ISO 27269-2021.docx

INTERNATIONA1.STANDARDISO27269editionFirSt202104Hea1.thinformaticsInternationa1.patientsummaryInformatiquedesant6RdSUm6internationa1.dudossiermedica1.dupatientCOPYRIGHTPROTECTEDDOCUMENT©ISO2021岫rkdea/山thUcdOthcnviscjft<c三orrtmcehDVBiwixuioiti08phnn11UatiocBhr<1.>hotoc<>p)Mng,ptbcatonpostingontheinternetoranintranet,withoutpriorwrittenpermission.PermissioncanherequestedfromeitherISOattheaddressbe1.oworIS<smemberbodyinthecountryoftherequester.%,tft晒Iandonnet8CH-1214*crnicr,GenevaPhone：M1.22749O1.11Pub1.ishedinSwitzerhndContentsForeword._.vi1233.3 Hea1.thcareactivity;3.7 ReSPOnSibi1.ity.一#.1.1.1.”-”.一16.1.6Coded151w*”，:.“-，”-“”，”,->->-“.“"，"-16.1.14Quantity176118String.一.187iiiIntroductionviiScope1Normativereferences1Termsanddefinitions13.1 Hea1.thcare23.2 Hea1.thcareactor23.4 matter3.5 Hea1.thcarep1.anning33.6 Time43.8 InformationManagement381ConCePtS-.3.8.2Mode1.s5Abbreviations8ConfornIanCe85.1 IntroductionH5.2 IPSConformanceDetai1.10DescriptorsfortheIPSDataSet136.1 PatternswithintheIPSDataSet14611CJenera1.146.1.1 1.istConcept6.1.2 Reference.IS6.1.3 PersonName156.1.7 DateTimeEIement6.1.8 Identifier16Te1.ecomName6.1.12 Text176113y./6.1.156.1.166.1.17RangePeriodGenera1.TimeSpecification18186.1.19Ratio6.2Mode1.ExtensibiIity19DefinitionoftheIPSDocument(IPS).197.1OverviewDescription:THEIPSDOCUMENT(Tab1.e4)197.2Detai1.edDescription:THEIPSDOCUMENT20DefinitionforIPSAttributeCo1.1.ection:PATIENTATTRIBUTES238.1OverviewDescription:PATIENTATTRIBUTES(Tab1.e5)238.2Detai1.edDescription：PATIENTATTRIBUTES23DefinitionforIPSAttributeCo1.1.ection:HEA1.THCARKPROVIDER259.1OverviewDescriptionforHEA1.THCAREPROVIDER(Tab1.e6)2510111213141516171819202122232425DefinitionforIPSAttributeCo1.1.ection:PATIENTSADDRESSBOOK2510.1 OverviewDescriptionforPATIENT'SADDRESSBOOK(Tab1.e7)2510.2 Detai1.edDescriptionforPATIENTSADDRESSBOOK26DefinitionforIPSSection：ADVANCEDIRECTIVES.-2711.1 OverviewDescriptionforADvANcEDIRECTIVES(Tab1.ee)2711.2 Detai1.edDescriptionforADVANCEDIRECTIVES28DefinitionforIPSSection:A1.1.ERGIESandINTO1.ERANCES3012.1 OverviewDescriptionforA1.1.ERGIESandINTO1.ERANCES(Tab1.e9)3012.2 Detai1.edDescriptionforA1.1.ERGIESandINTO1.ERANCES30DefinitionforipssectionjFuNCTIONA1.STATUS3413.1 OverviewDescriptionforFUNCTIONA1.STATUS(Tab1.e10)3413.2 Detai1.edDescriptionforFUNCTIONA1.STATUS34DenitionforIPSSection:HISTORYOFPASTPROB1.EMS.3614.1 OverviewDescriptionforHISTORYOFPASTPROB1.EMS(Tab1.e11)3614.2 Detai1.edDescriptionforHISTORYOFPASTPROB1.EMS36Definitionforipssection=HISTORYOFPREGNANCY3815.1 OverviewDescriptionforHISTORYOFPREGNANCY(Tab1.e12)3815.2 Detai1.edDescriptionforHISTORYOFPREGNANCY3HDefinitionforIPSSection:HISTORYOFPROCEDURES4116.1 OverviewDescriptionforHISTORYOFPROCEDURES(Tah1.e13)4116.2 Detai1.edDescriptionforHISTORYOFPROCEDURES41DefinitionforIPSSection:IMMUNIZATIONS4317.1 OverviewDescriptionforIMMUNIZATIONS(Tab1.e14).4317.2 Detai1.edDescriptionforIMMUNIZTIONS43DefinitionforIPSSection:MEDICA1.DEVICES._._._.