DECOR Information for Project: epSOS (epsos-)

Scenarios

draft ePrescription (eP) 2013‑11‑02

Name Id
ePrescription (eP) epsos-scenario-1
doublearrow Transaction group id: epsos-transactions-17
Status draft Draft
Version / effective date 2013‑11‑02
Name Request eP/Receive eP
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Content
arrowright Transaction id: epsos-transactions-18
Status draft Draft
Version / effective date 2013‑11‑02
Name Request eP from country A
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
Actor - Sender (organization)
Name HP B
Description Health Care Provider B
Actor - Receiver (organization)
Name HP A
Description Health Care Provider A
Representing template
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
0..* epsos-dataelement-5
Information about the patient
 
treetree folder Identification
0..* epsos-dataelement-6
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-7
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-8
Personal information about the patient
 
treeblank treetree folder Full Name
0..* epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
0..* epsos-dataelement-12
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-13
This field can containe more than one element.
 
treeblank treetree draft  Date of Birth
0..* epsos-dataelement-10
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-11
It must contained a recognized valid value for this field.
 
folder Document Data
0..1 epsos-dataelement-62
Information about the document itself
 
treetree draft  Type
1..1 epsos-dataelement-296
Type of the document
 
arrowleft Transaction id: epsos-transactions-19
Status draft Draft
Version / effective date 2013‑11‑02
Name Return eP from country A
Model ClinicalDocument 
Label ePrescription 
Actor - Sender (organization)
Name HP A
Description Health Care Provider A
Actor - Receiver (organization)
Name HP B
Description Health Care Provider B
Representing template
Template epSOS-ePrescription (1.3.6.1.4.1.12559.11.10.1.3.1.1.1 / 2013‑12‑20)
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
0..1 epsos-dataelement-5
Information about the patient
 
treetree folder Identification
1..1 Mandatory epsos-dataelement-6
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-7
Country ID from the country of origin, unique for the patient in that country. Example: ID for United Kingdom patient
 
treeblank treetree draft  Other Identifier
0..* epsos-dataelement-235
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 Required epsos-dataelement-8
Personal information about the patient
 
treeblank treetree folder Full Name
1..1 Required epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
1..1 Required epsos-dataelement-12
The Name of the patient (Example: John). This field can contain more than one element
 
treeblank treeblank treetree draft  Family Name/Surname
1..1 Required epsos-dataelement-13
This field can containe more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-263
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-264
 
treeblank treetree draft  Date of Birth
1..1 Required epsos-dataelement-10
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
1..1 Required epsos-dataelement-11
It must contained a recognized valid value for this field.
 
treetree folder Contact Information
0..* epsos-dataelement-26
Contact information of the patient, including information of the contacts of the patient.
 
treeblank treetree folder Address
0..* epsos-dataelement-27
Address of the patient
 
treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-51
Name of street where the patient lives
 
treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-52
House number where the patient lives
 
treeblank treeblank treetree draft  City
0..1 epsos-dataelement-55
City where the patient lives
 
treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-53
Postal code where the patient lives
 
treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-56
State or province where the patient lives
 
treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-54
Country where the patient lives
 
treeblank treetree folder Telecom
1..* Required epsos-dataelement-300
Telecommunication addresses of the patient
 
treeblank treeblank treetree draft  Telephone No
0..* epsos-dataelement-28
Telephone number of the patient
 
treeblank treeblank treetree draft  Email
0..* epsos-dataelement-29
Email address of the patient
 
treeblank treetree folder Preferred HP to contact
0..1 epsos-dataelement-30
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
1..1 Mandatory epsos-dataelement-46
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
Conditional epsos-dataelement-47
The Name of the HP (Example: John). This field can contain more than one element
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Family Name/Surname
Conditional epsos-dataelement-48
This field can contain more than one element.
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Prefix
Conditional epsos-dataelement-265
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Suffix
Conditional epsos-dataelement-266
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Telephone No
1..* Required epsos-dataelement-41
Telephone number of the HP/name of the legal organization
 
treeblank treeblank treetree draft  Email
1..* Required epsos-dataelement-43
Email address of the HP/name of the legal organization
 
folder Clinical Data
0..* epsos-dataelement-16
Clinical information of the patient
 
treetree folder Medication
0..1 epsos-dataelement-101
 
treeblank treetree folder Prescription
0..* epsos-dataelement-102
 
treeblank treeblank treetree draft  Prescription identification
1..1 Mandatory epsos-dataelement-134
Unique identification of the prescription
 
treeblank treeblank treetree draft  Medicinal product code
0..1 Required epsos-dataelement-135
Code that identifies the medicinal product description
 
treeblank treeblank treetree draft  Date of issue of prescription
1..1 Mandatory epsos-dataelement-136
Date when medicine has been prescribed
 
treeblank treeblank treetree draft  Brand name
1..1 Required epsos-dataelement-137
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..* Mandatory epsos-dataelement-103
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-104
Code that identifies the Active ingredient
 
treeblank treeblank treetree draft  Strength
1..* Mandatory epsos-dataelement-105
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-138
The size of the package prescribed
 
treeblank treeblank treetree draft  Pharmaceutical dose form
1..1 Mandatory epsos-dataelement-106
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-139
Number of boxes that have been prescribed
 
treeblank treeblank treetree draft  Number of units per intake
1..1 Required epsos-dataelement-107
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-108
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
 
treeblank treeblank treetree draft  Duration of treatment
1..1 Required epsos-dataelement-109
 
treeblank treeblank treetree draft  Date of onset of treatment
1..1 Required epsos-dataelement-110
Date when patient needs to start taking the medicine prescribed
 
treeblank treeblank treetree draft  Route of administration
0..1 Required epsos-dataelement-140

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-141
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-142
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-236
 
treeblank treeblank treeblank treetree draft  Prescriber Profession
0..1 epsos-dataelement-237
 
treeblank treeblank treeblank treetree draft  Prescriber Speciality
0..* epsos-dataelement-238
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-239
Date/time the medication was prescribed
 
treeblank treeblank treeblank treetree draft  Prescriber Identification
0..1 epsos-dataelement-240
Unique identification of the prescriber
 
treeblank treeblank treeblank treetree folder Prescriber Full Name
0..1 epsos-dataelement-241
The full name of the Health Professional
 
treeblank treeblank treeblank treeblank treetree draft  Given Name
0..1 epsos-dataelement-242
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-243
This field can contain more than one element.
 
treeblank treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-269
 
treeblank treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-270
 
treeblank treeblank treeblank treetree folder Prescriber Telecom
0..* epsos-dataelement-282
 
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-280
 
treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-281
 
treeblank treeblank treeblank treetree folder Prescriber Healthcare Facility
0..1 epsos-dataelement-244
Information about the healthcare facility where the health professional works
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-245
Unique identification of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-246
Name of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0..* epsos-dataelement-283
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-278
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-279
 
treeblank treeblank treeblank treetree folder Prescriber Credentialing Organization
0..1 epsos-dataelement-290
The organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-291
Unique identification of the organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-292
The name of the organization which provided the credentialing for the prescriber
 
folder Document Data
1..1 Mandatory epsos-dataelement-62
Information about the document itself
 
treetree draft  Identification
1..1 Mandatory epsos-dataelement-176
Identification of the document
 
treetree draft  Type
1..1 Mandatory epsos-dataelement-296
Type of the document
 
treetree draft  Confidentiality
0..1 Required epsos-dataelement-297
Confidentiality of the document as a whole
 
treetree draft  Language
1..1 Mandatory epsos-dataelement-298
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-63
Name of country A
 
treetree folder Topicality
1..1 Mandatory epsos-dataelement-64
 
treeblank treetree draft  Date Created
1..1 Mandatory epsos-dataelement-65
Date on which the document was generated
 
treetree folder Author
0..1 epsos-dataelement-67
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-22
Unique identification of the Health Professional.
 
treeblank treetree folder Author Full Name
1..1 Mandatory epsos-dataelement-19
The full name of the Health Professional
 
treeblank treeblank treetree draft  Given Name
1..1 Mandatory epsos-dataelement-20
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-21
This field can contain more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-273
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-274
 
treeblank treetree folder Author Healthcare Facility
0..1 epsos-dataelement-23
Information about the healthcare facility where the health professional works
 
treeblank treeblank treetree draft  Identifier
1..1 Mandatory epsos-dataelement-25
Unique identification of the healthcare facility
 
treeblank treeblank treetree draft  Name
1..1 Mandatory epsos-dataelement-24
Name of the healthcare facility
 

draft eDispensation (eD) 2013‑11‑02

Name Id
eDispensation (eD) epsos-scenario-2
doublearrow Transaction group id: epsos-transactions-24
Status draft Draft
Version / effective date 2013‑11‑02
Name Send eD/Receive ACK
You need SVG support in your browser for this image
Content
arrowright Transaction id: epsos-transactions-25
Status draft Draft
Version / effective date 2013‑11‑02
Name Send eD to country A
Model ClinicalDocument 
Label eDispensation 
Actor - Sender (organization)
Name HP B
Description Health Care Provider B
Actor - Receiver (organization)
Name HP A
Description Health Care Provider A
Representing template
Template epSOS-eDispensation (1.3.6.1.4.1.12559.11.10.1.3.1.1.2 / 2013‑12‑20)
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
0..1 epsos-dataelement-5
Information about the patient
 
treetree folder Identification
1..1 Mandatory epsos-dataelement-6
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-7
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..1 Required epsos-dataelement-234
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-235
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 Required epsos-dataelement-8
Personal information about the patient
 
treeblank treetree folder Full Name
1..1 Required epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
1..1 Required epsos-dataelement-12
The Name of the patient (Example: John). This field can contain more than one element
 
treeblank treeblank treetree draft  Family Name/Surname
1..1 Required epsos-dataelement-13
This field can containe more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-263
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-264
 
treeblank treetree draft  Date of Birth
1..1 Required epsos-dataelement-10
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
1..1 Required epsos-dataelement-11
It must contained a recognized valid value for this field.
 
