Transaction IPS Created

ID: 2.16.840.1.113883.3.1937.777.13.4.2Version Label: 2018-08-29T11:43:19Concepts: 182 (Groups: 69 - Items: 113)

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Name ID[‑] Mandatory[‑] Max[‑] Datatype CC[‑] Datatype[‑] Property[‑] Example[‑] Codes[‑] Description[‑] Context[‑] Source[‑] Rationale[‑] Operationalizations[‑] Comment[‑] Mapping[‑] Enable when[‑] Terminology[‑] Value Set[‑] Type[‑] Parent concept[‑] Inherit from[‑]
Patient Attributes hl7ips-dataelement-2.1 - 1 1 … 1 R 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
CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care An IPS Attribute Collection will provide various data used individually or collectively to identify, or to assure the identity of a person and/or patient to an attending clinician at the point of care.  
      Group
      Patient's Name hl7ips-dataelement-3 - n 1 … * R Collection of data Collection of data 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care It requires family and given name components.
          Item Patient Attributes
          Patient’s address and telecom hl7ips-dataelement-155 - n 0 … * R 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
              Group Patient Attributes
              Address hl7ips-dataelement-162 - n 0 … * R Collection of data Collection of data
                  Item Patient’s address and telecom
                  Telecoms hl7ips-dataelement-100 - n 0 … * R Count Count
                      Item Patient’s address and telecom
                      Administrative Gender hl7ips-dataelement-4 - 1 0 … 1 R Code Code 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’ CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                          Item Patient Attributes
                          Date of Birth hl7ips-dataelement-5 - 1 1 … 1 R Date/time Date/time
                          • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                              Item Patient Attributes
                              Patient’s preferred language hl7ips-dataelement-135 - 1 0 … 1 Code Code
                                  Item Patient Attributes
                                  Healthcare related Identifiers hl7ips-dataelement-202 - n 0 … * R
                                  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.
                                  CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                      Group Patient Attributes
                                      Patient Identifier hl7ips-dataelement-6 - n 0 … * R Identifier Identifier 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                          Item Healthcare related Identifiers
                                          Insurance Information hl7ips-dataelement-203 - n 0 … * 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                              Group Patient Attributes
                                              Insurance identifier hl7ips-dataelement-7 - n 0 … * R Identifier Identifier
                                                  Item Insurance Information
                                                  Patient’s Address Book hl7ips-dataelement-154 - 1 0 … 1 R 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.
                                                  CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care This IPS Attribute Collection provides an Address Book resource detailing the address details of the patient, and people and organisations relevant to the patient with respect to the IPS.
                                                      Group
                                                      Preferred Healthcare providers hl7ips-dataelement-163 - 1 0 … 1 R 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                          Group Patient’s Address Book
                                                          Healthcare Provider (person) (HP, HCP) hl7ips-dataelement-165 - n 0 … * C
                                                              Group Preferred Healthcare providers
                                                              Name hl7ips-dataelement-121 - n 1 … * R Collection of data Collection of data It requires family and given name components.
                                                                  Item Healthcare Provider (person)
                                                                  Telecoms hl7ips-dataelement-169 - n 0 … * R Collection of data Collection of data
                                                                      Item Healthcare Provider (person)
                                                                      Healthcare Provider (organisation) hl7ips-dataelement-166 - n 0 … * C
                                                                          Group Preferred Healthcare providers
                                                                          Organisation’s Name hl7ips-dataelement-172 - n 1 … * R String String
                                                                              Item Healthcare Provider (organisation)
                                                                              Telecoms hl7ips-dataelement-174 - n 0 … * R Collection of data Collection of data
                                                                                  Item Healthcare Provider (organisation) hl7ips-dataelement-169
                                                                                  Other's Contacts’ Details hl7ips-dataelement-164 - 1 0 … 1 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). CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                      Group Patient’s Address Book
                                                                                      Contact hl7ips-dataelement-167 - n 1 … * R
                                                                                          Group Other's Contacts’ Details
                                                                                          Role hl7ips-dataelement-175 - 1 0 … 1 R Code Code
                                                                                              Item Contact
                                                                                              Name hl7ips-dataelement-157 - n 1 … * R Collection of data Collection of data It requires family and given name components.
                                                                                                  Item Contact hl7ips-dataelement-121
                                                                                                  Address hl7ips-dataelement-120 - n 0 … * Collection of data Collection of data Address
                                                                                                      Item Contact
                                                                                                      Telecoms hl7ips-dataelement-122 - n 0 … * R Collection of data Collection of data
                                                                                                          Item Contact hl7ips-dataelement-169
                                                                                                          Advance Directives (AD Section, Living will, Personal directive) hl7ips-dataelement-8 - 1 0 … 1
                                                                                                          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
                                                                                                          CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care Deemed to be of value in unplanned care if a life-threatening event or fatality occurs and the patient or a legitimate decision maker has stipulated what should happen with respect to the patient who is too ill or hurt to express their wishes.
                                                                                                              Group
                                                                                                              Advance Directives (AD List) hl7ips-dataelement-24 - 1 1 … 1 R
                                                                                                              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
                                                                                                              CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                  Group Advance Directives
                                                                                                                  Advance Directive hl7ips-dataelement-179 - n 1 … * R
                                                                                                                      Group Advance Directives
                                                                                                                      Person authorising Directive hl7ips-dataelement-22 - 1 0 … 1 R 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                          Group Advance Directive
                                                                                                                          Name hl7ips-dataelement-118 - n 0 … * R Collection of data Collection of data It requires family and given name components.
                                                                                                                              Item Person authorising Directive hl7ips-dataelement-121
                                                                                                                              Telecoms hl7ips-dataelement-178 - n 0 … * R Count Count
                                                                                                                                  Item Person authorising Directive hl7ips-dataelement-100
                                                                                                                                  Directive category hl7ips-dataelement-180 - n 0 … * Code Code 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                      Item Advance Directive
                                                                                                                                      Description hl7ips-dataelement-26 - n 0 … * C Text Text
                                                                                                                                      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.
                                                                                                                                      CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                          Item Advance Directive
                                                                                                                                          Reference to Legal Document hl7ips-dataelement-27 - n 0 … * C Collection of data Collection of data The Directives may take the form of a reference to a legal document (e.g. Living Will) or an external textual description. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                              Item Advance Directive
                                                                                                                                              Allergies and Intolerances hl7ips-dataelement-9 - 1 1 … 1 R
                                                                                                                                              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.
                                                                                                                                              CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care To inform the treatment and care provisioning of an attending clinician to identify problem or to avoid adverse events arising from action taken. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
                                                                                                                                                  Group