一.4518.1 OverviewDescriptionforMEDICA1.DEVICES(Tab1.e15)4518.2 Detai1.edDescriptionforMEDICA1.DEVICES45DefinitionforipssectiomMEDICATIONSUMMARY4619.1 OverviewDescriptionforMEDICATIONSUMMARY(Tab1.es16and17)4619.2 TheIPSMedicationSummaryandIDMP4619.3 Detai1.edDescriptionforMEDICATIONSUMMARY47DefinitionforIPSSection:P1.ANOFCARE5020.1 OverviewDescriptionforP1.MiOFCARE(Tab1.e18)20.2 Detai1.edDescriptionforP1.ANOFCAREDefinitionforIPSSection:PROB1.EMS21.1 OverviewDescriptionforPROB1.EMS(Tab1.e19)21.2 Detai1.edDescriptionforPROB1.EMSDefinitionforIPSSection:RESU1.TS22.1 OverviewDescriptionforRESU1.TS(Tab1.e20)22.2 Detai1.edDescriptionforRESU1.TS.DeHnitionforIPSSection:SOCIA1.HISTORY23.1 OverviewDescriptionforSOCIA1.HISTORY(Tab1.e21)23.2 Detai1.edDescriptionforsOC1.A1.HISTORYDefinitionforIPSSection:VITA1.SIGNS124.4.22OverviewDescriptionforVITA1.SIGNS(Tab1.e22Detai1.edDescriptionforVITA1.SIGNS26DefinitionforIPSAttributeCo1.1.ection：ProvenanceMetadata6126.1 OverviewDescriptionforPROVENANCE(Tab1.e24)6126.2 Detai1.edDescriptionforPROVENANCE61Annex(informative)ThefirstIPSScenariofocussedon'unschedu1.ed,cross-bordercare'63Annex B (informative)Exp1.icitTracebetweene1.1.NGuide1.ineVersion270Annex C (informative)TheeHNGuide1.ine,theJICPSStandardsSet,andIPS74Bib1.iography._.75ForewordISO(theInternationa1.OrganizationforStandardization)isawor1.dwidefederationofnationa1.standardsttiugh(ISOmrtm匕0)bMdmi)rwcekdHPfff1.QbbGgbodyI1tf1.nmtiJMiai6sndrifc3owhtd1.ysQcchit2committeehasbeenestab1.ishedhastherighttoberepresentedonthatcommittee.Internationa1.organizations,governmenta1.andnon-governmenta1.,in1.iaisonwithISO,a1.sotakepartinthework.ISOco1.1.aboratesc1.ose1.ywiththee1.ectrotechnica1.standardization.Internationa1.E1.ectrotechnica1.Commission(IEC)ona1.1.mattersofTheproceduresusedtodeve1.opthisdocumentandthoseintendedforitsfurthermaintenanceareeditoria1.ru1.esoftheISO/IECDirectives,Part2(seewww.iso.org/directives).时歌Onrightsd跳地拗n鼠解哪ns仲（f解吸R的用刑foc1.Wr犯战牌服.subjectof9埋修理也搬OnSOIEC（陶曲解翩1.b1.not科般用帕班脚解蚓娜联肝er%8rdance&Fhthe V*WW*-一r一.I-r-”V*一=9Anytradeusedinthisanypatentrightsidentifiedduringthedeve1.opmentofthedocumentwi1.1.beintheIntroductionand/orontheISO1.istofpatentdec1.arationsreceived(seewww.iso.org/patents).constitutenameendorsement.documentisinformationgivenfortheconvenienceofusersanddoesnotForanexp1.anationofthevo1.untarynatureofstandards,themeaningofISOspecifictermsand脚B麒%用酬%tionc。的福P奥限融处he叶断除棉麻麻En南版淮6华哂脚郸礴isoforeword.htn1.informatics.