MyHealth@EU refined base model for Patient Summary

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.

Date and optionally time of authoring/issuing

Status of the resource or document

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time period of information covered in the document

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian

Document attestation details

Attester who validated the document

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)

Date and time when the document was authorised

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

Nature of the Patient Summary

Related document

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Substantial alerts or warnings that health professionals should be aware of.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

Reason for absence of data

Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.

ISO IPS

Free text notes by the health professional

Section: Allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

List of structured allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)

1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason

This element is present in MyHealth@EU specifications and ISO IPS. The proposed way of modelling is identical to the newest version of FHIR IPS IG. See general description of Patient summary modelling for more information about this element. MH@EU has a similar concept, but it is modelled in slightly different way.

Free text notes by the health professional

Conditions and symptoms affecting the health of the patient.

Narrative, potentially formatted, content of the whole section.

Use if no conditions are listed

Health conditions affecting the health of the patient.

Free text notes by the health professional

Current and relevant past medicines.

Narrative, potentially formatted, content of the whole section.

Use if no medicines are listed

Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.

Free text notes by the health professional

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

Narrative, potentially formatted, content of the whole section.

Reason for absence of data

Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.

Free text notes by the health professional

Significant procedures performed on the patient.

Narrative, potentially formatted, content of the whole section.

Reason for absence of data

List of procedures

Free text notes by the health professional

A patient's immunisation status (vaccination and other prophylaxis). The section should include current immunisation status and may contain the entire history that is relevant to the period of time being summarised. Adverse reactions against vaccines should be documented in the allergy section.

Narrative, potentially formatted, content of the whole section.

Immunisations given to the patient and their status at the point of care.

eHN PS Guideline

Free text notes by the health professional

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

Condition information describing patient's functional status or disability.

Assessment results regarding functional status.

Free text notes by the health professional

Observations on social factors such as alcohol consumption or smoking. From the healthcare perspective, life-style factors relate to well-being but can also provide a source of risk factors.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

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

eHN PS Guideline, MyHealth@EU, ISO IPS

Free text notes by the health professional

To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.

eHN PS Guideline, ISO IPS

Narrative, potentially formatted, content of the whole section.

Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.

eHN PS Guideline, ISO IPS

Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.

Free text notes by the health professional

Captures relevant information about the patient's recent travel history that may be of clinical relevance — particularly in relation to exposure to infectious diseases, epidemiological risks, or environmental factors. The intent is to support clinical decision-making and risk assessment, especially in contexts such as outbreaks or endemic disease regions.

eHN PS Guideline, ISO IPS

Narrative, potentially formatted, content of the whole section.

Travel history for one country

eHN PS Guideline, ISO IPS

Free text notes by the health professional

A concise narrative from the patient’s perspective about their present health state. This is a record of things that a person feels are important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.

ISO IPS

Free text notes by the health professional

Provision for healthcare decisions if, in the future, a person is unable to make those decisions.

Narrative, potentially formatted, content of the whole section.

Provision for healthcare decisions if, in the future, a person is unable to make those decisions

Free text notes by the health professional

Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.

Narrative, potentially formatted, content of the whole section.

Observation results pertaining to the subject of care's health condition and which might have impact on future treatments

Free text notes by the health professional

Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries

Narrative, potentially formatted, content of the whole section.

Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

Free text notes by the health professional

MyHealth@EU refined base model for Patient Summary

Nature of the Patient Summary

Related document

MyHealth@EU refined base model for Patient Summary

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.

Date and optionally time of authoring/issuing

Status of the resource or document

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time period of information covered in the document

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian

Document attestation details

Attester who validated the document

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)

Date and time when the document was authorised

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

LOINC, SNOMED CT, dicom-cid-33-Modality

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

Nature of the Patient Summary

Related document

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Substantial alerts or warnings that health professionals should be aware of.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

Reason for absence of data

Description of medical alerts in textual format: any clinical information that is imperative to know so that the life or health of the patient does not come under threat.