                                                                                                                                                  Allergies/Intolerances Content Status hl7ips-dataelement-182 - 1 0 … 1 C Code Code 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                      Item Allergies and Intolerances
                                                                                                                                                      Allergy or Intolerance list hl7ips-dataelement-28 - 1 0 … 1 C 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                          Group Allergies and Intolerances
                                                                                                                                                          Allergy/Intolerance hl7ips-dataelement-184 + n 1 … * M
                                                                                                                                                              Group Allergy or Intolerance list
                                                                                                                                                              Description hl7ips-dataelement-183 - 1 1 … 1 R Text Text
                                                                                                                                                              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.
                                                                                                                                                              CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                  Item Allergy/Intolerance
                                                                                                                                                                  Clinical Status hl7ips-dataelement-186 - 1 1 … 1 R Code Code
                                                                                                                                                                  • active
                                                                                                                                                                  • inactive
                                                                                                                                                                  • resolved
                                                                                                                                                                  Provides the current status of the allergy or intolerance, for example, whether it is active, in remission, resolved, and so on.
                                                                                                                                                                  CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                      Item Allergy/Intolerance
                                                                                                                                                                      Onset date hl7ips-dataelement-187 - 1 1 … 1 R Date/time Date/time
                                                                                                                                                                      It shall be provided with the highest known precision, at least year
                                                                                                                                                                      CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                          Item Allergy/Intolerance
                                                                                                                                                                          End Date hl7ips-dataelement-188 - 1 0 … 1 C Date/time Date/time
                                                                                                                                                                          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.
                                                                                                                                                                          CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                              Item Allergy/Intolerance
                                                                                                                                                                              Criticality hl7ips-dataelement-189 - 1 0 … 1 Code Code
                                                                                                                                                                              • High
                                                                                                                                                                              • Low
                                                                                                                                                                              • unable to assess criticality
                                                                                                                                                                              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.
                                                                                                                                                                              CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                  Item Allergy/Intolerance
                                                                                                                                                                                  Certainty hl7ips-dataelement-190 - 1 0 … 1 Code Code
                                                                                                                                                                                  • Provisional
                                                                                                                                                                                  • Differential
                                                                                                                                                                                  • Confirmed
                                                                                                                                                                                  • Refuted
                                                                                                                                                                                  Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                      Item Allergy/Intolerance
                                                                                                                                                                                      Type of propensity hl7ips-dataelement-191 - 1 0 … 1 R Code Code
                                                                                                                                                                                      • Allergy
                                                                                                                                                                                      • Intolerance
                                                                                                                                                                                      • propensity to adverse reaction (allergy or intolerance)
                                                                                                                                                                                      Type of allergy or intolerance. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                          Item Allergy/Intolerance
                                                                                                                                                                                          Diagnosis hl7ips-dataelement-185 - 1 0 … 1 Code Code
                                                                                                                                                                                          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
                                                                                                                                                                                          CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                              Item Allergy/Intolerance
                                                                                                                                                                                              Reaction hl7ips-dataelement-192 - n 0 … * R A Label Concept recognising that other data concerning the reaction may be made available in later versions of this standard. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                  Group Allergy/Intolerance
                                                                                                                                                                                                  Manifestation of the reaction hl7ips-dataelement-193 - 1 0 … 1 R Code Code
                                                                                                                                                                                                  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.
                                                                                                                                                                                                  CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                      Item Reaction
                                                                                                                                                                                                      Severity hl7ips-dataelement-194 - 1 0 … 1 R Code Code 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                          Item Reaction
                                                                                                                                                                                                          Agent hl7ips-dataelement-173 - 1 1 … 1 R
                                                                                                                                                                                                              Group Allergy/Intolerance
                                                                                                                                                                                                              Agent code hl7ips-dataelement-196 - 1 1 … 1 R Code Code 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                                  Item Agent
                                                                                                                                                                                                                  Category hl7ips-dataelement-195 - 1 0 … 1 Code Code
                                                                                                                                                                                                                  • Food
                                                                                                                                                                                                                  • Medication
