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draft Scenario Health Care Encounter Report (HCER) 2.16.840.1.113883.3.1937.777.11.3.5

Name Details [‑]
draft Health Care Encounter Report (HCER)
epsos-scenario-5
Version / effective date 2013‑11‑02
draft doublearrow Send HCER/Receive ACK
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Version / effective date 2013‑11‑02    
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draft arrowright Send HCER to country A
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Version / effective date 2013‑11‑02    
Model ClinicalDocument Label HealthCareEncounterReport
Actor
Sender (organization) HP B
Receiver (organization) HP A
Associations
Contained concepts
Concept Card/Conf Id
folder Patient Data
1 … 1 Required
epsos-dataelement-5link
Information about the patient
treetree folder Identification
1 … 1 Mandatory
epsos-dataelement-6link
Country ID, unique for the patient in that country. Example: ID for United Kingdom patient
treeblank treetree draft  National Health Care patient ID (country of affiliation)
1 … 1 Mandatory
epsos-dataelement-7link
Country ID from the country of origin, unique for the patient in that country. Example: ID for United Kingdom patient
treeblank treetree draft  Other Identifier
0 … *
epsos-dataelement-235link
Other identifiers than the national health care patient IDs from either the country of affiliation or the country of treatment
treetree folder Personal Information
1 … 1 Mandatory
epsos-dataelement-8link
Personal information about the patient
treeblank treetree folder Full Name
1 … 1 Mandatory
epsos-dataelement-9link
The full name of the patient
treeblank treeblank treetree draft  Given name
1 … 1 Mandatory
epsos-dataelement-12link
The Name of the patient (Example: John). This field can contain more than one element
treeblank treeblank treetree draft  Family Name/Surname
1 … 1 Mandatory
epsos-dataelement-13link
This field can containe more than one element.
treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-263link
treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-264link
treeblank treetree draft  Date of Birth
1 … 1 Mandatory
epsos-dataelement-10link
The date of birth of the patient. This field may contain only the year if day and month are not available
treeblank treetree draft  Gender
1 … 1 Mandatory
epsos-dataelement-11link
It must contained a recognized valid value for this field.
treetree folder Contact Information
0 … 1
epsos-dataelement-26link
Contact information of the patient, including information of the contacts of the patient.
treeblank treetree folder Address
0 … *
epsos-dataelement-27link
Address of the patient
treeblank treeblank treetree draft  Street
0 … 1
epsos-dataelement-51link
Name of street where the patient lives
treeblank treeblank treetree draft  Number of Street
0 … 1
epsos-dataelement-52link
House number where the patient lives
treeblank treeblank treetree draft  City
0 … 1
epsos-dataelement-55link
City where the patient lives
treeblank treeblank treetree draft  Postal Code
0 … 1
epsos-dataelement-53link
Postal code where the patient lives
treeblank treeblank treetree draft  State or Province
0 … 1
epsos-dataelement-56link
State or province where the patient lives
treeblank treeblank treetree draft  Country
0 … 1
epsos-dataelement-54link
Country where the patient lives
treeblank treetree folder Telecom
1 … * Required
epsos-dataelement-300link
Telecommunication addresses of the patient
treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-28link
Telephone number of the patient
treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-29link
Email address of the patient
treeblank treetree folder Preferred HP to contact
0 … 1 Required
epsos-dataelement-30link
Preferred Health Professional to contact. A foreign HP may need a contact (HP/legal organization) who knows the patient
treeblank treeblank treetree folder Full Name
1 … 1 Required
epsos-dataelement-46link
Name of the HP/name of the legal organization. If it is an HP, the structure of the name will be the same as described in ‘Full name’ (Given name, family name/surname)
treeblank treeblank treeblank treetree draft  Given Name
1 … 1 Required
epsos-dataelement-47link
The Name of the HP (Example: John). This field can contain more than one element
treeblank treeblank treeblank treetree draft  Family Name/Surname
0 … 1 Required
epsos-dataelement-48link
This field can contain more than one element.