ISO IPS

Free text notes by the health professional

Section: Allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

List of structured allergies and intolerances

eHN PS Guideline, MyHealth@EU, ISO IPS

Reason for absence of data (indicates whether the person is known to have no allergies or the data is considered incomplete)

1.3.6.1.4.1.12559.11.10.1.3.1.42.47eHDSIAbsentOrUnknownAllergy; http://hl7.org/fhir/ValueSet/list-empty-reason

This element is present in MyHealth@EU specifications and ISO IPS. The proposed way of modelling is identical to the newest version of FHIR IPS IG. See general description of Patient summary modelling for more information about this element. MH@EU has a similar concept, but it is modelled in slightly different way.

Free text notes by the health professional

Conditions and symptoms affecting the health of the patient.

Narrative, potentially formatted, content of the whole section.

Use if no conditions are listed

Health conditions affecting the health of the patient.

Free text notes by the health professional

Current and relevant past medicines.

Narrative, potentially formatted, content of the whole section.

Use if no medicines are listed

Medication treatment/prescription relevant for this patient summary. Typically, medications whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not.

Free text notes by the health professional

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

Narrative, potentially formatted, content of the whole section.

Reason for absence of data

Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices (such as cardiac pacemakers, implantable defibrillator, prothesis, ferromagnetic bone implants etc.) that are important to know by the HP.

Free text notes by the health professional

Significant procedures performed on the patient.

Narrative, potentially formatted, content of the whole section.

Reason for absence of data

List of procedures

Free text notes by the health professional

A patient's immunisation status (vaccination and other prophylaxis). The section should include current immunisation status and may contain the entire history that is relevant to the period of time being summarised. Adverse reactions against vaccines should be documented in the allergy section.

Narrative, potentially formatted, content of the whole section.

Immunisations given to the patient and their status at the point of care.

eHN PS Guideline

Free text notes by the health professional

An individual's ability to perform normal daily activities required to meet basic needs, fulfil usual roles and maintain health and well-being.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

Condition information describing patient's functional status or disability.

Assessment results regarding functional status.

Free text notes by the health professional

Observations on social factors such as alcohol consumption or smoking. From the healthcare perspective, life-style factors relate to well-being but can also provide a source of risk factors.

eHN PS Guideline, MyHealth@EU, ISO IPS

Narrative, potentially formatted, content of the whole section.

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

eHN PS Guideline, MyHealth@EU, ISO IPS

Free text notes by the health professional

To present the current health state of the patient with respect to pregnancy and to provide chronological and outcome information about past pregnancies.

eHN PS Guideline, ISO IPS

Narrative, potentially formatted, content of the whole section.

Current state of the pregnancy at the date the observation was made, e.g. pregnant, not pregnant, unknown.

eHN PS Guideline, ISO IPS

Information about previous pregnancies, including outcomes and number of children/fetuses in each pregnancy.

Free text notes by the health professional

Captures relevant information about the patient's recent travel history that may be of clinical relevance — particularly in relation to exposure to infectious diseases, epidemiological risks, or environmental factors. The intent is to support clinical decision-making and risk assessment, especially in contexts such as outbreaks or endemic disease regions.

eHN PS Guideline, ISO IPS

Narrative, potentially formatted, content of the whole section.

Travel history for one country

eHN PS Guideline, ISO IPS

Free text notes by the health professional

A concise narrative from the patient’s perspective about their present health state. This is a record of things that a person feels are important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.

ISO IPS

Free text notes by the health professional

Provision for healthcare decisions if, in the future, a person is unable to make those decisions.

Narrative, potentially formatted, content of the whole section.

Provision for healthcare decisions if, in the future, a person is unable to make those decisions

Free text notes by the health professional

Relevant observation results obtained on the patient. These may be measurements, laboratory results, anatomic pathology results, radiology results or other imaging or clinical results.

Narrative, potentially formatted, content of the whole section.

Observation results pertaining to the subject of care's health condition and which might have impact on future treatments

Free text notes by the health professional

Therapeutic recommendations that do not include pharmacologic treatments, such as diet, physical exercise, planned surgeries

Narrative, potentially formatted, content of the whole section.

Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

Free text notes by the health professional