Back To Index  <<  Back To Scenarios

draft Scenario Patient Summary (PS) 2.16.840.1.113883.3.1937.777.11.3.3

Name Details [‑]
draft Patient Summary (PS)
epsos-scenario-3
Version / effective date 2012‑05‑02
Description The two use cases must be understood as an access to the PS.
  1. an occasional visitor in country B, for example someone on holiday or attending a business meeting. The distinguishing characteristic is that this type of visit is irregular, infrequent, and may not be repeated. This is a type of incidental encounter where the health professional may have no previous record of the person seeking care.
  2. the person is a regular visitor to country B, for example someone who lives in one country but works in another country. The distinguishing characteristic is that this type of visit is regular, frequent, and the person seeking care may be accustomed to using services in the country where he or she works as a matter of personal convenience. This is a type of occasional situation where the health professional may have some information available from previous encounters, therefore the patient could have a medical record locally stored in country B, and maybe a PS in country B plus in country A. If this is the case, both PSs should be available for the HP to be consulted.
draft doublearrow Request PS/Return PS
epsos-transactions-1link
Version / effective date 2012‑05‑02    
You need SVG support in your browser for this image
Description HP B requests the PS from HP A
draft arrowright Request PS of country A
epsos-transactions-11link
Version / effective date 2012‑05‑02    
Description Please note that requesting something comes down to an IHE XCF/XCA Request. This is not modelled in this specification. Refer to the IHE Profile for details. Once the identity of the patient is validated, the HP of country B requests, with the consent of the patient (FR04), the PS of country A that can be visualized by HP interface
Trigger Consult PS of country A
Dependencies Patient is identified, and has given consent
Actor
Sender (organization) HP B
Receiver (organization) HP A
Associations
Contained concepts
Concept Card/Conf Id
folder Patient Data
0 … *
epsos-dataelement-5link
Information about the patient
treetree folder Identification
0 … *
epsos-dataelement-6link
Country ID, unique for the patient in that country. Example: ID for United Kingdom patient
treeblank treetree draft  National Health Care patient ID (country of affiliation)
0 … *
epsos-dataelement-7link
Country ID from the country of origin, unique for the patient in that country. Example: ID for United Kingdom patient
treetree folder Personal Information
0 … *
epsos-dataelement-8link
Personal information about the patient
treeblank treetree folder Full Name
0 … *
epsos-dataelement-9link
The full name of the patient
treeblank treeblank treetree draft  Given name
0 … *
epsos-dataelement-12link
The Name of the patient (Example: John). This field can contain more than one element
treeblank treeblank treetree draft  Family Name/Surname
0 … *
epsos-dataelement-13link
This field can containe more than one element.
treeblank treetree draft  Date of Birth
0 … *
epsos-dataelement-10link
The date of birth of the patient. This field may contain only the year if day and month are not available
treeblank treetree draft  Gender
0 … *
epsos-dataelement-11link
It must contained a recognized valid value for this field.
folder Document Data
0 … 1
epsos-dataelement-62link
Information about the document itself
treetree draft  Type
1 … 1
epsos-dataelement-296link
Type of the document
draft arrowleft Return PS of country A
epsos-transactions-12link
Version / effective date 2012‑05‑02    
Model ClinicalDocument Label PatientSummary
Description HP A responds by sending the PS to HP B
Actor
Sender (organization) HP A
Receiver (organization) HP B
Associations
Contained concepts
Concept Card/Conf Id
folder Patient Data
1 … 1 Mandatory
epsos-dataelement-5link
Information about the patient
treetree folder Identification
1 … 1 Mandatory
epsos-dataelement-6link
Country ID, unique for the patient in that country. Example: ID for United Kingdom patient
treeblank treetree draft  National Health Care patient ID (country of affiliation)
1 … 1 Mandatory
epsos-dataelement-7link
Country ID from the country of origin, unique for the patient in that country. Example: ID for United Kingdom patient
treeblank treetree draft  National Health Care patient ID (country of treatment)
0 … 0 Not present
epsos-dataelement-234link
Country ID given in the country of treatment, unique for the patient in that country. Identifier that identifies that patient within the country B eHealth Infrastructure.