treeblank treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-265link
treeblank treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-266link
treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-41link
Telephone number of the HP/name of the legal organization
treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-43link
Email address of the HP/name of the legal organization
treeblank treetree folder Contact Person/legal guardian
0 … 1
epsos-dataelement-34link
Contact or guardian of the patient
treeblank treeblank treetree draft  Role of that person
0 … 1 Required
epsos-dataelement-35link
The role of the person: contact person or legal guardian
treeblank treeblank treetree folder Full Name
0 … 1
epsos-dataelement-36link
Full name of the contact person or guardian
treeblank treeblank treeblank treetree draft  Given Name
0 … 1
epsos-dataelement-37link
The Name of the person (Example: John). This field can contain more than one element
treeblank treeblank treeblank treetree draft  Family Name/Surname
0 … 1
epsos-dataelement-38link
This field can contain more than one element.
treeblank treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-267link
treeblank treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-268link
treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-39link
Telephone number of the person
treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-40link
Email address of the person
treetree folder Insurance Information
0 … 1
epsos-dataelement-14link
Information about the insurance of the patient
treeblank treetree draft  Insurance Number
0 … 1
epsos-dataelement-15link
European Health Insurance Code (EHIC) number of the patient
folder Clinical Data
0 … 1
epsos-dataelement-16link
Clinical information of the patient
treetree folder Medical Problems
0 … 1
epsos-dataelement-82link
treeblank treetree folder Problem/Diagnosis
0 … * Conditional
epsos-dataelement-228link
Card/Conf Condition
0 … * New problem/diagnosis
0 … 0 Not present otherwise
treeblank treeblank treetree draft  Problem/diagnosis Description
0 … 1
epsos-dataelement-229link
Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
treeblank treeblank treetree draft  Problem/diagnosis Id (Code)
0 … 1
epsos-dataelement-230link
Normalized identifier
treeblank treeblank treetree draft  Problem Status
0 … 1
epsos-dataelement-307link
treeblank treeblank treetree draft  Problem Severity
0 … 1
epsos-dataelement-303link
treeblank treeblank treetree draft  Onset Time
0 … 1
epsos-dataelement-231link
Date of problem onset
treeblank treetree folder Surgical Procedure
0 … * Conditional
epsos-dataelement-188link
Card/Conf Condition
0 … * Executed surgical procedures
0 … 0 Not present otherwise
treeblank treeblank treetree draft  Procedure description
0 … 1
epsos-dataelement-189link
Describes the type of procedure that has been executed as part of the healthcare event.
treeblank treeblank treetree draft  Procedure Id (code)
0 … 1
epsos-dataelement-190link
Normalized identifier
treeblank treeblank treetree draft  Procedure Date
0 … 1
epsos-dataelement-191link
Date when procedure was performed
treeblank treetree folder Medical Devices and Implants
0 … * Conditional
epsos-dataelement-87link
Card/Conf Condition
0 … * Required New medical devices/implants
0 … 0 Not present otherwise
treeblank treeblank treetree draft  Medical Devices and Implants Description
0 … 1
epsos-dataelement-88link
Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices as cardiac pacemakers, implantable defribillator, prothesis, feromagnetic bone implants etc that are important to be known by HP.
treeblank treeblank treetree draft  Device Code
0 … 1
epsos-dataelement-89link
Normalized identifier
treeblank treeblank treetree draft  Implant Date
0 … 1
epsos-dataelement-90link
treeblank treetree folder Treatments
0 … *
epsos-dataelement-128link
treeblank treeblank treetree draft  Treatment description
0 … 1
epsos-dataelement-129link
Therapeutic treatment that does not include drugs (diet, physical excersize constraints etc)
treeblank treeblank treetree draft  Treatment code
0 … 1
epsos-dataelement-130link
normalized identifier, concept code
treeblank treeblank treetree draft  Onset time
0 … 1
epsos-dataelement-131link
Date of treatment onset
treeblank treetree folder Care plan
0 … *
epsos-dataelement-95link
treeblank treeblank treetree draft  Recommendations Description
0 … 1
epsos-dataelement-96link
Therapeutic recommendations that do not include drugs (diet, physical exercise constraints, etc.)