treetree folder Contact Information
0..* epsos-dataelement-26
Contact information of the patient, including information of the contacts of the patient.
 
treeblank treetree folder Address
0..* epsos-dataelement-27
Address of the patient
 
treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-51
Name of street where the patient lives
 
treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-52
House number where the patient lives
 
treeblank treeblank treetree draft  City
0..1 epsos-dataelement-55
City where the patient lives
 
treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-53
Postal code where the patient lives
 
treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-56
State or province where the patient lives
 
treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-54
Country where the patient lives
 
treeblank treetree folder Telecom
1..* Required epsos-dataelement-300
Telecommunication addresses of the patient
 
treeblank treeblank treetree draft  Telephone No
0..* epsos-dataelement-28
Telephone number of the patient
 
treeblank treeblank treetree draft  Email
0..* epsos-dataelement-29
Email address of the patient
 
treeblank treetree folder Preferred HP to contact
0..1 epsos-dataelement-30
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
1..1 Mandatory epsos-dataelement-46
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
Conditional epsos-dataelement-47
The Name of the HP (Example: John). This field can contain more than one element
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Family Name/Surname
Conditional epsos-dataelement-48
This field can contain more than one element.
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Prefix
Conditional epsos-dataelement-265
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Suffix
Conditional epsos-dataelement-266
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Telephone No
1..* Required epsos-dataelement-41
Telephone number of the HP/name of the legal organization
 
treeblank treeblank treetree draft  Email
1..* Required epsos-dataelement-43
Email address of the HP/name of the legal organization
 
folder Clinical Data
0..* epsos-dataelement-16
Clinical information of the patient
 
treetree folder Medication
0..1 epsos-dataelement-101
 
treeblank treetree folder Dispense
0..* epsos-dataelement-143
Information about dispensed medication
 
treeblank treeblank treetree draft  Dispense identification
1..1 Mandatory epsos-dataelement-165
Unique identification of the dispensed medication
 
treeblank treeblank treetree draft  Date of issue of dispense
1..1 Required epsos-dataelement-173
Date when the medicine has been dispensed
 
treeblank treeblank treetree draft  Related Prescription
0..1 Required epsos-dataelement-162
The ID of the prescription serving as the basis for the dispensation
 
treeblank treeblank treetree draft  Related Prescription Item
0..1 Required epsos-dataelement-299
Identification of the item or medicine of the related prescription (country A) of the dispensed medicine. One prescription might contain more than one item or medicine. In the country where prescriptions contain just one item, then the prescription ID=Prescription ID item.
 
treeblank treeblank treetree draft  Brand name
0..1 Required epsos-dataelement-172
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..* Mandatory epsos-dataelement-160
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..* Required epsos-dataelement-159
Code that identifies the Active ingredient
 
treeblank treeblank treetree draft  Strength
1..* Mandatory epsos-dataelement-156
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 Mandatory epsos-dataelement-158
The size of the package prescribed
 
treeblank treeblank treetree draft  Pharmaceutical dose form
1..1 Mandatory epsos-dataelement-154
It is the form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablets, syrup)
 
treeblank treeblank treetree draft  Route of administration
0..1 Required epsos-dataelement-153

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  Number of packages
0..1 Required epsos-dataelement-152
Number of boxes that have been prescribed
 
treeblank treeblank treetree draft  Number of units per intake
1..1 Required epsos-dataelement-151
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-150
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
 
treeblank treeblank treetree draft  Substitution
0..1 Required epsos-dataelement-149
 
treeblank treeblank treetree draft  Duration of treatment
0..1 epsos-dataelement-148
 
treeblank treeblank treetree draft  Date of onset of treatment according to prescription
0..1 epsos-dataelement-147
Date when the patient needs to start taking the medicine prescribed
 
treeblank treeblank treetree draft  Validity of prescription
1..1 Required epsos-dataelement-146
Date of the end of the treatment or prescriptions where the end of treatment has expired
 
treeblank treeblank treetree draft  Date of onset of dispense
0..1 epsos-dataelement-145
Date when the patient starts taking the medicine dispensed
 
treeblank treeblank treetree draft  Expected date of end of treatment
0..1 epsos-dataelement-144
Expectation when the patient stops taking the medicine dispensed
 
treeblank treeblank treetree folder Dispenser
0..1 epsos-dataelement-247
 
treeblank treeblank treeblank treetree draft  Timestamp of dispensing
0..1 epsos-dataelement-248
Date/time the medication was dispensed
 
treeblank treeblank treeblank treetree draft  Dispenser Identification
0..1 epsos-dataelement-249
Unique identification of the dispenser
 
treeblank treeblank treeblank treetree folder Dispenser Full Name
0..1 epsos-dataelement-250
 
treeblank treeblank treeblank treeblank treetree draft  Given
0..1 epsos-dataelement-251
 
treeblank treeblank treeblank treeblank treetree draft  Family Name/Surname
0..1 epsos-dataelement-252
 
treeblank treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-271
 
treeblank treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-272
 
treeblank treeblank treeblank treetree folder Dispenser Telecom
0..* epsos-dataelement-287
 
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-288
 
treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-289
 
treeblank treeblank treeblank treetree folder Dispenser Healthcare Facility
0..1 epsos-dataelement-253
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-254
Unique identification of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-255
 
treeblank treeblank treeblank treeblank treetree folder Address
0..1 epsos-dataelement-256
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-257
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-258
 
treeblank treeblank treeblank treeblank treeblank treetree draft  City
0..1 epsos-dataelement-259
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-260
 
treeblank treeblank treeblank treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-261
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-262
 
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0..1 epsos-dataelement-284
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-285
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-286
 
treeblank treeblank treeblank treetree folder Dispenser Credentialing Organization
0..1 epsos-dataelement-293
The organization which provided the credentialing for the dispenser
 
treeblank treeblank treeblank treeblank treetree draft  Identification
0..1 epsos-dataelement-294
Unique identification of the organization which provided the credentialing for the dispenser
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-295
The name of the organization which provided the credentialing for the dispenser
 
folder Document Data
1..1 Mandatory epsos-dataelement-62
Information about the document itself
 
treetree draft  Identification
1..1 Mandatory epsos-dataelement-176
Identification of the document
 
treetree draft  Type
1..1 Mandatory epsos-dataelement-296
Type of the document
 
treetree draft  Confidentiality
0..1 Required epsos-dataelement-297
Confidentiality of the document as a whole
 
treetree draft  Language
1..1 Mandatory epsos-dataelement-298
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 B
1..1 Mandatory epsos-dataelement-179
Name of country B
 
treetree folder Topicality
1..1 Mandatory epsos-dataelement-64
 
treeblank treetree draft  Date Created
1..1 Mandatory epsos-dataelement-65
Date on which the document was generated
 
treetree folder Author
0..1 epsos-dataelement-67
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-22
Unique identification of the Health Professional.
 
treeblank treetree folder Author Full Name
1..1 Mandatory epsos-dataelement-19
The full name of the Health Professional
 
treeblank treeblank treetree draft  Given Name
1..1 Mandatory epsos-dataelement-20
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-21
This field can contain more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-273
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-274
 
treeblank treetree folder Author Healthcare Facility
0..1 epsos-dataelement-23
Information about the healthcare facility where the health professional works
 
treeblank treeblank treetree draft  Identifier
1..1 Mandatory epsos-dataelement-25
Unique identification of the healthcare facility
 
treeblank treeblank treetree draft  Name
1..1 Mandatory epsos-dataelement-24
Name of the healthcare facility
 
arrowleft Transaction id: epsos-transactions-26
Status draft Draft
Version / effective date 2013‑11‑02
Name Respond ACK
Description Please note that acknowledgements come down to an IHE XCF/XCA Response. This is not modelled in this specification. Refer to the IHE Profile for details
Actor - Sender (organization)
Name HP A
Description Health Care Provider A
Actor - Receiver (organization)
Name HP B
Description Health Care Provider B
Representing template
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)

draft Medication Related Overview (MRO) 2013‑11‑02

Name Id
Medication Related Overview (MRO) epsos-scenario-4
doublearrow Transaction group id: epsos-transactions-13
Status draft Draft
Version / effective date 2013‑11‑02
Name Request/Return MRO
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Content
arrowright Transaction id: epsos-transactions-14
Status draft Draft
Version / effective date 2013‑11‑02
Name Request MRO
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
Actor - Sender (organization)
Name HP B
Description Health Care Provider B
Actor - Receiver (organization)
Name HP A
Description Health Care Provider A
Representing template
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
0..* epsos-dataelement-5
Information about the patient
 
treetree folder Identification
0..* epsos-dataelement-6
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-7
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-8
Personal information about the patient
 
treeblank treetree folder Full Name
0..* epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
0..* epsos-dataelement-12
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-13
This field can containe more than one element.
 