treeblank treetree draft  Other Identifier
0 … *
epsos-dataelement-235link
Other identifiers than the national health care patient IDs from either the country of affiliation or the country of treatment
treetree folder Personal Information
1 … 1 Mandatory
epsos-dataelement-8link
Personal information about the patient
treeblank treetree folder Full Name
1 … 1 Mandatory
epsos-dataelement-9link
The full name of the patient
treeblank treeblank treetree draft  Given name
1 … 1 Mandatory
epsos-dataelement-12link
The Name of the patient (Example: John). This field can contain more than one element
treeblank treeblank treetree draft  Family Name/Surname
1 … 1 Mandatory
epsos-dataelement-13link
This field can containe more than one element.
treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-263link
treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-264link
treeblank treetree draft  Date of Birth
1 … 1 Mandatory
epsos-dataelement-10link
The date of birth of the patient. This field may contain only the year if day and month are not available
treeblank treetree draft  Gender
0 … 1
epsos-dataelement-11link
It must contained a recognized valid value for this field.
treetree folder Contact Information
0 … *
epsos-dataelement-26link
Contact information of the patient, including information of the contacts of the patient.
treeblank treetree folder Address
0 … *
epsos-dataelement-27link
Address of the patient
treeblank treeblank treetree draft  Street
0 … 1
epsos-dataelement-51link
Name of street where the patient lives
treeblank treeblank treetree draft  Number of Street
0 … 1
epsos-dataelement-52link
House number where the patient lives
treeblank treeblank treetree draft  City
0 … 1
epsos-dataelement-55link
City where the patient lives
treeblank treeblank treetree draft  Postal Code
0 … 1
epsos-dataelement-53link
Postal code where the patient lives
treeblank treeblank treetree draft  State or Province
0 … 1
epsos-dataelement-56link
State or province where the patient lives
treeblank treeblank treetree draft  Country
0 … 1
epsos-dataelement-54link
Country where the patient lives
treeblank treetree folder Telecom
1 … * Required
epsos-dataelement-300link
Telecommunication addresses of the patient
treeblank treeblank treetree draft  Telephone No
0 … *
epsos-dataelement-28link
Telephone number of the patient
treeblank treeblank treetree draft  Email
0 … *
epsos-dataelement-29link
Email address of the patient
treeblank treetree folder Preferred HP to contact
0 … 1
epsos-dataelement-30link
Preferred Health Professional to contact. A foreign HP may need a contact (HP/legal organization) who knows the patient
treeblank treeblank treetree folder Full Name
0 … 1
epsos-dataelement-46link
Name of the HP/name of the legal organization. If it is an HP, the structure of the name will be the same as described in ‘Full name’ (Given name, family name/surname)
treeblank treeblank treeblank treetree draft  Given Name
0 … 1
epsos-dataelement-47link
The Name of the HP (Example: John). This field can contain more than one element
treeblank treeblank treeblank treetree draft  Family Name/Surname
0 … 1
epsos-dataelement-48link
This field can contain more than one element.
treeblank treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-265link
treeblank treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-266link
treeblank treeblank treetree draft  Telephone No
0 … *
epsos-dataelement-41link
Telephone number of the HP/name of the legal organization
treeblank treeblank treetree draft  Email
0 … *
epsos-dataelement-43link
Email address of the HP/name of the legal organization
treeblank treetree folder Legal Organization to contact
0 … 1
epsos-dataelement-31link
Legal organization to contact about patient. A foreign HP may need a contact (HP/legal organization) who knows the patient
treeblank treeblank treetree draft  Organization Name
0 … 1
epsos-dataelement-33link
Name of the organization
treeblank treeblank treetree draft  Telephone No
0 … *
epsos-dataelement-49link
Telephone number of the organization
treeblank treeblank treetree draft  Email
0 … *
epsos-dataelement-50link
Email address of the organization
treeblank treetree folder Contact Person/legal guardian
0 … *
epsos-dataelement-34link
Contact or guardian of the patient
treeblank treeblank treetree draft  Role of that person
0 … 1
epsos-dataelement-35link
The role of the person: contact person or legal guardian
treeblank treeblank treetree folder Full Name
0 … 1
epsos-dataelement-36link
Full name of the contact person or guardian
treeblank treeblank treeblank treetree draft  Given Name
0 … 1
epsos-dataelement-37link
The Name of the person (Example: John). This field can contain more than one element
treeblank treeblank treeblank treetree draft  Family Name/Surname
0 … 1
epsos-dataelement-38link
This field can contain more than one element.