                                                                                                                                                                                                                  • Environment
                                                                                                                                                                                                                  Allergy substance category CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                                      Item Agent
                                                                                                                                                                                                                      Functional Status hl7ips-dataelement-10 - 1 0 … 1
                                                                                                                                                                                                                          Group
                                                                                                                                                                                                                          Disabilities List hl7ips-dataelement-156 - 1 0 … 1 C
                                                                                                                                                                                                                              Group Functional Status
                                                                                                                                                                                                                              Disability hl7ips-dataelement-29 - n 1 … * R
                                                                                                                                                                                                                                  Group Disabilities List
                                                                                                                                                                                                                                  Description hl7ips-dataelement-197 - 1 1 … 1 R Text Text
                                                                                                                                                                                                                                      Item Disability
                                                                                                                                                                                                                                      Disability Code hl7ips-dataelement-198 - 1 0 … 1 Code Code
                                                                                                                                                                                                                                          Item Disability
                                                                                                                                                                                                                                          Onset date hl7ips-dataelement-199 - 1 0 … 1 Date/time Date/time
                                                                                                                                                                                                                                              Item Disability
                                                                                                                                                                                                                                              Functional Assessments List hl7ips-dataelement-30 - 1 0 … 1 C
                                                                                                                                                                                                                                                  Group Functional Status
                                                                                                                                                                                                                                                  Functional Assessment hl7ips-dataelement-201 - n 1 … * R
                                                                                                                                                                                                                                                      Group Functional Assessments List
                                                                                                                                                                                                                                                      Description hl7ips-dataelement-137 - 1 1 … 1 R Text Text
                                                                                                                                                                                                                                                      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
                                                                                                                                                                                                                                                      CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                                                                          Item Functional Assessment
                                                                                                                                                                                                                                                          Date of assessment hl7ips-dataelement-204 - 1 0 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                          • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                              Item Functional Assessment
                                                                                                                                                                                                                                                              Type hl7ips-dataelement-205 - 1 0 … 1 R Code Code
                                                                                                                                                                                                                                                                  Item Functional Assessment
                                                                                                                                                                                                                                                                  Result hl7ips-dataelement-206 - 1 0 … 1 C Collection of data Collection of data
                                                                                                                                                                                                                                                                      Item Functional Assessment
                                                                                                                                                                                                                                                                      Functional Assessment hl7ips-dataelement-21 - 1 0 … 1 C
                                                                                                                                                                                                                                                                          Group Functional Assessment hl7ips-dataelement-201
                                                                                                                                                                                                                                                                          History of Past Illness hl7ips-dataelement-11 - 1 0 … 1
                                                                                                                                                                                                                                                                              Group
                                                                                                                                                                                                                                                                              Past illness content status hl7ips-dataelement-208 - 1 0 … 1 C Code Code
                                                                                                                                                                                                                                                                                  Item History of Past Illness
                                                                                                                                                                                                                                                                                  Past health conditions and problems list hl7ips-dataelement-31 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                      Group History of Past Illness
                                                                                                                                                                                                                                                                                      Health condition / Problem hl7ips-dataelement-209 - n 1 … * R
                                                                                                                                                                                                                                                                                          Group Past health conditions and problems list
                                                                                                                                                                                                                                                                                          Problem Type hl7ips-dataelement-210 - 1 0 … 1 R Code Code
                                                                                                                                                                                                                                                                                              Item Health condition / Problem
                                                                                                                                                                                                                                                                                              Description hl7ips-dataelement-35 - 1 1 … 1 R Text Text
                                                                                                                                                                                                                                                                                                  Item Health condition / Problem
                                                                                                                                                                                                                                                                                                  Diagnosis hl7ips-dataelement-36 - 1 1 … 1 R Code Code