treeblank treetree draft  Date of Birth
0..* epsos-dataelement-10
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-11
It must contained a recognized valid value for this field.
 
folder Document Data
0..1 epsos-dataelement-62
Information about the document itself
 
treetree draft  Type
1..1 epsos-dataelement-296
Type of the document
 
arrowleft Transaction id: epsos-transactions-23
Status draft Draft
Version / effective date 2013‑11‑02
Name Return MRO
Model ClinicalDocument 
Label MedicationRelatedOverview 
Actor - Sender (organization)
Name HP A
Description Health Care Provider A
Actor - Receiver (organization)
Name HP B
Description Health Care Provider B
Representing template
Template epSOS-Health Care Encounter Report (1.3.6.1.4.1.12559.11.10.1.3.1.1.4 / 2013‑12‑20)
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
0..1 epsos-dataelement-5
Information about the patient
 
treetree folder Identification
1..1 Mandatory epsos-dataelement-6
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-7
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)
1..1 Mandatory epsos-dataelement-234
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-235
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 Required epsos-dataelement-8
Personal information about the patient
 
treeblank treetree folder Full Name
1..1 Required epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
1..1 Required epsos-dataelement-12
The Name of the patient (Example: John). This field can contain more than one element
 
treeblank treeblank treetree draft  Family Name/Surname
1..1 Required epsos-dataelement-13
This field can containe more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-263
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-264
 
treeblank treetree draft  Date of Birth
1..1 Required epsos-dataelement-10
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
1..1 Required epsos-dataelement-11
It must contained a recognized valid value for this field.
 
treetree folder Contact Information
0..* epsos-dataelement-26
Contact information of the patient, including information of the contacts of the patient.
 
treeblank treetree folder Address
0..* epsos-dataelement-27
Address of the patient
 
treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-51
Name of street where the patient lives
 
treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-52
House number where the patient lives
 
treeblank treeblank treetree draft  City
0..1 epsos-dataelement-55
City where the patient lives
 
treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-53
Postal code where the patient lives
 
treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-56
State or province where the patient lives
 
treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-54
Country where the patient lives
 
treeblank treetree folder Telecom
1..* Required epsos-dataelement-300
Telecommunication addresses of the patient
 
treeblank treeblank treetree draft  Telephone No
0..* epsos-dataelement-28
Telephone number of the patient
 
treeblank treeblank treetree draft  Email
0..* epsos-dataelement-29
Email address of the patient
 
treeblank treetree folder Preferred HP to contact
0..1 epsos-dataelement-30
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
1..1 Mandatory epsos-dataelement-46
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
Conditional epsos-dataelement-47
The Name of the HP (Example: John). This field can contain more than one element
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Family Name/Surname
Conditional epsos-dataelement-48
This field can contain more than one element.
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Prefix
Conditional epsos-dataelement-265
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treeblank treetree draft  Suffix
Conditional epsos-dataelement-266
Condition Card/Conf
If it is an HP 0..1 Required
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Telephone No
1..* Required epsos-dataelement-41
Telephone number of the HP/name of the legal organization
 
treeblank treeblank treetree draft  Email
1..* Required epsos-dataelement-43
Email address of the HP/name of the legal organization
 
folder Clinical Data
0..1 epsos-dataelement-16
Clinical information of the patient
 
treetree folder Medical Problems
0..1 epsos-dataelement-82
 
treeblank treetree folder Problem/Diagnosis
Conditional epsos-dataelement-228
Condition Card/Conf
Current problem/diagnosis 0..*
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Problem/diagnosis Description
1..1 Required epsos-dataelement-229
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)
1..1 Required epsos-dataelement-230
Normalized identifier
 
treeblank treeblank treetree draft  Problem Status
0..1 epsos-dataelement-307
 
treeblank treeblank treetree draft  Problem Severity
0..1 epsos-dataelement-303
 
treeblank treeblank treetree draft  Onset Time
1..1 Required epsos-dataelement-231
Date of problem onset
 
treeblank treetree folder Disability or function
0..* epsos-dataelement-98
 
treeblank treeblank treetree draft  Invalidity description
0..1 Required epsos-dataelement-99
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-132
Date of invalidity onset
 
treetree folder Medication
0..1 epsos-dataelement-101
 
treeblank treetree folder Prescription
Conditional epsos-dataelement-102
Condition Card/Conf
All prescribed medicine whose period of time indicated for the treatment has not yet expired 0..* Required
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Prescription identification
1..1 Mandatory epsos-dataelement-134
Unique identification of the prescription
 
treeblank treeblank treetree draft  Medicinal product code
0..1 Required epsos-dataelement-135
Code that identifies the medicinal product description
 
treeblank treeblank treetree draft  Date of issue of prescription
1..1 Mandatory epsos-dataelement-136
Date when medicine has been prescribed
 
treeblank treeblank treetree draft  Brand name
1..1 Required epsos-dataelement-137
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-103
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-104
Code that identifies the Active ingredient
 
treeblank treeblank treetree draft  Strength
1..* Mandatory epsos-dataelement-105
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-138
The size of the package prescribed
 
treeblank treeblank treetree draft  Pharmaceutical dose form
1..1 Mandatory epsos-dataelement-106
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-139
Number of boxes that have been prescribed
 
treeblank treeblank treetree draft  Number of units per intake
1..1 Required epsos-dataelement-107
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-108
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
 
treeblank treeblank treetree draft  Duration of treatment
1..1 Required epsos-dataelement-109
 
treeblank treeblank treetree draft  Date of onset of treatment
1..1 Required epsos-dataelement-110
Date when patient needs to start taking the medicine prescribed
 
treeblank treeblank treetree draft  Route of administration
0..1 Required epsos-dataelement-140

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-141
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-142
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-236
 
treeblank treeblank treeblank treetree draft  Prescriber Profession
0..1 epsos-dataelement-237
 
treeblank treeblank treeblank treetree draft  Prescriber Speciality
0..1 epsos-dataelement-238
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-239
Date/time the medication was prescribed
 
treeblank treeblank treeblank treetree draft  Prescriber Identification
0..1 epsos-dataelement-240
Unique identification of the prescriber
 
treeblank treeblank treeblank treetree folder Prescriber Full Name
0..1 epsos-dataelement-241
The full name of the Health Professional
 
treeblank treeblank treeblank treeblank treetree draft  Given Name
0..1 epsos-dataelement-242
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-243
This field can contain more than one element.
 
treeblank treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-269
 
treeblank treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-270
 
treeblank treeblank treeblank treetree folder Prescriber Telecom
0..* epsos-dataelement-282
 
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-280
 
treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-281
 
treeblank treeblank treeblank treetree folder Prescriber Healthcare Facility
0..1 epsos-dataelement-244
Information about the healthcare facility where the health professional works
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-245
Unique identification of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-246
Name of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0..* epsos-dataelement-283
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-278
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-279
 
treeblank treeblank treeblank treetree folder Prescriber Credentialing Organization
0..1 epsos-dataelement-290
The organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-291
Unique identification of the organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-292
The name of the organization which provided the credentialing for the prescriber
 
treeblank treetree folder Dispense
0..* epsos-dataelement-143
Information about dispensed medication
 
treeblank treeblank treetree draft  Dispense identification
1..1 Mandatory epsos-dataelement-165
Unique identification of the dispensed medication
 
treeblank treeblank treetree draft  Date of issue of dispense
1..1 Required epsos-dataelement-173
Date when the medicine has been dispensed
 
treeblank treeblank treetree draft  Related Prescription
0..1 Required epsos-dataelement-162
The ID of the prescription serving as the basis for the dispensation
 
treeblank treeblank treetree draft  Related Prescription Item
0..1 Required epsos-dataelement-299
Identification of the item or medicine of the related prescription (country A) of the dispensed medicine. One prescription might contain more than one item or medicine. In the country where prescriptions contain just one item, then the prescription ID=Prescription ID item.
 
treeblank treeblank treetree draft  Brand name
0..1 Required epsos-dataelement-172
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..* Mandatory epsos-dataelement-160
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..* Required epsos-dataelement-159
Code that identifies the Active ingredient
 
treeblank treeblank treetree draft  Strength
1..* Mandatory epsos-dataelement-156
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 Mandatory epsos-dataelement-158
The size of the package prescribed
 
treeblank treeblank treetree draft  Pharmaceutical dose form
1..1 Mandatory epsos-dataelement-154
It is the form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablets, syrup)
 
treeblank treeblank treetree draft  Route of administration
0..1 Required epsos-dataelement-153