treeblank treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-267link
treeblank treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-268link
treeblank treeblank treetree draft  Telephone No
0 … *
epsos-dataelement-39link
Telephone number of the person
treeblank treeblank treetree draft  Email
0 … *
epsos-dataelement-40link
Email address of the person
treetree folder Insurance Information
0 … 1
epsos-dataelement-14link
Information about the insurance of the patient
treeblank treetree draft  Insurance Number
0 … 1
epsos-dataelement-15link
European Health Insurance Code (EHIC) number of the patient
folder Clinical Data
0 … *
epsos-dataelement-16link
Clinical information of the patient
treetree folder Alerts
0 … *
epsos-dataelement-197link
treeblank treetree folder Allergy
0 … *
epsos-dataelement-204link
Allergies and intolerances
treeblank treeblank treetree draft  Allergy description
0 … 1
epsos-dataelement-205link
Description of the clinical manifestation of the allergy reaction. Example: Anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction)
treeblank treeblank treetree draft  Allergy code
0 … 1
epsos-dataelement-206link
The code of the allergy
treeblank treeblank treetree draft  Onset Date
0 … 1
epsos-dataelement-207link
Date when the allergy started
treeblank treeblank treetree draft  Agent description
0 … 1
epsos-dataelement-208link
Describes the agent (drug, food, chemical agent, etc) that is responsible for the adverse reaction
treeblank treeblank treetree draft  Agent Code
0 … 1
epsos-dataelement-209link
The code of the allergen agent
treeblank treetree folder Medical Alert Information
0 … *
epsos-dataelement-214link
Other alerts not included in allergies
treeblank treeblank treetree draft  Health Care Alert code
0 … 1
epsos-dataelement-216link
The code of the health care alert
treeblank treeblank treetree draft  Health Care Alert description
0 … 1
epsos-dataelement-215link
Medical Alert Information: any other clinical information that is imperative to know so that the life or health of the patient does not come under threat
treetree folder History of Past Illness
0 … *
epsos-dataelement-192link
treeblank treetree folder Problem/Diagnosis
0 … *
epsos-dataelement-222link
treeblank treeblank treetree draft  Problem/diagnosis Description
0 … 1
epsos-dataelement-223link
Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
treeblank treeblank treetree draft  Problem/diagnosis Id (Code)
0 … 1
epsos-dataelement-224link
Normalized identifier
treeblank treeblank treetree draft  Problem Status
0 … 1
epsos-dataelement-306link
treeblank treeblank treetree draft  Problem Severity
0 … 1
epsos-dataelement-302link
treeblank treeblank treetree draft  Onset Time
0 … 1
epsos-dataelement-225link
Date of problem onset
treeblank treeblank treetree draft  End date
0 … 1
epsos-dataelement-226link
Problem resolution date
treeblank treeblank treetree draft  Resolution Circumstances
0 … 1
epsos-dataelement-227link
Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
treeblank treetree folder Vaccination
0 … *
epsos-dataelement-217link
treeblank treeblank treetree draft  Vaccine brand name
0 … 1
epsos-dataelement-218link
Brand name of the vaccination
treeblank treeblank treetree draft  Vaccine description
0 … 1
epsos-dataelement-219link
Description of the vaccine
treeblank treeblank treetree draft  Vaccine code
0 … 1
epsos-dataelement-220link
The code of the vaccine
treeblank treeblank treetree draft  Vaccination date
0 … 1
epsos-dataelement-221link
The date the vaccination was done
treeblank treetree folder Surgical Procedure
0 … *
epsos-dataelement-210link
treeblank treeblank treetree draft  Procedure description
0 … 1
epsos-dataelement-211link
Describes the type of procedure that has been executed as part of the healthcare event.