世世册希独挹出a'YWe郎斯1°凯照Peannf8用健庭院好料板NSdization（½K弗弱耳螭仰%8;2019） changed'thisEuropeanStandard*to"thisdocument*; changedany,ENISOxxxx,'referencesto,iSOxxxxreferences; changed'section"to"C1.ause",ifappropriate; definitionsofIPStermsinbodyoftextweremovedtoC1.ause3; Cause3wasreorganizedbaseduponexistingContSyshierarchy; moredescriptiononconformance,datab1.ocks,moreexamp1.esinconceptva1.uesandupdateddefinitioncitationsgiveninresponse. OitIfckpiementatidntiivjHwret破nt(H幄iU1.助grpir9hwrtr憾帆#rwwwb归Ftigs'pi解FmHthenatura1.wayofexpressioninsomeeasterncountriesandfaci1.itatecross-borderuse; 1.HeaIthcareProvider*became1anAttributeCo1.1.ectiondatab1.ock,definedandpositionedin4>Hse-Sthanbetreatedasdatatype. comp1.eteeditoria1.revision.(mQeriMigq6tcnsmn1.iRSt1.MaMn北派疝瑜租Nd>6目/阳油ghmNnationa1.standardsbody.Ad6nHfc2EHiRtiaqte1蚊*1.nwMgdkd<3McikMebnsMwtW3tItowrnatififiI1.byg制幅必由Onisnamcd.fortheIntroductioncomprisingcorecontent.SetprovidingseconddefinitiontheandEuropeandescriptionNetwork,s(eHN)dataTheprimaryinputtum,thebui1.dsStartingdocumentdefinesandbui1.dingUponinitia1.Specificationunp1.annedcareacrossnationa1.borders.regiona1.,state/provincia1.,necessaryconformanceofdatarequiredandtheinternationa1.businessextensibi1.ityofnotderivedmode1.optiona1.IPSe1.ements,giventhattheyshou1.dassuretheopennessandbetweencontributingartefactstoSUPpOrtbUtsing1.einvo1.vingfiveStandardfOrWard.Deve1.opmentOrganizationsForma1.izedanytermino1.ogy,a1.thoughitdoes1.GantidpatetheIHEIPS®2)pro111.e.standardmedication.imp1.ementation,whichcana1.sobeusedasanexamp1.eforotherjurisdictions.Wi1.1.madetoainternationa1.requirementsratherneed1.oca1.consideredtodifferentinternationa1.contextse1.ementsdocumentcompriseuponovera1.1.documentthepatientsummaryhierarchytheindividua1.dataB1.ockswithattributes.DescriptorsandconstraintsdatadescribedbetterComponentscharacteristics.informationH1.7givenforH1.7ConvenienceIPSuserstheregisteredCrademarkdoesHea1.thconstituteSevenInternationa1.ThisThisinformatontheregisteredconvenienceinternationa1.Hea1.thTermino1.ogyStandardsDeve1.opmentOrganization.©ISO2021-A1.1.rightsreservedviiThegoa1.ofthisdocumentistode1.iverasing1.e,commonInternationa1.PatientSummary(IPS),Thisdocumentachievesthatgoa1.bydefiningaminima1.yetnon-exhaustivedatasetanditsassociatedbusinessru1.es.Thisdocumentisimp1.ementationindependentyetsti1.1.supportiveofanyimp1.ementationbyistheforma1.revisionc1.eareHea1.thofasma1.1.datasetseti)1.which,todatauponsignificantc1.inica1.inputfromtheEuropeanPatients-SmartOpenServices(epSOS)pi1.otprojec112.Thisfromthisfocus,theIPS,withtheitthefocusuponisintendedtobeusedandbeusefu1.innationa1.and1.oca1.app1.icationsanda1.sotobesupportiveofbothp1.annedandunp1.annedcare.TheIPSisdesignedtoprovidec