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  Number of packages
0..1 Required epsos-dataelement-152
Number of boxes that have been prescribed
 
treeblank treeblank treetree draft  Number of units per intake
1..1 Required epsos-dataelement-151
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-150
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
 
treeblank treeblank treetree draft  Substitution
0..1 Required epsos-dataelement-149
 
treeblank treeblank treetree draft  Duration of treatment
0..1 epsos-dataelement-148
 
treeblank treeblank treetree draft  Date of onset of treatment according to prescription
0..1 epsos-dataelement-147
Date when the patient needs to start taking the medicine prescribed
 
treeblank treeblank treetree draft  Validity of prescription
1..1 Required epsos-dataelement-146
Date of the end of the treatment or prescriptions where the end of treatment has expired
 
treeblank treeblank treetree draft  Date of onset of dispense
0..1 epsos-dataelement-145
Date when the patient starts taking the medicine dispensed
 
treeblank treeblank treetree draft  Expected date of end of treatment
0..1 epsos-dataelement-144
Expectation when the patient stops taking the medicine dispensed
 
treeblank treeblank treetree folder Dispenser
0..1 epsos-dataelement-247
 
treeblank treeblank treeblank treetree draft  Timestamp of dispensing
0..1 epsos-dataelement-248
Date/time the medication was dispensed
 
treeblank treeblank treeblank treetree draft  Dispenser Identification
0..1 epsos-dataelement-249
Unique identification of the dispenser
 
treeblank treeblank treeblank treetree folder Dispenser Full Name
0..* epsos-dataelement-250
 
treeblank treeblank treeblank treeblank treetree draft  Given
0..1 epsos-dataelement-251
 
treeblank treeblank treeblank treeblank treetree draft  Family Name/Surname
0..1 epsos-dataelement-252
 
treeblank treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-271
 
treeblank treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-272
 
treeblank treeblank treeblank treetree folder Dispenser Telecom
0..* epsos-dataelement-287
 
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-288
 
treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-289
 
treeblank treeblank treeblank treetree folder Dispenser Healthcare Facility
0..* epsos-dataelement-253
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-254
Unique identification of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-255
 
treeblank treeblank treeblank treeblank treetree folder Address
0..1 epsos-dataelement-256
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-257
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-258
 
treeblank treeblank treeblank treeblank treeblank treetree draft  City
0..1 epsos-dataelement-259
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-260
 
treeblank treeblank treeblank treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-261
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-262
 
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0..1 epsos-dataelement-284
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-285
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-286
 
treeblank treeblank treeblank treetree folder Dispenser Credentialing Organization
0..* epsos-dataelement-293
The organization which provided the credentialing for the dispenser
 
treeblank treeblank treeblank treeblank treetree draft  Identification
0..1 epsos-dataelement-294
Unique identification of the organization which provided the credentialing for the dispenser
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-295
The name of the organization which provided the credentialing for the dispenser
 
treetree folder Physical Findings
0..* Required epsos-dataelement-117
 
treeblank treetree folder Vital Signs Observations
0..1 epsos-dataelement-118
 
treeblank treeblank treetree folder Blood Pressure
0..1 Required epsos-dataelement-119
One value of blood pressure which includes: systolic Blood Pressure and Diastolic Blood pressure
 
treeblank treeblank treeblank treetree draft  Systolic Blood Pressure
0..1 Required epsos-dataelement-120
 
treeblank treeblank treeblank treetree draft  Diastolic Blood Pressure
0..1 Required epsos-dataelement-121
 
treeblank treeblank treetree draft  Date when blood pressure was measured
0..1 Required epsos-dataelement-122
Date when blood pressure was measured
 
treetree folder Diagnostic Tests
0..* Required epsos-dataelement-123
 
treeblank treetree folder Blood Group
0..1 Required epsos-dataelement-124
 
treeblank treeblank treetree draft  Result of Blood Group
0..1 Required epsos-dataelement-125
Result from the blood group test made to the patient
 
treeblank treeblank treetree draft  Date
0..1 Required epsos-dataelement-126
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..* Required epsos-dataelement-167
 
treeblank treetree draft  Vaccine brand name
0..1 Required epsos-dataelement-168
Brand name of the vaccination
 
treeblank treetree draft  Vaccine description
0..1 Required epsos-dataelement-171
Description of the vaccine
 
treeblank treetree draft  Vaccine code
0..1 Required epsos-dataelement-170
The code of the vaccine
 
treeblank treetree draft  Vaccination date
0..1 Required epsos-dataelement-169
The date the vaccination was done
 
treetree folder Allergy
0..* Required epsos-dataelement-58
Allergies and intolerances
 
treeblank treetree draft  Allergy description
1..1 Required epsos-dataelement-68
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
1..1 Required epsos-dataelement-69
The code of the allergy
 
treeblank treetree draft  Allergy Severity
0..1 epsos-dataelement-304
 
treeblank treetree draft  Onset Date
0..1 epsos-dataelement-70
Date when the allergy started
 
treeblank treetree draft  Agent description
1..1 Required epsos-dataelement-71
Describes the agent (drug, food, chemical agent, etc) that is responsible for the adverse reaction
 
treeblank treetree draft  Agent Code
1..1 Required epsos-dataelement-72
The code of the allergen agent
 
treetree folder Pregnancy History
0..* Required epsos-dataelement-115
 
treeblank treetree draft  Expected date of delivery
0..1 Required epsos-dataelement-116
Date in which the woman is due to give birth. Year, day and month are required.
 
treetree folder Social History
0..1 Required epsos-dataelement-111
 
treeblank treetree folder Social History Observations
0..* Required epsos-dataelement-112
 
treeblank treeblank treetree draft  Social History Observations related to: smoke, alcohol and diet
0..1 Required epsos-dataelement-113
 
treeblank treeblank treetree draft  Date range of observation
0..1 Required epsos-dataelement-114
 
folder Document Data
1..1 Required epsos-dataelement-62
Information about the document itself
 
treetree draft  Identification
1..1 Mandatory epsos-dataelement-176
Identification of the document
 
treetree draft  Type
1..1 Mandatory epsos-dataelement-296
Type of the document
 
treetree draft  Confidentiality
0..1 Required epsos-dataelement-297
Confidentiality of the document as a whole
 
treetree draft  Language
1..1 Mandatory epsos-dataelement-298
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 B
1..1 Mandatory epsos-dataelement-179
Name of country B
 
treetree folder Topicality
1..1 Required epsos-dataelement-64
 
treeblank treetree draft  Date Created
1..1 Mandatory epsos-dataelement-65
Date on which the document was generated
 
treeblank treetree draft  Date of Last Update
1..1 Mandatory epsos-dataelement-66
Date on which the document was updated (date of last version)
 
treetree folder Author
1..1 Mandatory epsos-dataelement-67
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-22
Unique identification of the Health Professional.
 
treeblank treetree folder Author Full Name
1..1 Required epsos-dataelement-19
The full name of the Health Professional
 
treeblank treeblank treetree draft  Given Name
0..* Required epsos-dataelement-20
The Name of the HP (Example: John). This field can contain more than one element
 
treeblank treeblank treetree draft  Family Name/Surname
1..1 Required epsos-dataelement-21
This field can contain more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-273
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-274
 
treeblank treetree draft  Author Role
1..1 epsos-dataelement-180
Role or specialism the author was in when sending the document.
 
treetree folder Legal Entity
1..1 Required epsos-dataelement-177
Responsible for the data in the document
 
treeblank treetree draft  Health Professional ID
0..1 Required epsos-dataelement-185
Health professional ID responsible for the data in the document
 
treeblank treetree draft  Healthcare Provider ID
0..1 Required epsos-dataelement-181
Legal organization ID responsible for the data in het document
 
treeblank treetree folder Health Professional Full Name
0..1 epsos-dataelement-275
 
treeblank treeblank treetree draft  Given Name
0..1 Required epsos-dataelement-183
Given name of the Health professional responsible for the data in the document
 
treeblank treeblank treetree draft  Family Name/Surname
1..1 Required epsos-dataelement-184
Family name/Surname of the health professional responsible for the data in the document
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-276
Prefix of the health professional responsible for the data in the document
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-277
Suffix of the health professional responsible for the data in the document
 
treeblank treetree draft  Health Professional Role
0..1 epsos-dataelement-182
Role the health professional is in while being responsible for the document data
 

draft Health Care Encounter Report (HCER) 2013‑11‑02

Name Id
Health Care Encounter Report (HCER) epsos-scenario-5
doublearrow Transaction group id: epsos-transactions-20
Status draft Draft
Version / effective date 2013‑11‑02
Name Send HCER/Receive ACK
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Content
arrowright Transaction id: epsos-transactions-21
Status draft Draft
Version / effective date 2013‑11‑02
Name Send HCER to country A
Model ClinicalDocument 
Label HealthCareEncounterReport 
Actor - Sender (organization)
Name HP B
Description Health Care Provider B
Actor - Receiver (organization)
Name HP A
Description Health Care Provider A
Representing template
Template epSOS-Medication Related Overview (1.3.6.1.4.1.12559.11.10.1.3.1.1.5 / 2013‑12‑20)
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
1..1 Required epsos-dataelement-5
Information about the patient
 
treetree folder Identification
1..1 Mandatory epsos-dataelement-6
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-7
Country ID from the country of origin, unique for the patient in that country. Example: ID for United Kingdom patient
 
treeblank treetree draft  Other Identifier
0..* epsos-dataelement-235
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-8
Personal information about the patient
 
treeblank treetree folder Full Name
1..1 Mandatory epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
1..1 Mandatory epsos-dataelement-12
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-13
This field can containe more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-263
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-264
 
treeblank treetree draft  Date of Birth
1..1 Mandatory epsos-dataelement-10
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
1..1 Mandatory epsos-dataelement-11
It must contained a recognized valid value for this field.
 
treetree folder Contact Information
0..1 epsos-dataelement-26
Contact information of the patient, including information of the contacts of the patient.
 