treeblank treeblank treetree draft  Procedure Id (code)
0 … 1
epsos-dataelement-212link
Normalized identifier
treeblank treeblank treetree draft  Procedure Date
0 … 1
epsos-dataelement-213link
Date when procedure was performed
treetree folder Medical Problems
0 … *
epsos-dataelement-82link
treeblank treetree folder Problem/Diagnosis
0 … *
epsos-dataelement-228link
treeblank treeblank treetree draft  Problem/diagnosis Description
0 … 1
epsos-dataelement-229link
Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
treeblank treeblank treetree draft  Problem/diagnosis Id (Code)
0 … 1
epsos-dataelement-230link
Normalized identifier
treeblank treeblank treetree draft  Problem Status
0 … 1
epsos-dataelement-307link
treeblank treeblank treetree draft  Problem Severity
0 … 1
epsos-dataelement-303link
treeblank treeblank treetree draft  Onset Time
0 … 1
epsos-dataelement-231link
Date of problem onset
treeblank treeblank treetree draft  End date
0 … 1
epsos-dataelement-232link
Problem resolution date
treeblank treeblank treetree draft  Resolution Circumstances
0 … 1
epsos-dataelement-233link
Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
treeblank treetree folder Surgical Procedure
0 … *
epsos-dataelement-188link
treeblank treeblank treetree draft  Procedure description
0 … 1
epsos-dataelement-189link
Describes the type of procedure that has been executed as part of the healthcare event.
treeblank treeblank treetree draft  Procedure Id (code)
0 … 1
epsos-dataelement-190link
Normalized identifier
treeblank treeblank treetree draft  Procedure Date
0 … 1
epsos-dataelement-191link
Date when procedure was performed
treeblank treetree folder Medical Devices and Implants
0 … *
epsos-dataelement-87link
treeblank treeblank treetree draft  Medical Devices and Implants Description
0 … 1
epsos-dataelement-88link
Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices as cardiac pacemakers, implantable defribillator, prothesis, feromagnetic bone implants etc that are important to be known by HP.
treeblank treeblank treetree draft  Device Code
0 … 1
epsos-dataelement-89link
Normalized identifier
treeblank treeblank treetree draft  Implant Date
0 … 1
epsos-dataelement-90link
treeblank treetree folder Treatments
0 … *
epsos-dataelement-128link
treeblank treeblank treetree draft  Treatment description
0 … 1
epsos-dataelement-129link
Therapeutic treatment that does not include drugs (diet, physical excersize constraints etc)
treeblank treeblank treetree draft  Treatment code
0 … 1
epsos-dataelement-130link
normalized identifier, concept code
treeblank treeblank treetree draft  Onset time
0 … 1
epsos-dataelement-131link
Date of treatment onset
treeblank treetree folder Care plan
0 … *
epsos-dataelement-95link
treeblank treeblank treetree draft  Recommendations Description
0 … 1
epsos-dataelement-96link
Therapeutic recommendations that do not include drugs (diet, physical exercise constraints, etc.)
treeblank treeblank treetree draft  Recommendations Id (code)
0 … 1
epsos-dataelement-97link
Normalized identifier
treeblank treetree folder Disability or function
0 … *
epsos-dataelement-98link
treeblank treeblank treetree draft  Invalidity description
0 … 1
epsos-dataelement-99link
Need of the patient to be continuously assisted by third parties. Invalidity status may influence decisions about how to administer treatments
treeblank treeblank treetree draft  Onset time
0 … 1
epsos-dataelement-132link
Date of invalidity onset
treetree folder Medication
0 … 1
epsos-dataelement-101link
treeblank treetree folder Prescription
0 … *
epsos-dataelement-102link
treeblank treeblank treetree draft  Prescription identification
1 … 1 Mandatory
epsos-dataelement-134link
Unique identification of the prescription
treeblank treeblank treetree draft  Medicinal product code
0 … 1 Required
epsos-dataelement-135link
Code that identifies the medicinal product description
treeblank treeblank treetree draft  Date of issue of prescription
1 … 1 Mandatory
epsos-dataelement-136link
Date when medicine has been prescribed
treeblank treeblank treetree draft  Brand name
1 … 1 Required
epsos-dataelement-137link
Original brand name of the medicine (in the language of the country in which the prescription was made)
treeblank treeblank treetree draft  Active ingredient
1 … * Required
epsos-dataelement-103link
Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product.