                                                                                                                                                                                                                                                                                                      Item Health condition / Problem
                                                                                                                                                                                                                                                                                                      Severity hl7ips-dataelement-136 - 1 0 … 1 Code Code 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. CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                                                                                                                          Item Health condition / Problem hl7ips-dataelement-194
                                                                                                                                                                                                                                                                                                          Onset Date hl7ips-dataelement-32 - 1 1 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                                                                          • Timestamp precision: at least year (YYYY)
                                                                                                                                                                                                                                                                                                          Date of the first observation of adverse reactions SPECIFIC GUIDELINES FOR ELECTRONIC EXCHANGE OF HEALTH DATA UNDER THE CROSS-BORDER DIRECTIVE 2011/24/EU RELEASE 2 PATIENT SUMMARY FOR UNSCHEDULED CARE
                                                                                                                                                                                                                                                                                                              Item Health condition / Problem
                                                                                                                                                                                                                                                                                                              Resolution hl7ips-dataelement-33 - 1 0 … 1 Code Code
                                                                                                                                                                                                                                                                                                                  Item Health condition / Problem
                                                                                                                                                                                                                                                                                                                  Date resolved hl7ips-dataelement-34 - 1 0 … 1 C Date/time Date/time
                                                                                                                                                                                                                                                                                                                  • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                                                                                      Item Health condition / Problem
                                                                                                                                                                                                                                                                                                                      Specialist Contact hl7ips-dataelement-124 - n 0 … * Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                          Item Health condition / Problem
                                                                                                                                                                                                                                                                                                                          History of Pregnancy hl7ips-dataelement-12 - 1 0 … 1
                                                                                                                                                                                                                                                                                                                              Group
                                                                                                                                                                                                                                                                                                                              Status of pregnancy hl7ips-dataelement-37 - 1 1 … 1 R
                                                                                                                                                                                                                                                                                                                                  Group History of Pregnancy
                                                                                                                                                                                                                                                                                                                                  Pregnancy Description hl7ips-dataelement-225 - 1 0 … 1 C Text Text
                                                                                                                                                                                                                                                                                                                                      Item Status of pregnancy
                                                                                                                                                                                                                                                                                                                                      Structured Description hl7ips-dataelement-168 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                                                                          Group Status of pregnancy
                                                                                                                                                                                                                                                                                                                                          Date of Observation hl7ips-dataelement-211 - 1 1 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                                                                                                          • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                                                                                                              Item Structured Description
                                                                                                                                                                                                                                                                                                                                              Pregnancy State hl7ips-dataelement-212 - 1 1 … 1 R Code Code
                                                                                                                                                                                                                                                                                                                                                  Item Structured Description
                                                                                                                                                                                                                                                                                                                                                  Expected delivery date hl7ips-dataelement-213 - 1 0 … 1 C Date/time Date/time
                                                                                                                                                                                                                                                                                                                                                  • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                                                                                                                      Item Structured Description
                                                                                                                                                                                                                                                                                                                                                      Specialist Contact hl7ips-dataelement-200 - n 0 … * Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                          Item Status of pregnancy hl7ips-dataelement-124
                                                                                                                                                                                                                                                                                                                                                          Previous Pregnancies hl7ips-dataelement-38 - 1 0 … 1
                                                                                                                                                                                                                                                                                                                                                              Group History of Pregnancy
                                                                                                                                                                                                                                                                                                                                                              Previous Pregnancies Description hl7ips-dataelement-39 - 1 0 … 1 C Text Text
                                                                                                                                                                                                                                                                                                                                                                  Item Previous Pregnancies
                                                                                                                                                                                                                                                                                                                                                                  Previous Pregnancies List hl7ips-dataelement-1 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                                                                                                      Group Previous Pregnancies
                                                                                                                                                                                                                                                                                                                                                                      Previous Pregnancy hl7ips-dataelement-40 - n 0 … * R