treeblank treetree folder Address
0..* epsos-dataelement-27
Address of the patient
 
treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-51
Name of street where the patient lives
 
treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-52
House number where the patient lives
 
treeblank treeblank treetree draft  City
0..1 epsos-dataelement-55
City where the patient lives
 
treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-53
Postal code where the patient lives
 
treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-56
State or province where the patient lives
 
treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-54
Country where the patient lives
 
treeblank treetree folder Telecom
1..* Required epsos-dataelement-300
Telecommunication addresses of the patient
 
treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-28
Telephone number of the patient
 
treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-29
Email address of the patient
 
treeblank treetree folder Preferred HP to contact
0..1 Required epsos-dataelement-30
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
1..1 Required epsos-dataelement-46
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
1..1 Required epsos-dataelement-47
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 Required epsos-dataelement-48
This field can contain more than one element.
 
treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-265
 
treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-266
 
treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-41
Telephone number of the HP/name of the legal organization
 
treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-43
Email address of the HP/name of the legal organization
 
treeblank treetree folder Contact Person/legal guardian
0..1 epsos-dataelement-34
Contact or guardian of the patient
 
treeblank treeblank treetree draft  Role of that person
0..1 Required epsos-dataelement-35
The role of the person: contact person or legal guardian
 
treeblank treeblank treetree folder Full Name
0..1 epsos-dataelement-36
Full name of the contact person or guardian
 
treeblank treeblank treeblank treetree draft  Given Name
0..1 epsos-dataelement-37
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-38
This field can contain more than one element.
 
treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-267
 
treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-268
 
treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-39
Telephone number of the person
 
treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-40
Email address of the person
 
treetree folder Insurance Information
0..1 epsos-dataelement-14
Information about the insurance of the patient
 
treeblank treetree draft  Insurance Number
0..1 epsos-dataelement-15
European Health Insurance Code (EHIC) number of the patient
 
folder Clinical Data
0..1 epsos-dataelement-16
Clinical information of the patient
 
treetree folder Medical Problems
0..1 epsos-dataelement-82
 
treeblank treetree folder Problem/Diagnosis
Conditional epsos-dataelement-228
Condition Card/Conf
New problem/diagnosis 0..*
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Problem/diagnosis Description
0..1 epsos-dataelement-229
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-230
Normalized identifier
 
treeblank treeblank treetree draft  Problem Status
0..1 epsos-dataelement-307
 
treeblank treeblank treetree draft  Problem Severity
0..1 epsos-dataelement-303
 
treeblank treeblank treetree draft  Onset Time
0..1 epsos-dataelement-231
Date of problem onset
 
treeblank treetree folder Surgical Procedure
Conditional epsos-dataelement-188
Condition Card/Conf
Executed surgical procedures 0..*
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Procedure description
0..1 epsos-dataelement-189
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-190
Normalized identifier
 
treeblank treeblank treetree draft  Procedure Date
0..1 epsos-dataelement-191
Date when procedure was performed
 
treeblank treetree folder Medical Devices and Implants
Conditional epsos-dataelement-87
Condition Card/Conf
New medical devices/implants 0..* Required
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Medical Devices and Implants Description
0..1 epsos-dataelement-88
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-89
Normalized identifier
 
treeblank treeblank treetree draft  Implant Date
0..1 epsos-dataelement-90
 
treeblank treetree folder Treatments
0..* epsos-dataelement-128
 
treeblank treeblank treetree draft  Treatment description
0..1 epsos-dataelement-129
Therapeutic treatment that does not include drugs (diet, physical excersize constraints etc)
 
treeblank treeblank treetree draft  Treatment code
0..1 epsos-dataelement-130
normalized identifier, concept code
 
treeblank treeblank treetree draft  Onset time
0..1 epsos-dataelement-131
Date of treatment onset
 
treeblank treetree folder Care plan
0..* epsos-dataelement-95
 
treeblank treeblank treetree draft  Recommendations Description
0..1 epsos-dataelement-96
Therapeutic recommendations that do not include drugs (diet, physical exercise constraints, etc.)
 
treeblank treeblank treetree draft  Recommendations Id (code)
0..1 epsos-dataelement-97
Normalized identifier
 
treeblank treetree folder Disability or function
0..* epsos-dataelement-98
 
treeblank treeblank treetree draft  Invalidity description
0..1 epsos-dataelement-99
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-132
Date of invalidity onset
 
treetree folder Medication
0..1 epsos-dataelement-101
 
treeblank treetree folder Prescription
Conditional epsos-dataelement-102
Condition Card/Conf
All prescribed medicine whose period of time indicated for the treatment has not yet expired 0..* Required
otherwise 0..0 Not present
 
treeblank treeblank treetree draft  Prescription identification
1..1 Mandatory epsos-dataelement-134
Unique identification of the prescription
 
treeblank treeblank treetree draft  Medicinal product code
0..1 Required epsos-dataelement-135
Code that identifies the medicinal product description
 
treeblank treeblank treetree draft  Date of issue of prescription
1..1 Mandatory epsos-dataelement-136
Date when medicine has been prescribed
 
treeblank treeblank treetree draft  Brand name
1..1 Required epsos-dataelement-137
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-103
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-104
Code that identifies the Active ingredient
 
treeblank treeblank treetree draft  Strength
1..* Mandatory epsos-dataelement-105
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-138
The size of the package prescribed
 
treeblank treeblank treetree draft  Pharmaceutical dose form
1..1 Mandatory epsos-dataelement-106
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-139
Number of boxes that have been prescribed
 
treeblank treeblank treetree draft  Number of units per intake
1..1 Required epsos-dataelement-107
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-108
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
 
treeblank treeblank treetree draft  Duration of treatment
1..1 Required epsos-dataelement-109
 
treeblank treeblank treetree draft  Date of onset of treatment
1..1 Required epsos-dataelement-110
Date when patient needs to start taking the medicine prescribed
 
treeblank treeblank treetree draft  Route of administration
0..1 Required epsos-dataelement-140

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-141
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-142
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-236
 
treeblank treeblank treeblank treetree draft  Prescriber Profession
0..1 epsos-dataelement-237
 
treeblank treeblank treeblank treetree draft  Prescriber Speciality
0..1 epsos-dataelement-238
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-239
Date/time the medication was prescribed
 
treeblank treeblank treeblank treetree draft  Prescriber Identification
0..1 epsos-dataelement-240
Unique identification of the prescriber
 
treeblank treeblank treeblank treetree folder Prescriber Full Name
0..1 epsos-dataelement-241
The full name of the Health Professional
 
treeblank treeblank treeblank treeblank treetree draft  Given Name
0..1 epsos-dataelement-242
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-243
This field can contain more than one element.
 
treeblank treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-269
 
treeblank treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-270
 
treeblank treeblank treeblank treetree folder Prescriber Telecom
0..* epsos-dataelement-282
 
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-280
 
treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-281
 
treeblank treeblank treeblank treetree folder Prescriber Healthcare Facility
0..1 epsos-dataelement-244
Information about the healthcare facility where the health professional works
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-245
Unique identification of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-246
Name of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0..* epsos-dataelement-283
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-278
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-279
 
treeblank treeblank treeblank treetree folder Prescriber Credentialing Organization
0..1 epsos-dataelement-290
The organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-291
Unique identification of the organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-292
The name of the organization which provided the credentialing for the prescriber
 
treeblank treetree folder Dispense
0..* epsos-dataelement-143
Information about dispensed medication
 
treeblank treeblank treetree draft  Dispense identification
1..1 Mandatory epsos-dataelement-165
Unique identification of the dispensed medication
 
treeblank treeblank treetree draft  Date of issue of dispense
1..1 Required epsos-dataelement-173
Date when the medicine has been dispensed
 
treeblank treeblank treetree draft  Related Prescription
0..1 Required epsos-dataelement-162
The ID of the prescription serving as the basis for the dispensation
 
treeblank treeblank treetree draft  Brand name
0..1 Required epsos-dataelement-172
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..* Mandatory epsos-dataelement-160
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..* Required epsos-dataelement-159
Code that identifies the Active ingredient
 
treeblank treeblank treetree draft  Strength
1..* Mandatory epsos-dataelement-156
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 Mandatory epsos-dataelement-158
The size of the package prescribed
 
treeblank treeblank treetree draft  Pharmaceutical dose form
1..1 Mandatory epsos-dataelement-154
It is the form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablets, syrup)
 
treeblank treeblank treetree draft  Route of administration
0..1 Required epsos-dataelement-153

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  Number of packages
0..1 Required epsos-dataelement-152
Number of boxes that have been prescribed
 
treeblank treeblank treetree draft  Number of units per intake
1..1 Required epsos-dataelement-151
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-150
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
 
treeblank treeblank treetree draft  Substitution
0..1 Required epsos-dataelement-149
 
treeblank treeblank treetree draft  Duration of treatment
0..1 epsos-dataelement-148
 
treeblank treeblank treetree draft  Date of onset of treatment according to prescription
0..1 epsos-dataelement-147
Date when the patient needs to start taking the medicine prescribed
 
treeblank treeblank treetree draft  Validity of prescription
1..1 Required epsos-dataelement-146
Date of the end of the treatment or prescriptions where the end of treatment has expired
 
treeblank treeblank treetree draft  Date of onset of dispense
0..1 epsos-dataelement-145
Date when the patient starts taking the medicine dispensed
 
treeblank treeblank treetree draft  Expected date of end of treatment
0..1 epsos-dataelement-144
Expectation when the patient stops taking the medicine dispensed
 
treeblank treeblank treetree folder Dispenser
0..1 epsos-dataelement-247
 
treeblank treeblank treeblank treetree draft  Timestamp of dispensing
0..1 epsos-dataelement-248
Date/time the medication was dispensed
 
treeblank treeblank treeblank treetree draft  Dispenser Identification
0..1 epsos-dataelement-249
Unique identification of the dispenser
 
treeblank treeblank treeblank treetree folder Dispenser Full Name
0..1 epsos-dataelement-250
 
treeblank treeblank treeblank treeblank treetree draft  Given
0..1 epsos-dataelement-251
 
treeblank treeblank treeblank treeblank treetree draft  Family Name/Surname
0..1 epsos-dataelement-252
 
treeblank treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-271
 
treeblank treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-272
 
treeblank treeblank treeblank treetree folder Dispenser Telecom
0..* epsos-dataelement-287
 
