. from March 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks). In case of unbounded period (continuous therapy) the end element will be valued with an exceptional
value.

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The patient has had no previous problems, or the problem information is unknown

# item[].item[].item[]._text.extension[].valueString
The patient has had no previous problems, or the problem information is unknown

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The problem list comprises members that are current, either because they are active, unresolved or of concern and being monitored.

# item[].item[].item[]._text.extension[].valueString
The problem list comprises members that are current, either because they are active, unresolved or of concern and being monitored.

# item[].item[].item[].item[].text
One or more problems are listed; each comprising the same structure describing the nature of the problem and its date of onset.

# item[].item[].item[].item[]._text.extension[].valueString
One or more problems are listed; each comprising the same structure describing the nature of the problem and its date of onset.

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Label used to describe a problem; usually coded.

# item[].item[].item[].item[].item[]._text.extension[].valueString
Label used to describe a problem; usually coded.

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Statement about presence/absence of content.

# item[].item[].item[]._text.extension[].valueString
Statement about presence/absence of content.

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A conditional list of all observation results pertaining to the subject of care’s health condition

# item[].item[].item[]._text.extension[].valueString
A conditional list of all observation results pertaining to the subject of care’s health condition

# item[].item[].item[].item[].item[].text
The list contains members representing the types of results.Note: the eHN give only two examples (non-exhaustive) and these may be represented in a value set with these two types included:Diagnostic resultsPhysical findings

# item[].item[].item[].item[].item[]._text.extension[].valueString
The list contains members representing the types of results.

Note: the eHN give only two examples (non-exhaustive) and these may be represented in a value set with these two types included:

Diagnostic results

Physical findings

# item[].item[].item[].item[].item[].text
The measurement value and details about how the tests were done to get the result values.

# item[].item[].item[].item[].item[]._text.extension[].valueString
The measurement value and details about how the tests were done to get the result values.

# item[].item[].item[].item[].item[].text
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 IPS document. 

# item[].item[].item[].item[].item[]._text.extension[].valueString
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 IPS document.

# item[].item[].item[].text
An open-ended list of composite objects that describes the past and current habits of the patient with respect to a particular life style observation.If this IPS Section is present then the list shall be non-empty.Composite object describing the name of the lifestyle factor and
descriptive text or structured codes providing more details, with ranges and amounts when applicable; Textual information if coded/quantified data are not available. 

# item[].item[].item[]._text.extension[].valueString
An open-ended list of composite objects that describes the past and current habits of the patient with respect to a particular life style observation.

If this IPS Section is present then the list shall be non-empty.

Composite object describing the name of the lifestyle factor and descriptive text or structured codes providing more details, with ranges and amounts when applicable; Textual information if coded/quantified data are not available.