Document

Patient/subject information

Root concept of the Patient information model. This root concept contains all data elements of the Patient information model.

Unique identifier of the document

Author(s) of the document

Date of finalizing/issuing the document

Status of the document

CompositionStatus

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

Common Languages

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

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

Time of service that is being documented, NOTE: placeholder awaiting a generic functional datatype for period

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

Document attestation details

Actor who validated the document

Indicates the level of authority of the attestation. The type of attestation the authenticator offers. Fixed value: Professional

CompositionAttestationMode

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organization taking responsibility for the content of the document.

Indicates the level of authority of the attestation. The type of attestation the authenticator offers. Fixed value: Legal

CompositionAttestationMode

Date and time when the document was authorised

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

v3 Code System ActCode

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

SNOMED CT

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

A formally or informally recognized grouping of people or organizations formed for the purpose of achieving some form of collective action. Includes companies, institutions, corporations, departments, community groups, healthcare practice groups, payer/insurer, etc.

Section for Allergies

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

Root concept of the AllergyIntolerance information model. This root concept contains all data elements of the AllergyIntolerance information model.

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

Root concept of the Procedure information model. This root concept contains all data elements of the Procedure information model.

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

DeviceUse

RedenAfwezigheid

List Empty Reasons

(in development) Section for medication information. For medication information within NL-PS, the ‘MedicationUse’ building blocks – including ‘Instructions for Use’ and ‘PharmaceuticalProduct’ – from the Medication Process 9 (MP9) information standard, version 3.0.0-rc.x, will be used. These building blocks are expected to be made EHDS-compliant in the near future and will be added to the NL-PS logical model when they become available.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

RedenAfwezigheid

List Empty Reasons

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

Document

Patient/subject information

Root concept of the Patient information model. This root concept contains all data elements of the Patient information model.

Unique identifier of the document

Author(s) of the document

Date of finalizing/issuing the document

Status of the document

CompositionStatus

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

Common Languages

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

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

Time of service that is being documented, NOTE: placeholder awaiting a generic functional datatype for period

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

Document attestation details

Actor who validated the document

Indicates the level of authority of the attestation. The type of attestation the authenticator offers. Fixed value: Professional

CompositionAttestationMode

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organization taking responsibility for the content of the document.

Indicates the level of authority of the attestation. The type of attestation the authenticator offers. Fixed value: Legal

CompositionAttestationMode

Date and time when the document was authorised

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

v3 Code System ActCode

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

SNOMED CT

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

A formally or informally recognized grouping of people or organizations formed for the purpose of achieving some form of collective action. Includes companies, institutions, corporations, departments, community groups, healthcare practice groups, payer/insurer, etc.

Section for Allergies

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

Root concept of the AllergyIntolerance information model. This root concept contains all data elements of the AllergyIntolerance information model.

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

Root concept of the Procedure information model. This root concept contains all data elements of the Procedure information model.

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

DeviceUse

RedenAfwezigheid

List Empty Reasons

(in development) Section for medication information. For medication information within NL-PS, the ‘MedicationUse’ building blocks – including ‘Instructions for Use’ and ‘PharmaceuticalProduct’ – from the Medication Process 9 (MP9) information standard, version 3.0.0-rc.x, will be used. These building blocks are expected to be made EHDS-compliant in the near future and will be added to the NL-PS logical model when they become available.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

RedenAfwezigheid

List Empty Reasons

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

Document

Patient/subject information

Root concept of the Patient information model. This root concept contains all data elements of the Patient information model.

Unique identifier of the document

Author(s) of the document

Date of finalizing/issuing the document

Status of the document

CompositionStatus

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

Common Languages

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

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

Time of service that is being documented, NOTE: placeholder awaiting a generic functional datatype for period

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

Document attestation details

Actor who validated the document

Indicates the level of authority of the attestation. The type of attestation the authenticator offers. Fixed value: Professional

CompositionAttestationMode

Date and time of the approval of the document by Attester

Document legal authentication details

The person or organization taking responsibility for the content of the document.

Indicates the level of authority of the attestation. The type of attestation the authenticator offers. Fixed value: Legal

CompositionAttestationMode

Date and time when the document was authorised

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

v3 Code System ActCode

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

SNOMED CT

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

A formally or informally recognized grouping of people or organizations formed for the purpose of achieving some form of collective action. Includes companies, institutions, corporations, departments, community groups, healthcare practice groups, payer/insurer, etc.

Section for Allergies

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

Root concept of the AllergyIntolerance information model. This root concept contains all data elements of the AllergyIntolerance information model.

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

Root concept of the Procedure information model. This root concept contains all data elements of the Procedure information model.

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

DeviceUse

RedenAfwezigheid

List Empty Reasons

(in development) Section for medication information. For medication information within NL-PS, the ‘MedicationUse’ building blocks – including ‘Instructions for Use’ and ‘PharmaceuticalProduct’ – from the Medication Process 9 (MP9) information standard, version 3.0.0-rc.x, will be used. These building blocks are expected to be made EHDS-compliant in the near future and will be added to the NL-PS logical model when they become available.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

RedenAfwezigheid

List Empty Reasons

(in development) Sections containing the Composition and Content/Rules for all slices. This section is repeatable, with different constraints applied to specific concepts such as Allergies and Procedures.

Free text notes by the health professional

Title

code

Narrative - DRAFT should probably not be used, because it should be autogenerated. This SHOULD NOT be a user entry field.

A reference to data that supports this section

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

RedenAfwezigheid

List Empty Reasons

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