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-288
 
treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-289
 
treeblank treeblank treeblank treetree folder Dispenser Healthcare Facility
0..1 epsos-dataelement-253
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-254
Unique identification of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-255
 
treeblank treeblank treeblank treeblank treetree folder Address
0..1 epsos-dataelement-256
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-257
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-258
 
treeblank treeblank treeblank treeblank treeblank treetree draft  City
0..1 epsos-dataelement-259
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-260
 
treeblank treeblank treeblank treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-261
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-262
 
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0..* epsos-dataelement-284
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-285
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-286
 
treeblank treeblank treeblank treetree folder Dispenser Credentialing Organization
0..1 epsos-dataelement-293
The organization which provided the credentialing for the dispenser
 
treeblank treeblank treeblank treeblank treetree draft  Identification
0..1 epsos-dataelement-294
Unique identification of the organization which provided the credentialing for the dispenser
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-295
The name of the organization which provided the credentialing for the dispenser
 
treetree folder Physical Findings
0..* Required epsos-dataelement-117
 
treeblank treetree folder Vital Signs Observations
0..1 epsos-dataelement-118
 
treeblank treeblank treetree folder Blood Pressure
0..1 Required epsos-dataelement-119
One value of blood pressure which includes: systolic Blood Pressure and Diastolic Blood pressure
 
treeblank treeblank treeblank treetree draft  Systolic Blood Pressure
0..1 Required epsos-dataelement-120
 
treeblank treeblank treeblank treetree draft  Diastolic Blood Pressure
0..1 Required epsos-dataelement-121
 
treeblank treeblank treetree draft  Date when blood pressure was measured
0..1 Required epsos-dataelement-122
Date when blood pressure was measured
 
treetree folder Diagnostic Tests
0..* Required epsos-dataelement-123
 
treeblank treetree folder Blood Group
0..1 Required epsos-dataelement-124
 
treeblank treeblank treetree draft  Result of Blood Group
0..1 Required epsos-dataelement-125
Result from the blood group test made to the patient
 
treeblank treeblank treetree draft  Date
0..1 Required epsos-dataelement-126
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..* Required epsos-dataelement-167
 
treeblank treetree draft  Vaccine brand name
0..1 Required epsos-dataelement-168
Brand name of the vaccination
 
treeblank treetree draft  Vaccine description
0..1 Required epsos-dataelement-171
Description of the vaccine
 
treeblank treetree draft  Vaccine code
0..1 Required epsos-dataelement-170
The code of the vaccine
 
treeblank treetree draft  Vaccination date
0..1 Required epsos-dataelement-169
The date the vaccination was done
 
treetree folder Allergy
0..* Required epsos-dataelement-58
Allergies and intolerances
 
treeblank treetree draft  Allergy description
1..1 Required epsos-dataelement-68
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
1..1 Required epsos-dataelement-69
The code of the allergy
 
treeblank treetree draft  Allergy Severity
0..1 epsos-dataelement-304
 
treeblank treetree draft  Onset Date
0..1 epsos-dataelement-70
Date when the allergy started
 
treeblank treetree draft  Agent description
1..1 Required epsos-dataelement-71
Describes the agent (drug, food, chemical agent, etc) that is responsible for the adverse reaction
 
treeblank treetree draft  Agent Code
1..1 Required epsos-dataelement-72
The code of the allergen agent
 
treetree folder Pregnancy History
0..* Required epsos-dataelement-115
 
treeblank treetree draft  Expected date of delivery
0..1 Required epsos-dataelement-116
Date in which the woman is due to give birth. Year, day and month are required.
 
treetree folder Social History
0..1 Required epsos-dataelement-111
 
treeblank treetree folder Social History Observations
0..* Required epsos-dataelement-112
 
treeblank treeblank treetree draft  Social History Observations related to: smoke, alcohol and diet
0..1 Required epsos-dataelement-113
 
treeblank treeblank treetree draft  Date range of observation
0..1 Required epsos-dataelement-114
 
folder Document Data
1..1 Required epsos-dataelement-62
Information about the document itself
 
treetree draft  Identification
1..1 Mandatory epsos-dataelement-176
Identification of the document
 
treetree draft  Type
1..1 Mandatory epsos-dataelement-296
Type of the document
 
treetree draft  Confidentiality
1..1 Required epsos-dataelement-297
Confidentiality of the document as a whole
 
treetree draft  Language
1..1 Mandatory epsos-dataelement-298
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 B
1..1 Mandatory epsos-dataelement-179
Name of country B
 
treetree folder Topicality
1..1 Required epsos-dataelement-64
 
treeblank treetree draft  Date Created
1..1 Mandatory epsos-dataelement-65
Date on which the document was generated
 
treeblank treetree draft  Date of Last Update
1..1 Mandatory epsos-dataelement-66
Date on which the document was updated (date of last version)
 
treetree folder Author
1..1 Mandatory epsos-dataelement-67
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-22
Unique identification of the Health Professional.
 
treeblank treetree folder Author Full Name
1..1 Required epsos-dataelement-19
The full name of the Health Professional
 
treeblank treeblank treetree draft  Given Name
0..* Required epsos-dataelement-20
The Name of the HP (Example: John). This field can contain more than one element
 
treeblank treeblank treetree draft  Family Name/Surname
1..1 Required epsos-dataelement-21
This field can contain more than one element.
 
treeblank treetree draft  Author Role
1..1 epsos-dataelement-180
Role or specialism the author was in when sending the document.
 
treetree folder Legal Entity
1..1 Required epsos-dataelement-177
Responsible for the data in the document
 
treeblank treetree draft  Health Professional ID
0..1 Required epsos-dataelement-185
Health professional ID responsible for the data in the document
 
treeblank treetree draft  Healthcare Provider ID
0..1 Required epsos-dataelement-181
Legal organization ID responsible for the data in het document
 
treeblank treetree draft  Health Professional Role
0..1 epsos-dataelement-182
Role the health professional is in while being responsible for the document data
 
arrowleft Transaction id: epsos-transactions-22
Status draft Draft
Version / effective date 2013‑11‑02
Name Respond ACK
Description Please note that acknowledgements come down to an IHE XCF/XCA Response. This is not modelled in this specification. Refer to the IHE Profile for details
Actor - Sender (organization)
Name HP A
Description Health Care Provider A
Actor - Receiver (organization)
Name HP B
Description Health Care Provider B
Representing template
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)

draft Patient Summary (PS) 2012‑05‑02

The two use cases must be understood as an access to the PS. an occasional visitor in country B, for example someone on holiday or attending a business meeting. The distinguishi...
Name Id
Patient Summary (PS) epsos-scenario-3
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.
doublearrow Transaction group id: epsos-transactions-1
Status draft Draft
Version / effective date 2012‑05‑02
Name Request PS/Return PS
Description HP B requests the PS from HP A
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Content
arrowright Transaction id: epsos-transactions-11
Status draft Draft
Version / effective date 2012‑05‑02
Name Request PS of country A
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)
Name HP B
Description Health Care Provider B
Actor - Receiver (organization)
Name HP A
Description Health Care Provider A
Representing template
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
0..* epsos-dataelement-5
Information about the patient
 
treetree folder Identification
0..* epsos-dataelement-6
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-7
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-8
Personal information about the patient
 
treeblank treetree folder Full Name
0..* epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
0..* epsos-dataelement-12
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-13
This field can containe more than one element.
 
treeblank treetree draft  Date of Birth
0..* epsos-dataelement-10
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-11
It must contained a recognized valid value for this field.
 
folder Document Data
0..1 epsos-dataelement-62
Information about the document itself
 
treetree draft  Type
1..1 epsos-dataelement-296
Type of the document
 
arrowleft Transaction id: epsos-transactions-12
Status draft Draft
Version / effective date 2012‑05‑02
Name Return PS of country A
Description HP A responds by sending the PS to HP B
Model ClinicalDocument 
Label PatientSummary 
Actor - Sender (organization)
Name HP A
Description Health Care Provider A
Actor - Receiver (organization)
Name HP B
Description Health Care Provider B
Representing template
Template epSOS-Patient Summary (1.3.6.1.4.1.12559.11.10.1.3.1.1.3 / 2013‑12‑20)
Source data set epSOS Data Set (2.16.840.1.113883.3.1937.777.10.1.1 / 2013‑05‑30)
Contained concepts
Concept Card/Conf Id
folder Patient Data
1..1 Mandatory epsos-dataelement-5
Information about the patient
 
treetree folder Identification
1..1 Mandatory epsos-dataelement-6
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-7
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-234
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-235
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-8
Personal information about the patient
 
treeblank treetree folder Full Name
1..1 Mandatory epsos-dataelement-9
The full name of the patient
 
treeblank treeblank treetree draft  Given name
1..1 Mandatory epsos-dataelement-12
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-13
This field can containe more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-263
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-264
 
treeblank treetree draft  Date of Birth
1..1 Mandatory epsos-dataelement-10
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-11
It must contained a recognized valid value for this field.
 