treeblank treeblank treetree draft  Active ingredient code
1 … * Mandatory
epsos-dataelement-104link
Code that identifies the Active ingredient
treeblank treeblank treetree draft  Strength
1 … * Mandatory
epsos-dataelement-105link
The content of the active ingredient expressed quantitatively per dosage unit, per unit of volume or per unit of weight, according to the pharmaceutical dose form. Example: 500 mg per tablet
treeblank treeblank treetree draft  Medicinal product package size
1 … 1 Required
epsos-dataelement-138link
The size of the package prescribed
treeblank treeblank treetree draft  Pharmaceutical dose form
1 … 1 Mandatory
epsos-dataelement-106link
It is the form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablets, syrup)
treeblank treeblank treetree draft  Number of packages
1 … 1 Required
epsos-dataelement-139link
Number of boxes that have been prescribed
treeblank treeblank treetree draft  Number of units per intake
1 … 1 Required
epsos-dataelement-107link
The number of units per intake that the patient is taking (e.g. 1 tablet)
treeblank treeblank treetree draft  Frequency of intakes
1 … * Required
epsos-dataelement-108link
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
treeblank treeblank treetree draft  Duration of treatment
1 … 1 Required
epsos-dataelement-109link
treeblank treeblank treetree draft  Date of onset of treatment
1 … 1 Required
epsos-dataelement-110link
Date when patient needs to start taking the medicine prescribed
treeblank treeblank treetree draft  Route of administration
0 … 1 Required
epsos-dataelement-140link

Indicates the part of the body through or into which, or the way in which, the medicinal product is intended to be introduced. In some cases a medicinal product can be intended for more than one route and/or method of administration.

NOTE FOR GUIDANCE ON DATA ELEMENTS AND STANDARDS FOR DRUG DICTIONARIES

(EMEA/CHMP/ICH/168535/2005)
treeblank treeblank treetree draft  Instructions to patient
0 … 1 Required
epsos-dataelement-141link
The prescriber might give to the patient instructions; They must be presented in the original language.
treeblank treeblank treetree draft  Advice to dispenser
0 … 1
epsos-dataelement-142link
The prescriber might give instructions to the dispenser. The information will be in the original language as automatic translation is not secure enough. To avoid legal and ethical issues to the dispenser, it should be wise to implement an option that allows the dispenser to decide, knowing that this data is available, whether he wants to consult it or not.
treeblank treeblank treetree folder Prescriber
0 … 1
epsos-dataelement-236link
treeblank treeblank treeblank treetree draft  Prescriber Profession
0 … 1
epsos-dataelement-237link
treeblank treeblank treeblank treetree draft  Prescriber Speciality
0 … 1
epsos-dataelement-238link
Some countries need the specialty of the prescriber for the epSOS ePrescription to be seen as valid. In the epSOS phase 1 ePrescription data set, this element is not basic (minimum), therefore not always filled in. The proposal is to define the specialty of the prescriber as a basic element, so it should be filled in, if available. As it could be that this information is not available in every country, null values should be allowed.
treeblank treeblank treeblank treetree draft  Timestamp of Prescribing
0 … 1
epsos-dataelement-239link
Date/time the medication was prescribed
treeblank treeblank treeblank treetree draft  Prescriber Identification
0 … 1
epsos-dataelement-240link
Unique identification of the prescriber
treeblank treeblank treeblank treetree folder Prescriber Full Name
0 … 1
epsos-dataelement-241link
The full name of the Health Professional
treeblank treeblank treeblank treeblank treetree draft  Given Name
0 … 1
epsos-dataelement-242link
The Name of the Prescriber (Example: John). This field can contain more than one element
treeblank treeblank treeblank treeblank treetree draft  Family Name/Surname
0 … 1
epsos-dataelement-243link
This field can contain more than one element.