treeblank treeblank treetree draft  Recommendations Id (code)
0 … 1
epsos-dataelement-97link
Normalized identifier
treeblank treetree folder Disability or function
0 … *
epsos-dataelement-98link
treeblank treeblank treetree draft  Invalidity description
0 … 1
epsos-dataelement-99link
Need of the patient to be continuously assisted by third parties. Invalidity status may influence decisions about how to administer treatments
treeblank treeblank treetree draft  Onset time
0 … 1
epsos-dataelement-132link
Date of invalidity onset
treetree folder Medication
0 … 1
epsos-dataelement-101link
treeblank treetree folder Prescription
0 … * Conditional
epsos-dataelement-102link
Card/Conf Condition
0 … * Required All prescribed medicine whose period of time indicated for the treatment has not yet expired
0 … 0 Not present otherwise
treeblank treeblank treetree draft  Prescription identification
1 … 1 Mandatory
epsos-dataelement-134link
Unique identification of the prescription
treeblank treeblank treetree draft  Medicinal product code
0 … 1 Required
epsos-dataelement-135link
Code that identifies the medicinal product description
treeblank treeblank treetree draft  Date of issue of prescription
1 … 1 Mandatory
epsos-dataelement-136link
Date when medicine has been prescribed
treeblank treeblank treetree draft  Brand name
1 … 1 Required
epsos-dataelement-137link
Original brand name of the medicine (in the language of the country in which the prescription was made)
treeblank treeblank treetree draft  Active ingredient
1 … * Required
epsos-dataelement-103link
Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product.
treeblank treeblank treetree draft  Active ingredient code
1 … * Mandatory
epsos-dataelement-104link
Code that identifies the Active ingredient
treeblank treeblank treetree draft  Strength
1 … * Mandatory
epsos-dataelement-105link
The content of the active ingredient expressed quantitatively per dosage unit, per unit of volume or per unit of weight, according to the pharmaceutical dose form. Example: 500 mg per tablet
treeblank treeblank treetree draft  Medicinal product package size
1 … 1 Required
epsos-dataelement-138link
The size of the package prescribed
treeblank treeblank treetree draft  Pharmaceutical dose form
1 … 1 Mandatory
epsos-dataelement-106link
It is the form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablets, syrup)
treeblank treeblank treetree draft  Number of packages
1 … 1 Required
epsos-dataelement-139link
Number of boxes that have been prescribed
treeblank treeblank treetree draft  Number of units per intake
1 … 1 Required
epsos-dataelement-107link
The number of units per intake that the patient is taking (e.g. 1 tablet)
treeblank treeblank treetree draft  Frequency of intakes
1 … * Required
epsos-dataelement-108link
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
treeblank treeblank treetree draft  Duration of treatment
1 … 1 Required
epsos-dataelement-109link
treeblank treeblank treetree draft  Date of onset of treatment
1 … 1 Required
epsos-dataelement-110link
Date when patient needs to start taking the medicine prescribed
treeblank treeblank treetree draft  Route of administration
0 … 1 Required
epsos-dataelement-140link

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

NOTE FOR GUIDANCE ON DATA ELEMENTS AND STANDARDS FOR DRUG DICTIONARIES

(EMEA/CHMP/ICH/168535/2005)

treeblank treeblank treetree draft  Instructions to patient
0 … 1 Required
epsos-dataelement-141link
The prescriber might give to the patient instructions; They must be presented in the original language.
treeblank treeblank treetree draft  Advice to dispenser
0 … 1
epsos-dataelement-142link
The prescriber might give instructions to the dispenser. The information will be in the original language as automatic translation is not secure enough. To avoid legal and ethical issues to the dispenser, it should be wise to implement an option that allows the dispenser to decide, knowing that this data is available, whether he wants to consult it or not.
treeblank treeblank treetree folder Prescriber
0 … 1
epsos-dataelement-236link
treeblank treeblank treeblank treetree draft  Prescriber Profession
0 … 1
epsos-dataelement-237link
treeblank treeblank treeblank treetree draft  Prescriber Speciality
0 … 1
epsos-dataelement-238link
Some countries need the specialty of the prescriber for the epSOS ePrescription to be seen as valid. In the epSOS phase 1 ePrescription data set, this element is not basic (minimum), therefore not always filled in. The proposal is to define the specialty of the prescriber as a basic element, so it should be filled in, if available. As it could be that this information is not available in every country, null values should be allowed.