                                                                                                                                                                                                                                                                                                                                                                          Group Previous Pregnancies List
                                                                                                                                                                                                                                                                                                                                                                          Outcome date hl7ips-dataelement-41 - 1 0 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                                                                                                                                          • Timestamp precision: at least year (YYYY)
                                                                                                                                                                                                                                                                                                                                                                              Item Previous Pregnancy
                                                                                                                                                                                                                                                                                                                                                                              Outcome hl7ips-dataelement-42 - 1 0 … 1 R Text Text
                                                                                                                                                                                                                                                                                                                                                                                  Item Previous Pregnancy
                                                                                                                                                                                                                                                                                                                                                                                  Summary Metric hl7ips-dataelement-214 - 1 0 … 1 C Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                      Item Previous Pregnancies
                                                                                                                                                                                                                                                                                                                                                                                      Specialist Contact hl7ips-dataelement-125 - n 0 … * Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                          Item Previous Pregnancies hl7ips-dataelement-124
                                                                                                                                                                                                                                                                                                                                                                                          History of Procedures hl7ips-dataelement-13 - 1 0 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                              Group
                                                                                                                                                                                                                                                                                                                                                                                              Procedures Content Status hl7ips-dataelement-44 - 1 0 … 1 C Code Code
                                                                                                                                                                                                                                                                                                                                                                                              History of procedures informing whether there is no information about procedures or no known procedure 
                                                                                                                                                                                                                                                                                                                                                                                                  Item History of Procedures
                                                                                                                                                                                                                                                                                                                                                                                                  Procedure list hl7ips-dataelement-43 - 1 0 … 1 C A list of procedures performed on the subject of care
                                                                                                                                                                                                                                                                                                                                                                                                      Group History of Procedures
                                                                                                                                                                                                                                                                                                                                                                                                      Procedure hl7ips-dataelement-47 - n 1 … * R Each member of the list describes the type of procedure and identifies the actual procedure performed and when it happened.
                                                                                                                                                                                                                                                                                                                                                                                                          Group Procedure list
                                                                                                                                                                                                                                                                                                                                                                                                          Procedure code hl7ips-dataelement-49 - 1 1 … 1 R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                              Item Procedure
                                                                                                                                                                                                                                                                                                                                                                                                              Procedure description hl7ips-dataelement-51 - 1 0 … 1 R Text 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 Procedure
                                                                                                                                                                                                                                                                                                                                                                                                                  Body site hl7ips-dataelement-216 - n 0 … *
                                                                                                                                                                                                                                                                                                                                                                                                                      Item Procedure
                                                                                                                                                                                                                                                                                                                                                                                                                      Procedure date hl7ips-dataelement-48 - 1 1 … 1 R Collection of data Collection of data Period or Date Time
                                                                                                                                                                                                                                                                                                                                                                                                                          Item Procedure
                                                                                                                                                                                                                                                                                                                                                                                                                          Immunizations hl7ips-dataelement-14 - 1 0 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                              Group
                                                                                                                                                                                                                                                                                                                                                                                                                              Immunizations Content Status hl7ips-dataelement-46 - 1 0 … 1 C Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                  Item Immunizations
                                                                                                                                                                                                                                                                                                                                                                                                                                  Immunizations list hl7ips-dataelement-50 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                                                                                                                                                                      Group Immunizations
                                                                                                                                                                                                                                                                                                                                                                                                                                      Immunization hl7ips-dataelement-45 - n 1 … * R