treetree folder Contact Information
0..* epsos-dataelement-26
Contact information of the patient, including information of the contacts of the patient.
 
treeblank treetree folder Address
0..* epsos-dataelement-27
Address of the patient
 
treeblank treeblank treetree draft  Street
0..1 epsos-dataelement-51
Name of street where the patient lives
 
treeblank treeblank treetree draft  Number of Street
0..1 epsos-dataelement-52
House number where the patient lives
 
treeblank treeblank treetree draft  City
0..1 epsos-dataelement-55
City where the patient lives
 
treeblank treeblank treetree draft  Postal Code
0..1 epsos-dataelement-53
Postal code where the patient lives
 
treeblank treeblank treetree draft  State or Province
0..1 epsos-dataelement-56
State or province where the patient lives
 
treeblank treeblank treetree draft  Country
0..1 epsos-dataelement-54
Country where the patient lives
 
treeblank treetree folder Telecom
1..* Required epsos-dataelement-300
Telecommunication addresses of the patient
 
treeblank treeblank treetree draft  Telephone No
0..* epsos-dataelement-28
Telephone number of the patient
 
treeblank treeblank treetree draft  Email
0..* epsos-dataelement-29
Email address of the patient
 
treeblank treetree folder Preferred HP to contact
0..1 epsos-dataelement-30
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-46
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-47
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-48
This field can contain more than one element.
 
treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-265
 
treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-266
 
treeblank treeblank treetree draft  Telephone No
0..* epsos-dataelement-41
Telephone number of the HP/name of the legal organization
 
treeblank treeblank treetree draft  Email
0..* epsos-dataelement-43
Email address of the HP/name of the legal organization
 
treeblank treetree folder Legal Organization to contact
0..1 epsos-dataelement-31
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-33
Name of the organization
 
treeblank treeblank treetree draft  Telephone No
0..* epsos-dataelement-49
Telephone number of the organization
 
treeblank treeblank treetree draft  Email
0..* epsos-dataelement-50
Email address of the organization
 
treeblank treetree folder Contact Person/legal guardian
0..* epsos-dataelement-34
Contact or guardian of the patient
 
treeblank treeblank treetree draft  Role of that person
0..1 epsos-dataelement-35
The role of the person: contact person or legal guardian
 
treeblank treeblank treetree folder Full Name
0..1 epsos-dataelement-36
Full name of the contact person or guardian
 
treeblank treeblank treeblank treetree draft  Given Name
0..1 epsos-dataelement-37
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-38
This field can contain more than one element.
 
treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-267
 
treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-268
 
treeblank treeblank treetree draft  Telephone No
0..* epsos-dataelement-39
Telephone number of the person
 
treeblank treeblank treetree draft  Email
0..* epsos-dataelement-40
Email address of the person
 
treetree folder Insurance Information
0..1 epsos-dataelement-14
Information about the insurance of the patient
 
treeblank treetree draft  Insurance Number
0..1 epsos-dataelement-15
European Health Insurance Code (EHIC) number of the patient
 
folder Clinical Data
0..* epsos-dataelement-16
Clinical information of the patient
 
treetree folder Alerts
0..* epsos-dataelement-197
 
treeblank treetree folder Allergy
0..* epsos-dataelement-204
Allergies and intolerances
 
treeblank treeblank treetree draft  Allergy description
0..1 epsos-dataelement-205
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-206
The code of the allergy
 
treeblank treeblank treetree draft  Onset Date
0..1 epsos-dataelement-207
Date when the allergy started
 
treeblank treeblank treetree draft  Agent description
0..1 epsos-dataelement-208
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-209
The code of the allergen agent
 
treeblank treetree folder Medical Alert Information
0..* epsos-dataelement-214
 
treeblank treeblank treetree draft  Health Care Alert code
0..1 epsos-dataelement-216
The code of the health care alert
 
treeblank treeblank treetree draft  Health Care Alert description
0..1 epsos-dataelement-215
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-192
 
treeblank treetree folder Problem/Diagnosis
0..* epsos-dataelement-222
 
treeblank treeblank treetree draft  Problem/diagnosis Description
0..1 epsos-dataelement-223
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-224
Normalized identifier
 
treeblank treeblank treetree draft  Problem Status
0..1 epsos-dataelement-306
 
treeblank treeblank treetree draft  Problem Severity
0..1 epsos-dataelement-302
 
treeblank treeblank treetree draft  Onset Time
0..1 epsos-dataelement-225
Date of problem onset
 
treeblank treeblank treetree draft  End date
0..1 epsos-dataelement-226
Problem resolution date
 
treeblank treeblank treetree draft  Resolution Circumstances
0..1 epsos-dataelement-227
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-217
 
treeblank treeblank treetree draft  Vaccine brand name
0..1 epsos-dataelement-218
Brand name of the vaccination
 
treeblank treeblank treetree draft  Vaccine description
0..1 epsos-dataelement-219
Description of the vaccine
 
treeblank treeblank treetree draft  Vaccine code
0..1 epsos-dataelement-220
The code of the vaccine
 
treeblank treeblank treetree draft  Vaccination date
0..1 epsos-dataelement-221
The date the vaccination was done
 
treeblank treetree folder Surgical Procedure
0..* epsos-dataelement-210
 
treeblank treeblank treetree draft  Procedure description
0..1 epsos-dataelement-211
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-212
Normalized identifier
 
treeblank treeblank treetree draft  Procedure Date
0..1 epsos-dataelement-213
Date when procedure was performed
 
treetree folder Medical Problems
0..* epsos-dataelement-82
 
treeblank treetree folder Problem/Diagnosis
0..* epsos-dataelement-228
 
treeblank treeblank treetree draft  Problem/diagnosis Description
0..1 epsos-dataelement-229
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-230
Normalized identifier
 
treeblank treeblank treetree draft  Problem Status
0..1 epsos-dataelement-307
 
treeblank treeblank treetree draft  Problem Severity
0..1 epsos-dataelement-303
 
treeblank treeblank treetree draft  Onset Time
0..1 epsos-dataelement-231
Date of problem onset
 
treeblank treeblank treetree draft  End date
0..1 epsos-dataelement-232
Problem resolution date
 
treeblank treeblank treetree draft  Resolution Circumstances
0..1 epsos-dataelement-233
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-188
 
treeblank treeblank treetree draft  Procedure description
0..1 epsos-dataelement-189
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-190
Normalized identifier
 
treeblank treeblank treetree draft  Procedure Date
0..1 epsos-dataelement-191
Date when procedure was performed
 
treeblank treetree folder Medical Devices and Implants
0..* epsos-dataelement-87
 
treeblank treeblank treetree draft  Medical Devices and Implants Description
0..1 epsos-dataelement-88
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-89
Normalized identifier
 
treeblank treeblank treetree draft  Implant Date
0..1 epsos-dataelement-90
 
treeblank treetree folder Treatments
0..* epsos-dataelement-128
 
treeblank treeblank treetree draft  Treatment description
0..1 epsos-dataelement-129
Therapeutic treatment that does not include drugs (diet, physical excersize constraints etc)
 
treeblank treeblank treetree draft  Treatment code
0..1 epsos-dataelement-130
normalized identifier, concept code
 
treeblank treeblank treetree draft  Onset time
0..1 epsos-dataelement-131
Date of treatment onset
 
treeblank treetree folder Care plan
0..* epsos-dataelement-95
 
treeblank treeblank treetree draft  Recommendations Description
0..1 epsos-dataelement-96
Therapeutic recommendations that do not include drugs (diet, physical exercise constraints, etc.)
 
treeblank treeblank treetree draft  Recommendations Id (code)
0..1 epsos-dataelement-97
Normalized identifier
 
treeblank treetree folder Disability or function
0..* epsos-dataelement-98
 
treeblank treeblank treetree draft  Invalidity description
0..1 epsos-dataelement-99
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-132
Date of invalidity onset
 
treetree folder Medication
0..1 epsos-dataelement-101
 
treeblank treetree folder Prescription
0..* epsos-dataelement-102
 
treeblank treeblank treetree draft  Prescription identification
1..1 Mandatory epsos-dataelement-134
Unique identification of the prescription
 
treeblank treeblank treetree draft  Medicinal product code
0..1 Required epsos-dataelement-135
Code that identifies the medicinal product description
 
treeblank treeblank treetree draft  Date of issue of prescription
1..1 Mandatory epsos-dataelement-136
Date when medicine has been prescribed
 
treeblank treeblank treetree draft  Brand name
1..1 Required epsos-dataelement-137
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-103
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-104
Code that identifies the Active ingredient
 
treeblank treeblank treetree draft  Strength
1..* Mandatory epsos-dataelement-105
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-138
The size of the package prescribed
 
treeblank treeblank treetree draft  Pharmaceutical dose form
1..1 Mandatory epsos-dataelement-106
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-139
Number of boxes that have been prescribed
 
treeblank treeblank treetree draft  Number of units per intake
1..1 Required epsos-dataelement-107
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-108
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
 
treeblank treeblank treetree draft  Duration of treatment
1..1 Required epsos-dataelement-109
 
treeblank treeblank treetree draft  Date of onset of treatment
1..1 Required epsos-dataelement-110
Date when patient needs to start taking the medicine prescribed
 
treeblank treeblank treetree draft  Route of administration
0..1 Required epsos-dataelement-140