treeblank treeblank treeblank treetree draft  Timestamp of Prescribing
0 … 1
epsos-dataelement-239link
Date/time the medication was prescribed
treeblank treeblank treeblank treetree draft  Prescriber Identification
0 … 1
epsos-dataelement-240link
Unique identification of the prescriber
treeblank treeblank treeblank treetree folder Prescriber Full Name
0 … 1
epsos-dataelement-241link
The full name of the Health Professional
treeblank treeblank treeblank treeblank treetree draft  Given Name
0 … 1
epsos-dataelement-242link
The Name of the Prescriber (Example: John). This field can contain more than one element
treeblank treeblank treeblank treeblank treetree draft  Family Name/Surname
0 … 1
epsos-dataelement-243link
This field can contain more than one element.
treeblank treeblank treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-269link
treeblank treeblank treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-270link
treeblank treeblank treeblank treetree folder Prescriber Telecom
0 … *
epsos-dataelement-282link
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-280link
treeblank treeblank treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-281link
treeblank treeblank treeblank treetree folder Prescriber Healthcare Facility
0 … 1
epsos-dataelement-244link
Information about the healthcare facility where the health professional works
treeblank treeblank treeblank treeblank treetree draft  Identifier
0 … 1
epsos-dataelement-245link
Unique identification of the healthcare facility
treeblank treeblank treeblank treeblank treetree draft  Name
0 … 1
epsos-dataelement-246link
Name of the healthcare facility
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0 … *
epsos-dataelement-283link
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-278link
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-279link
treeblank treeblank treeblank treetree folder Prescriber Credentialing Organization
0 … 1
epsos-dataelement-290link
The organization which provided the credentialing for the prescriber
treeblank treeblank treeblank treeblank treetree draft  Identifier
0 … 1
epsos-dataelement-291link
Unique identification of the organization which provided the credentialing for the prescriber
treeblank treeblank treeblank treeblank treetree draft  Name
0 … 1
epsos-dataelement-292link
The name of the organization which provided the credentialing for the prescriber
treeblank treetree folder Dispense
0 … *
epsos-dataelement-143link
Information about dispensed medication
treeblank treeblank treetree draft  Dispense identification
1 … 1 Mandatory
epsos-dataelement-165link
Unique identification of the dispensed medication
treeblank treeblank treetree draft  Date of issue of dispense
1 … 1 Required
epsos-dataelement-173link
Date when the medicine has been dispensed
treeblank treeblank treetree draft  Related Prescription
0 … 1 Required
epsos-dataelement-162link
The ID of the prescription serving as the basis for the dispensation
treeblank treeblank treetree draft  Brand name
0 … 1 Required
epsos-dataelement-172link
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-160link
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-159link
Code that identifies the Active ingredient
treeblank treeblank treetree draft  Strength
1 … * Mandatory
epsos-dataelement-156link
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-158link
The size of the package prescribed
treeblank treeblank treetree draft  Pharmaceutical dose form
1 … 1 Mandatory
epsos-dataelement-154link
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-153link

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-152link
Number of boxes that have been prescribed
treeblank treeblank treetree draft  Number of units per intake
1 … 1 Required
epsos-dataelement-151link
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-150link
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
treeblank treeblank treetree draft  Substitution
0 … 1 Required
epsos-dataelement-149link
treeblank treeblank treetree draft  Duration of treatment
0 … 1
epsos-dataelement-148link
treeblank treeblank treetree draft  Date of onset of treatment according to prescription
0 … 1
epsos-dataelement-147link
Date when the patient needs to start taking the medicine prescribed
treeblank treeblank treetree draft  Validity of prescription
1 … 1 Required
epsos-dataelement-146link
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-145link
Date when the patient starts taking the medicine dispensed
treeblank treeblank treetree draft  Expected date of end of treatment
0 … 1
epsos-dataelement-144link