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

                                                                                                                                                                                                                                                                                                                                                                                                                                          Group Immunizations list
                                                                                                                                                                                                                                                                                                                                                                                                                                          Vaccine for type of disease hl7ips-dataelement-52 - n 1 … * R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                              Item Immunization
                                                                                                                                                                                                                                                                                                                                                                                                                                              Target disease list hl7ips-dataelement-181 - 1 0 … 1
                                                                                                                                                                                                                                                                                                                                                                                                                                                  Group Immunization
                                                                                                                                                                                                                                                                                                                                                                                                                                                  Target disease hl7ips-dataelement-207 - n 1 … * R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                      Item Target disease list
                                                                                                                                                                                                                                                                                                                                                                                                                                                      Date of Immunization hl7ips-dataelement-53 - 1 1 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                                                                                                                                                                                                                      • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                                                                                                                                                                                                                          Item Immunization
                                                                                                                                                                                                                                                                                                                                                                                                                                                          Product Administered hl7ips-dataelement-54 - 1 0 … 1
                                                                                                                                                                                                                                                                                                                                                                                                                                                              Group Immunization
                                                                                                                                                                                                                                                                                                                                                                                                                                                              Brand name hl7ips-dataelement-55 - 1 0 … 1 R String String
                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Item Product Administered
                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Product Administration Process hl7ips-dataelement-215 - 1 0 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Group Immunization
                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Performer hl7ips-dataelement-56 - n 0 … * Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Item Product Administration Process
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Route of administration hl7ips-dataelement-217 - 1 0 … 1 Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Item Product Administration Process
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Medical Devices hl7ips-dataelement-15 - 1 0 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Group
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Device content Status hl7ips-dataelement-218 - 1 0 … 1 C Code Code

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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Item Medical Devices
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Device List hl7ips-dataelement-219 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Group Medical Devices
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Device hl7ips-dataelement-57 - n 1 … * R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Group Device List
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Device Type hl7ips-dataelement-58 - n 1 … * R Code Code Category of the device
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Item Device
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Device Identifier hl7ips-dataelement-60 - n 0 … * R Identifier Identifier
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  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 Device
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Use start date hl7ips-dataelement-59 - 1 1 … 1 R Date/time Date/time 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 Device
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Use end date hl7ips-dataelement-150 - 1 0 … 1 Date/time Date/time
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Item Device
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Medication Summary hl7ips-dataelement-16 - 1 1 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Group
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Medication Summary content status hl7ips-dataelement-220 - 1 0 … 1 C Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Item Medication Summary
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      List of medication hl7ips-dataelement-61 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Group Medication Summary
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Medication hl7ips-dataelement-104 - n 1 … * R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Group List of medication
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Reason hl7ips-dataelement-226 - 1 0 … 1 Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Item Medication
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Medicinal Product hl7ips-dataelement-2 - 1 1 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Group Medication
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Product Code (Medicinal product Identifier ) hl7ips-dataelement-105 - n 0 … * Code Code A code identifying the medicine. 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      • To be clarified if at this level we need to distiguish among the different types of "products" : e.g. packaged products; medicinal product; class of products; pharmaceutical products;...
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Item Medicinal Product
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Product Common Name (and Strength) hl7ips-dataelement-171 - 1 0 … 1 R String String
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Item Medicinal Product
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Pharmaceutical dose form hl7ips-dataelement-227 - 1 1 … 1 R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            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.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            EN-ISO IDMP 11615
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Medicinal Product
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Brand Name hl7ips-dataelement-117 - 1 0 … 1 String String
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Medicinal Product
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Active ingredient List hl7ips-dataelement-170 - 1 1 … 1 R CEN/TC 251 prEN 17269:2018 Health informatics — The Patient Summary for Unscheduled Cross-border Care
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Group Medicinal Product
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Active Ingredient hl7ips-dataelement-129 - 1 1 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Group Active ingredient List
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Substance code hl7ips-dataelement-132 - 1 1 … 1 R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Active Ingredient
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Strength hl7ips-dataelement-133 - 1 1 … 1 R Quantity Quantity
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Active Ingredient
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Administration Instruction hl7ips-dataelement-222 - 1 1 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Group Medication
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Instruction hl7ips-dataelement-228 - 1 0 … 1 Text Text
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Item Administration Instruction
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Period of Medication Use hl7ips-dataelement-103 - 1 1 … 1 R Duration Duration 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 Administration Instruction
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Route of administration hl7ips-dataelement-102 - 1 0 … 1 Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Administration Instruction hl7ips-dataelement-217
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Dose Instruction hl7ips-dataelement-119 - 1 1 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Group Administration Instruction
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Number of units per intake hl7ips-dataelement-223 - 1 1 … 1 R Quantity Quantity Range or Quantity
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Item Dose Instruction
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Frequency of intake hl7ips-dataelement-224 - 1 1 … 1 R Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Dose Instruction
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Plan Of Care hl7ips-dataelement-17 - 1 0 … 1
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Group
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Plan Description hl7ips-dataelement-110 - 1 0 … 1 C Text Text
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Item Plan Of Care
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Plan Description list hl7ips-dataelement-134 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Group Plan Of Care
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Plan hl7ips-dataelement-114 - n 1 … * R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Group Plan Description list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Plan Type hl7ips-dataelement-108 - 1 0 … 1 R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Plan
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Plan Date hl7ips-dataelement-107 - 1 0 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Item Plan
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Recommendations list (Core Care Plan) hl7ips-dataelement-109 - 1 0 … 1 C
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Group Plan Description list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Recommendation for treatment hl7ips-dataelement-113 - 1 1 … 1 R Identifier Identifier
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Recommendations list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Given Recommendations date hl7ips-dataelement-111 - 1 0 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Recommendations list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Applicable dates hl7ips-dataelement-112 - 1 0 … 1 R Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Item Recommendations list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Extended Plan (trade name) hl7ips-dataelement-116 - 1 0 … 1 C Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Item Plan Description list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Problems hl7ips-dataelement-18 - 1 1 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Group
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Problem content status hl7ips-dataelement-115 - 1 0 … 1 C Code Code The patient has had no previous problems, or the problem information is unknown
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Problems
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Problem list hl7ips-dataelement-139 - 1 0 … 1 C