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-141
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-142
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-236
 
treeblank treeblank treeblank treetree draft  Prescriber Profession
0..1 epsos-dataelement-237
 
treeblank treeblank treeblank treetree draft  Prescriber Speciality
0..1 epsos-dataelement-238
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-239
Date/time the medication was prescribed
 
treeblank treeblank treeblank treetree draft  Prescriber Identification
0..1 epsos-dataelement-240
Unique identification of the prescriber
 
treeblank treeblank treeblank treetree folder Prescriber Full Name
0..1 epsos-dataelement-241
The full name of the Health Professional
 
treeblank treeblank treeblank treeblank treetree draft  Given Name
0..1 epsos-dataelement-242
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-243
This field can contain more than one element.
 
treeblank treeblank treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-269
 
treeblank treeblank treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-270
 
treeblank treeblank treeblank treetree folder Prescriber Telecom
0..* epsos-dataelement-282
 
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-280
 
treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-281
 
treeblank treeblank treeblank treetree folder Prescriber Healthcare Facility
0..1 epsos-dataelement-244
Information about the healthcare facility where the health professional works
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-245
Unique identification of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-246
Name of the healthcare facility
 
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0..* epsos-dataelement-283
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0..1 epsos-dataelement-278
 
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0..1 epsos-dataelement-279
 
treeblank treeblank treeblank treetree folder Prescriber Credentialing Organization
0..* epsos-dataelement-290
The organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Identifier
0..1 epsos-dataelement-291
Unique identification of the organization which provided the credentialing for the prescriber
 
treeblank treeblank treeblank treeblank treetree draft  Name
0..1 epsos-dataelement-292
The name of the organization which provided the credentialing for the prescriber
 
treetree folder Surgical Procedure
0..* epsos-dataelement-1
 
treeblank treetree draft  Procedure description
0..1 epsos-dataelement-3
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-2
Normalized identifier
 
treeblank treetree draft  Procedure Date
0..1 epsos-dataelement-4
Date when procedure was performed
 
treetree folder Problem/Diagnosis
0..* epsos-dataelement-83
 
treeblank treetree draft  Problem/diagnosis Description
0..1 epsos-dataelement-84
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-85
Normalized identifier
 
treeblank treetree draft  Problem Status
0..1 epsos-dataelement-305
 
treeblank treetree draft  Problem Severity
0..1 epsos-dataelement-301
 
treeblank treetree draft  Onset Time
0..1 epsos-dataelement-86
Date of problem onset
 
treeblank treetree draft  End date
0..1 epsos-dataelement-174
Problem resolution date
 
treeblank treetree draft  Resolution Circumstances
0..1 epsos-dataelement-175
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-117
 
treeblank treetree folder Vital Signs Observations
0..* epsos-dataelement-118
 
treeblank treeblank treetree folder Blood Pressure
0..* epsos-dataelement-119
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-120
 
treeblank treeblank treeblank treetree draft  Diastolic Blood Pressure
0..1 epsos-dataelement-121
 
treeblank treeblank treetree draft  Date when blood pressure was measured
0..1 epsos-dataelement-122
Date when blood pressure was measured
 
treetree folder Diagnostic Tests
0..* epsos-dataelement-123
 
treeblank treetree folder Blood Group
0..1 epsos-dataelement-124
 
treeblank treeblank treetree draft  Result of Blood Group
0..1 epsos-dataelement-125
Result from the blood group test made to the patient
 
treeblank treeblank treetree draft  Date
0..1 epsos-dataelement-126
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-167
 
treeblank treetree draft  Vaccine brand name
0..1 epsos-dataelement-168
Brand name of the vaccination
 
treeblank treetree draft  Vaccine description
0..1 epsos-dataelement-171
Description of the vaccine
 
treeblank treetree draft  Vaccine code
0..1 epsos-dataelement-170
The code of the vaccine
 
treeblank treetree draft  Vaccination date
0..1 epsos-dataelement-169
The date the vaccination was done
 
treetree folder Allergy
0..* epsos-dataelement-58
Allergies and intolerances
 
treeblank treetree draft  Allergy description
0..1 epsos-dataelement-68
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-69
The code of the allergy
 
treeblank treetree draft  Allergy Severity
0..1 epsos-dataelement-304
 
treeblank treetree draft  Onset Date
0..1 epsos-dataelement-70
Date when the allergy started
 
treeblank treetree draft  Agent description
0..1 epsos-dataelement-71
Describes the agent (drug, food, chemical agent, etc) that is responsible for the adverse reaction
 
treeblank treetree draft  Agent Code
0..1 epsos-dataelement-72
The code of the allergen agent
 
treetree folder Pregnancy History
0..* epsos-dataelement-115
 
treeblank treetree draft  Expected date of delivery
0..1 epsos-dataelement-116
Date in which the woman is due to give birth. Year, day and month are required.
 
treetree folder Social History
0..* epsos-dataelement-111
 
treeblank treetree folder Social History Observations
0..* epsos-dataelement-112
 
treeblank treeblank treetree draft  Social History Observations related to: smoke, alcohol and diet
0..1 epsos-dataelement-113
 
treeblank treeblank treetree draft  Date range of observation
0..1 epsos-dataelement-114
 
folder Document Data
1..1 Mandatory epsos-dataelement-62
Information about the document itself
 
treetree draft  Identification
1..1 Mandatory epsos-dataelement-176
Identification of the document
 
treetree draft  Type
1..1 Mandatory epsos-dataelement-296
Type of the document
 
treetree draft  Confidentiality
0..1 Required epsos-dataelement-297
Confidentiality of the document as a whole
 
treetree draft  Language
1..1 Mandatory epsos-dataelement-298
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-63
Name of country A
 
treetree folder Topicality
1..1 Mandatory epsos-dataelement-64
 
treeblank treetree draft  Date Created
1..1 Mandatory epsos-dataelement-65
Date on which the document was generated
 
treetree folder Author
0..1 epsos-dataelement-67
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-22
Unique identification of the Health Professional.
 
treeblank treetree folder Author Full Name
1..1 Mandatory epsos-dataelement-19
The full name of the Health Professional
 
treeblank treeblank treetree draft  Given Name
1..1 Mandatory epsos-dataelement-20
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-21
This field can contain more than one element.
 
treeblank treeblank treetree draft  Prefix
0..1 epsos-dataelement-273
 
treeblank treeblank treetree draft  Suffix
0..1 epsos-dataelement-274
 
treeblank treetree folder Author Healthcare Facility
0..1 epsos-dataelement-23
Information about the healthcare facility where the health professional works
 
treeblank treeblank treetree draft  Identifier
1..1 Mandatory epsos-dataelement-25
Unique identification of the healthcare facility
 
treeblank treeblank treetree draft  Name
1..1 Mandatory epsos-dataelement-24
Name of the healthcare facility
 

Scenario Summary

Scenarios 5
Transaction groups 5
Transactions 10

Transactions per Actor

Transactions for Actor organization: HP A

Role Type Transaction Model Representing template
  Group Request eP/Receive eP    
Receiver initial    Request eP from country A
Sender back    Return eP from country A ClinicalDocument epSOS-ePrescription (2013‑12‑20)
  Group Send eD/Receive ACK    
Receiver initial    Send eD to country A ClinicalDocument epSOS-eDispensation (2013‑12‑20)
Sender back    Respond ACK
  Group Request/Return MRO    
Receiver initial    Request MRO
Sender back    Return MRO ClinicalDocument epSOS-Health Care Encounter Report (2013‑12‑20)
  Group Send HCER/Receive ACK    
Receiver initial    Send HCER to country A ClinicalDocument epSOS-Medication Related Overview (2013‑12‑20)
Sender back    Respond ACK
  Group Request PS/Return PS    
Receiver initial    Request PS of country A
Sender back    Return PS of country A ClinicalDocument epSOS-Patient Summary (2013‑12‑20)

Transactions for Actor organization: HP B

Role Type Transaction Model Representing template
  Group Request eP/Receive eP    
Sender initial    Request eP from country A
Receiver back    Return eP from country A ClinicalDocument epSOS-ePrescription (2013‑12‑20)
  Group Send eD/Receive ACK    
Sender initial    Send eD to country A ClinicalDocument epSOS-eDispensation (2013‑12‑20)
Receiver back    Respond ACK
  Group Request/Return MRO    
Sender initial    Request MRO
Receiver back    Return MRO ClinicalDocument epSOS-Health Care Encounter Report (2013‑12‑20)
  Group Send HCER/Receive ACK    
Sender initial    Send HCER to country A ClinicalDocument epSOS-Medication Related Overview (2013‑12‑20)
Receiver back    Respond ACK
  Group Request PS/Return PS    
Sender initial    Request PS of country A
Receiver back    Return PS of country A ClinicalDocument epSOS-Patient Summary (2013‑12‑20)

Transactions for Actor device: NCP A

Role Type Transaction Model Representing template

Transactions for Actor device: NCP B

Role Type Transaction Model Representing template

Data sets, codes, OIDs and Rules: this information is used for rendering and validation purposes.