Expectation when the patient stops taking the medicine dispensed
treeblank treeblank treetree folder Dispenser
0 … 1
epsos-dataelement-247link
treeblank treeblank treeblank treetree draft  Timestamp of dispensing
0 … 1
epsos-dataelement-248link
Date/time the medication was dispensed
treeblank treeblank treeblank treetree draft  Dispenser Identification
0 … 1
epsos-dataelement-249link
Unique identification of the dispenser
treeblank treeblank treeblank treetree folder Dispenser Full Name
0 … 1
epsos-dataelement-250link
treeblank treeblank treeblank treeblank treetree draft  Given
0 … 1
epsos-dataelement-251link
treeblank treeblank treeblank treeblank treetree draft  Family Name/Surname
0 … 1
epsos-dataelement-252link
treeblank treeblank treeblank treeblank treetree draft  Prefix
0 … 1
epsos-dataelement-271link
treeblank treeblank treeblank treeblank treetree draft  Suffix
0 … 1
epsos-dataelement-272link
treeblank treeblank treeblank treetree folder Dispenser Telecom
0 … *
epsos-dataelement-287link
treeblank treeblank treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-288link
treeblank treeblank treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-289link
treeblank treeblank treeblank treetree folder Dispenser Healthcare Facility
0 … 1
epsos-dataelement-253link
treeblank treeblank treeblank treeblank treetree draft  Identifier
0 … 1
epsos-dataelement-254link
Unique identification of the healthcare facility
treeblank treeblank treeblank treeblank treetree draft  Name
0 … 1
epsos-dataelement-255link
treeblank treeblank treeblank treeblank treetree folder Address
0 … 1
epsos-dataelement-256link
treeblank treeblank treeblank treeblank treeblank treetree draft  Street
0 … 1
epsos-dataelement-257link
treeblank treeblank treeblank treeblank treeblank treetree draft  Number of Street
0 … 1
epsos-dataelement-258link
treeblank treeblank treeblank treeblank treeblank treetree draft  City
0 … 1
epsos-dataelement-259link
treeblank treeblank treeblank treeblank treeblank treetree draft  Postal Code
0 … 1
epsos-dataelement-260link
treeblank treeblank treeblank treeblank treeblank treetree draft  State or Province
0 … 1
epsos-dataelement-261link
treeblank treeblank treeblank treeblank treeblank treetree draft  Country
0 … 1
epsos-dataelement-262link
treeblank treeblank treeblank treeblank treetree folder Healthcare Facility Telecom
0 … *
epsos-dataelement-284link
treeblank treeblank treeblank treeblank treeblank treetree draft  Telephone No
0 … 1
epsos-dataelement-285link
treeblank treeblank treeblank treeblank treeblank treetree draft  Email
0 … 1
epsos-dataelement-286link
treeblank treeblank treeblank treetree folder Dispenser Credentialing Organization
0 … 1
epsos-dataelement-293link
The organization which provided the credentialing for the dispenser
treeblank treeblank treeblank treeblank treetree draft  Identification
0 … 1
epsos-dataelement-294link
Unique identification of the organization which provided the credentialing for the dispenser
treeblank treeblank treeblank treeblank treetree draft  Name
0 … 1
epsos-dataelement-295link
The name of the organization which provided the credentialing for the dispenser
treetree folder Physical Findings
0 … * Required
epsos-dataelement-117link
treeblank treetree folder Vital Signs Observations
0 … 1
epsos-dataelement-118link
treeblank treeblank treetree folder Blood Pressure
0 … 1 Required
epsos-dataelement-119link
One value of blood pressure which includes: systolic Blood Pressure and Diastolic Blood pressure
treeblank treeblank treeblank treetree draft  Systolic Blood Pressure
0 … 1 Required
epsos-dataelement-120link
treeblank treeblank treeblank treetree draft  Diastolic Blood Pressure
0 … 1 Required
epsos-dataelement-121link
treeblank treeblank treetree draft  Date when blood pressure was measured
0 … 1 Required
epsos-dataelement-122link
Date when blood pressure was measured
treetree folder Diagnostic Tests
0 … * Required
epsos-dataelement-123link
treeblank treetree folder Blood Group
0 … 1 Required
epsos-dataelement-124link
treeblank treeblank treetree draft  Result of Blood Group
0 … 1 Required
epsos-dataelement-125link
Result from the blood group test made to the patient
treeblank treeblank treetree draft  Date
0 … 1 Required
epsos-dataelement-126link
Date in which the blood group test was done. This field may contain only the year if day and month are not available. Eg: 01/01/2009
treetree folder Vaccination
0 … * Required
epsos-dataelement-167link
treeblank treetree draft  Vaccine brand name
0 … 1 Required
epsos-dataelement-168link
Brand name of the vaccination