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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Group Problems
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Problem hl7ips-dataelement-140 - n 1 … * R

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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Group Problem list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Problem type hl7ips-dataelement-101 - 1 0 … 1 R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Problem
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Description hl7ips-dataelement-130 - 1 1 … 1 R Text Text
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Problem
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Diagnosis hl7ips-dataelement-131 - 1 1 … 1 R Code Code

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Label used to describe a problem; usually coded.


                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Item Problem
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Severity hl7ips-dataelement-128 - 1 0 … 1 R Code Code
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Item Problem
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Onset date hl7ips-dataelement-127 - 1 1 … 1 R Date/time Date/time
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            • Timestamp precision: at least day (DD), month (MM) and year (YYYY)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Problem
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Specialist Contact hl7ips-dataelement-25 - 1 0 … 1 Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Problem hl7ips-dataelement-124
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Results hl7ips-dataelement-19 - 1 0 … 1 R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Group
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Observation Results Content Status hl7ips-dataelement-141 - 1 0 … 1 C Code Code

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Statement about presence/absence of content.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Item Results
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Observations results list hl7ips-dataelement-126 - 1 0 … 1 C A conditional list of all observation results pertaining to the subject of care’s health condition
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Group Results
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Observation Result hl7ips-dataelement-106 - n 1 … * R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Group Observations results list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Date of observation hl7ips-dataelement-143 - 1 1 … 1 R Duration Duration Date Time or Period
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Item Observation Result
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Observation Type hl7ips-dataelement-144 - 1 1 … 1 R Code Code

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        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 Observation Result
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Result Description hl7ips-dataelement-142 - n 1 … * R Text Text
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Observation Result
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Value hl7ips-dataelement-145 - 1 0 … 1 C Collection of data Collection of data

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                The measurement value and details about how the tests were done to get the result values.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Item Observation Result
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Observation Result hl7ips-dataelement-23 - n 0 … * C
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Group Observation Result hl7ips-dataelement-106
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Performer hl7ips-dataelement-146 - n 0 … * R Collection of data Collection of data

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        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 Observation Result
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Observer hl7ips-dataelement-177 - n 0 … * R Collection of data Collection of data
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Observation Result
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Social History hl7ips-dataelement-20 - 1 0 … 1
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Group
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Life Style Factor list hl7ips-dataelement-147 - 1 1 … 1 R

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    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. 


                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Group Social History
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Life Style Factor hl7ips-dataelement-148 - n 1 … * R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Group Life Style Factor list
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Description hl7ips-dataelement-149 - 1 1 … 1 R Text Text
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Item Life Style Factor
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Life Style Factor hl7ips-dataelement-176 - n 0 … *
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Group Life Style Factor hl7ips-dataelement-148
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Reference date range hl7ips-dataelement-151 - 1 0 … 1 R Duration Duration
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Item Life Style Factor