treeblank treeblank treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-269link
treeblank treeblank treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-270link
treeblank treeblank treeblank treetree folder Prescriber Telecom
0 … *
epsos-dataelement-282link
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-280link
treeblank treeblank treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-281link
treeblank treeblank treeblank treetree folder Prescriber Healthcare Facility
0 … 1
epsos-dataelement-244link
Information about the healthcare facility where the health professional works
treeblank treeblank treeblank treeblank treetree draft  Identifier
0 … 1
epsos-dataelement-245link
Unique identification of the healthcare facility
treeblank treeblank treeblank treeblank treetree draft  Name
0 … 1
epsos-dataelement-246link
Name of the healthcare facility
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0 … *
epsos-dataelement-283link
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-278link
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-279link
treeblank treeblank treeblank treetree folder Prescriber Credentialing Organization
0 … *
epsos-dataelement-290link
The organization which provided the credentialing for the prescriber
treeblank treeblank treeblank treeblank treetree draft  Identifier
0 … 1
epsos-dataelement-291link
Unique identification of the organization which provided the credentialing for the prescriber
treeblank treeblank treeblank treeblank treetree draft  Name
0 … 1
epsos-dataelement-292link
The name of the organization which provided the credentialing for the prescriber
treetree folder Surgical Procedure
0 … *
epsos-dataelement-1link
treeblank treetree draft  Procedure description
0 … 1
epsos-dataelement-3link
Describes the type of procedure that has been executed as part of the healthcare event.
treeblank treetree draft  Procedure Id (code)
0 … 1
epsos-dataelement-2link
Normalized identifier
treeblank treetree draft  Procedure Date
0 … 1
epsos-dataelement-4link
Date when procedure was performed
treetree folder Problem/Diagnosis
0 … *
epsos-dataelement-83link
treeblank treetree draft  Problem/diagnosis Description
0 … 1
epsos-dataelement-84link
Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
treeblank treetree draft  Problem/diagnosis Id (Code)
0 … 1
epsos-dataelement-85link
Normalized identifier
treeblank treetree draft  Problem Status
0 … 1
epsos-dataelement-305link
treeblank treetree draft  Problem Severity
0 … 1
epsos-dataelement-301link
treeblank treetree draft  Onset Time
0 … 1
epsos-dataelement-86link
Date of problem onset
treeblank treetree draft  End date
0 … 1
epsos-dataelement-174link
Problem resolution date
treeblank treetree draft  Resolution Circumstances
0 … 1
epsos-dataelement-175link
Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
treetree folder Physical Findings
0 … *
epsos-dataelement-117link
treeblank treetree folder Vital Signs Observations
0 … *
epsos-dataelement-118link
treeblank treeblank treetree folder Blood Pressure
0 … *
epsos-dataelement-119link
One value of blood pressure which includes: systolic Blood Pressure and Diastolic Blood pressure
treeblank treeblank treeblank treetree draft  Systolic Blood Pressure
0 … 1
epsos-dataelement-120link
treeblank treeblank treeblank treetree draft  Diastolic Blood Pressure
0 … 1
epsos-dataelement-121link
treeblank treeblank treetree draft  Date when blood pressure was measured
0 … 1
epsos-dataelement-122link
Date when blood pressure was measured
treetree folder Diagnostic Tests
0 … *
epsos-dataelement-123link
treeblank treetree folder Blood Group
0 … 1
epsos-dataelement-124link
treeblank treeblank treetree draft  Result of Blood Group
0 … 1
epsos-dataelement-125link
Result from the blood group test made to the patient
treeblank treeblank treetree draft  Date
0 … 1
epsos-dataelement-126link
Date in which the blood group test was done. This field may contain only the year if day and month are not available. Eg: 01/01/2009
treetree folder Vaccination
0 … *
epsos-dataelement-167link
treeblank treetree draft  Vaccine brand name
0 … 1
epsos-dataelement-168link
Brand name of the vaccination