treeblank treetree draft  Vaccine description
0 … 1 Required
epsos-dataelement-171link
Description of the vaccine
treeblank treetree draft  Vaccine code
0 … 1 Required
epsos-dataelement-170link
The code of the vaccine
treeblank treetree draft  Vaccination date
0 … 1 Required
epsos-dataelement-169link
The date the vaccination was done
treetree folder Allergy
0 … * Required
epsos-dataelement-58link
Allergies and intolerances
treeblank treetree draft  Allergy description
1 … 1 Required
epsos-dataelement-68link
Description of the clinical manifestation of the allergy reaction. Example: Anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction)
treeblank treetree draft  Allergy code
1 … 1 Required
epsos-dataelement-69link
The code of the allergy
treeblank treetree draft  Allergy Severity
0 … 1
epsos-dataelement-304link
treeblank treetree draft  Onset Date
0 … 1
epsos-dataelement-70link
Date when the allergy started
treeblank treetree draft  Agent description
1 … 1 Required
epsos-dataelement-71link
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-72link
The code of the allergen agent
treetree folder Pregnancy History
0 … * Required
epsos-dataelement-115link
treeblank treetree draft  Expected date of delivery
0 … 1 Required
epsos-dataelement-116link
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-111link
treeblank treetree folder Social History Observations
0 … * Required
epsos-dataelement-112link
treeblank treeblank treetree draft  Social History Observations related to: smoke, alcohol and diet
0 … 1 Required
epsos-dataelement-113link
treeblank treeblank treetree draft  Date range of observation
0 … 1 Required
epsos-dataelement-114link
folder Document Data
1 … 1 Required
epsos-dataelement-62link
Information about the document itself
treetree draft  Identification
1 … 1 Mandatory
epsos-dataelement-176link
Identification of the document
treetree draft  Type
1 … 1 Mandatory
epsos-dataelement-296link
Type of the document
treetree draft  Confidentiality
1 … 1 Required
epsos-dataelement-297link
Confidentiality of the document as a whole
treetree draft  Language
1 … 1 Mandatory
epsos-dataelement-298link
The principal language of the documentThe language code SHALL be in the form nn-CC. The nn portion SHALL be an ISO-639-1 language code in lower case derived by the Value Set epSOSLanguage. The CC portion SHALL be an ISO-3166 country code in upper case derived by the value Set epSOSCountry
treetree draft  Country B
1 … 1 Mandatory
epsos-dataelement-179link
Name of country B
treetree folder Topicality
1 … 1 Required
epsos-dataelement-64link
treeblank treetree draft  Date Created
1 … 1 Mandatory
epsos-dataelement-65link
Date on which the document was generated
treeblank treetree draft  Date of Last Update
1 … 1 Mandatory
epsos-dataelement-66link
Date on which the document was updated (date of last version)
treetree folder Author
1 … 1 Mandatory
epsos-dataelement-67link
To highlight if the data is collected manually by an HP or is collected automatically from different sources (eg: hospital doctor repository, GPs...etc) through predetermined clinical rules.
treeblank treetree draft  Author Identification
1 … 1 Mandatory
epsos-dataelement-22link
Unique identification of the Health Professional.
treeblank treetree folder Author Full Name
1 … 1 Required
epsos-dataelement-19link
The full name of the Health Professional
treeblank treeblank treetree draft  Given Name
0 … * Required
epsos-dataelement-20link
The Name of the HP (Example: John). This field can contain more than one element
treeblank treeblank treetree draft  Family Name/Surname
1 … 1 Required
epsos-dataelement-21link
This field can contain more than one element.
treeblank treetree draft  Author Role
1 … 1
epsos-dataelement-180link
Role or specialism the author was in when sending the document.
treetree folder Legal Entity
1 … 1 Required
epsos-dataelement-177link
Responsible for the data in the document
treeblank treetree draft  Health Professional ID
0 … 1 Required
epsos-dataelement-185link
Health professional ID responsible for the data in the document
treeblank treetree draft  Healthcare Provider ID
0 … 1 Required
epsos-dataelement-181link
Legal organization ID responsible for the data in het document
treeblank treetree draft  Health Professional Role
0 … 1
epsos-dataelement-182link
Role the health professional is in while being responsible for the document data
draft arrowleft Respond ACK
epsos-transactions-22link
Version / effective date 2013‑11‑02    
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) HP A
Receiver (organization) HP B
Associations