treeblank treetree draft  Vaccine description
0 … 1
epsos-dataelement-171link
Description of the vaccine
treeblank treetree draft  Vaccine code
0 … 1
epsos-dataelement-170link
The code of the vaccine
treeblank treetree draft  Vaccination date
0 … 1
epsos-dataelement-169link
The date the vaccination was done
treetree folder Allergy
0 … *
epsos-dataelement-58link
Allergies and intolerances
treeblank treetree draft  Allergy description
0 … 1
epsos-dataelement-68link
Description of the clinical manifestation of the allergy reaction. Example: Anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction)
treeblank treetree draft  Allergy code
0 … 1
epsos-dataelement-69link
The code of the allergy
treeblank treetree draft  Allergy Severity
0 … 1
epsos-dataelement-304link
treeblank treetree draft  Onset Date
0 … 1
epsos-dataelement-70link
Date when the allergy started
treeblank treetree draft  Agent description
0 … 1
epsos-dataelement-71link
Describes the agent (drug, food, chemical agent, etc) that is responsible for the adverse reaction
treeblank treetree draft  Agent Code
0 … 1
epsos-dataelement-72link
The code of the allergen agent
treetree folder Pregnancy History
0 … *
epsos-dataelement-115link
treeblank treetree draft  Expected date of delivery
0 … 1
epsos-dataelement-116link
Date in which the woman is due to give birth. Year, day and month are required.
treetree folder Social History
0 … *
epsos-dataelement-111link
treeblank treetree folder Social History Observations
0 … *
epsos-dataelement-112link
treeblank treeblank treetree draft  Social History Observations related to: smoke, alcohol and diet
0 … 1
epsos-dataelement-113link
treeblank treeblank treetree draft  Date range of observation
0 … 1
epsos-dataelement-114link
folder Document Data
1 … 1 Mandatory
epsos-dataelement-62link
Information about the document itself
treetree draft  Identification
1 … 1 Mandatory
epsos-dataelement-176link
Identification of the document
treetree draft  Type
1 … 1 Mandatory
epsos-dataelement-296link
Type of the document
treetree draft  Confidentiality
0 … 1 Required
epsos-dataelement-297link
Confidentiality of the document as a whole
treetree draft  Language
1 … 1 Mandatory
epsos-dataelement-298link
The principal language of the documentThe language code SHALL be in the form nn-CC. The nn portion SHALL be an ISO-639-1 language code in lower case derived by the Value Set epSOSLanguage. The CC portion SHALL be an ISO-3166 country code in upper case derived by the value Set epSOSCountry
treetree draft  Country A
1 … 1 Mandatory
epsos-dataelement-63link
Name of country A
treetree folder Topicality
1 … 1 Mandatory
epsos-dataelement-64link
treeblank treetree draft  Date Created
1 … 1 Mandatory
epsos-dataelement-65link
Date on which the document was generated
treetree folder Author
0 … 1
epsos-dataelement-67link
To highlight if the data is collected manually by an HP or is collected automatically from different sources (eg: hospital doctor repository, GPs...etc) through predetermined clinical rules.
treeblank treetree draft  Author Identification
1 … 1 Mandatory
epsos-dataelement-22link
Unique identification of the Health Professional.
treeblank treetree folder Author Full Name
1 … 1 Mandatory
epsos-dataelement-19link
The full name of the Health Professional
treeblank treeblank treetree draft  Given Name
1 … 1 Mandatory
epsos-dataelement-20link
The Name of the HP (Example: John). This field can contain more than one element
treeblank treeblank treetree draft  Family Name/Surname
1 … 1 Mandatory
epsos-dataelement-21link
This field can contain more than one element.
treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-273link
treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-274link
treeblank treetree folder Author Healthcare Facility
0 … 1
epsos-dataelement-23link
Information about the healthcare facility where the health professional works
treeblank treeblank treetree draft  Identifier
1 … 1 Mandatory
epsos-dataelement-25link
Unique identification of the healthcare facility
treeblank treeblank treetree draft  Name
1 … 1 Mandatory
epsos-dataelement-24link
Name of the healthcare facility