1.inica1.informationtoassistcareacrossanyjurisdictiona1.border(e.g.1.oca1.ru1.estosupportuseandthenationa1.).Itemphasizesthetheusecaseforanassociatedpatientsummary.Eventhoughthedatasetisre1.ative1.ysma1.1.,thereisnoexpectationthatthefu1.1.datasethastoberea1.izedforaconformantimp1.ementationorconformantspecificationtobeproduced.Suchartefactsneedthespecifya1.1.theThedatasetdescribedisintendedforg1.oba1.usebeginningwithasharedvisionfromaco1.1.aborationeachCEN/TC251andH1.7(g)2)rthenowso1.utionIPSgoingFromtheIPSreferencemode1.itispossib1.etoderiveanumberofcomp1.iant1.ogica1.mode1.sthatconstrainit,andthese1.eadtoimp1.ementab1.especifications,suchastheIPSCDandFHIRimp1.ementationGuides.TheseguidesareboundbyintheH1.7CDAIG®z)andH1.72)anduseoftheIDMPTheIPSforDatasetisSN0MED®3)Internationa1.hasprovidedaG1.oba1.PatientSetfortheIPSimp1.ementations.CENhasproducedaseparateTechnica1.Specification3,thatprovidesaEuropean-specificguide1.ineforIPSThe1.Internationarc1.ementoftheIPSemphasizestheneedtoprovidegenericso1.utionsforg1.oba1.app1.icationmovingbeyondaparticu1.arregionorcountry;consequent1.y,whereverpossib1.e,referenceisoffervarietyofstandards,thantobeones.Howevenensurethatpatientsafetyiscompromised.TheIPSisunderpinnedbyISO13940,whichisasystemofconceptstosupportcontinuityofcare(andusesthoseconceptsintheinitia1.IPSscenario,whichisfu1.1.ydescribedinAnnexA.Thisthatfocusesit.Thethe1.ayoutofthisstructureof(seeTab1.e1)usesaswe1.1.asof1.eve1.s(HOtoH7)tofaci1.itatemoredetai1.eddescriptionwiththepurposeofsupportingconsistentimp1.ementationofthedatase1.The1.eve1.,H0,describestheIPSDocumentasawho1.e,whi1.st1.eve1.sH1H7describetheIPSDataTheH1.7,isCDIG,theIGandH1.7ofareofthisdocumentandofnot1.eve1.anendorsementbyISOoftheproductsnamed.SNOMEDisisgivenforthctradcmarkofofUSVrSofthisdocumentanddocsnotconstituteanendorsementbyISOoftheproductnamed.HOr1.eve1.documentStnictureareaddedeachwi1.1.bee1.ementtofirst,DiedefinethewithH1.(e.g.IPSSections,IPSAttributeCo1.1.ections).Tab1.e1DescriptionofIPSDataSetconceptsandtheirhierarchica1.re1.ationshipsDescriptivehIerar-IOH1.H2-H7chyIPSDaUB1.ocks.1.ndiridua1.IPSSections.HieFdrehie1.-dese4ptieH-ef-da½-e1.eIPSAttributeCo1.1.ections否B时咏用鹤褂忖器喻神K监HoWS叙Umeift和3里¥加解9珀湘剧刊田S州画(FK那C1.iniCa1.hereisusedpure1.ytohe1.ppresentation.However,inpracticeitisrecognizedthatindividua1.attributesmightappearindifferentcategoriesdependingondynamicuseratherthanstaticc1.assification.6MVhtsa由GUntinfOrmatiOnUSIngfOrt处的啸1.fi蚓B砒Va丽6%W1.nbq¾1.ab1.ct1.wfifanoverviewofthehierarchica1.structureanditsrequirementwithexp1.icit1.inkstomoredetai1.susingaconsistentsetofdescriptors.Thoseattributesinthetab1.ethatdonothavea1.inktofurtherdetai1.areiseithe圃P厢国视q肺np1.i抑制Qf帼1他触眠糊礼姓脑皿酬用桐%esi田做帅ff晒ntcontextua1.izedbythehierarchysoastoavoidanymisunderstanding.Eorexamp1.e,theterm1.)eviceType,wi1.1.beusedratherthanjust"Type"a1.beitthatitreferstoadatac1.ementpositionedwithintheMedica1.DeviceIPSDataB1.ock.viii©ISO2021-A1.1.rightsreservedHea1.thinformaticsInternationa1.patientsummary1Scopecase,scenariopersoncoordinationborderhea1.thcare.intendedspedfica1.1.yintemationa1.supportingsummarycontexts,Unp1.annedincreasingp1.anneduti1.ityandcanva1.ue.supportedbythisdatasetwithin1.oca1.andnationa1.thentakesspecificationconsiderationg1.oba1.internationa1.patientsummaryprojectstoprovideaninteroperab1.eimp1.ementab1.e.Dueimp1.yautomatictherefore,interoperabi1.ity;awareresu1.t,enab1.edcomp1.iancedocumentsubsequentdatadocspresentationrassimi1.ation,processesagtgrega1.ion.Furthermore,thissummarization.app1.icationImp1.ementationguidanceconccrnedspecifica1.1.ythejurisdic1.iona1.ConcernsjayersDirectives.areparticu1.ar,representationbyTenninO1.OgyCodingschemes,additiona1.structuresRefcrencetermino1.ogiesthisnecessaryUnti1.cannotbecomesestab1.ishedPOintnOrm.timeandrecognizesthatinterimschemesmight2 Normativereferences3 Termsanddefinitionsnatthefo1.1.owingISOandIECmaintaintermino1.ogica1.databasesforUSeinStandardizatioaddresses:ThisdocumentdefinesthecoredatasetforapatientsummarydocumentthatsupportscontinuityofcareforjAH.1.怔；2驶,"”时CrOSSOftheircare,andisItistobeanaimedpatientthuse1.rbj.Whi1.sttnatasetisminima1.andnon-exhaustive,itprovidesarobust,we1.1.-definedcoresetofdataitems.Thetightfocusonthisusecasea1.soenab1.estheIPStobeusedinp1.annedcare.ThismeansthatboththerebyanditscaredataItusestheEuropeanGuide1.inefromtheeHNastheinitia1.sourceforthepatientsummaryrequirements,thathasotherapp1.ication.ThisdocumentprovidesanabstractdefinitionofaPatientSummaryfromwhichderivedmode1.sarcdocumentdoesnottoitsnaturetechnica1.readersshou1.dthisthatthebythiswiththiscanbereachedwiththeconformitytostandardsindicatedintheassociatedtechnica1.specificationandimp1.ementationguides.Thisdocumentcovertheworkf1.owofdataentry,dataco1.1.ection,datadocumentdoescoverthesummarizationactitse1.f,i.e,theinte1.1.igenceski1.1.com>etencethatresu1.tsinthedatasummarizationworkf1.ow.Itis1.ayer.guidethatisforVvithvarioustechnica1.-e.g,beneaththtermino1.ogies,formats,etc.,anexamp1.eisspecifiedintheassociatedTechnica1.Specificationpj.Innotofthisdocumentvariousanditsbindingareaddressedinand3.TheIdentificationofMedicina1.Productsstandards(abbreviatedtoIDMP)aretherecommendedtargetfortheMedicationSummaryre1.atedtothisdocumentbutrpriortoIDMP,sfu1.1.imp1.ementationinpractice,beIPSstandardIDMPinsistinuseasainTherearenonormativereferencesinthisdocument.Forthepurposesofthisdocument,thefo1.1.owingtermsanddefinitionsapp1.y.ISOOn1.inebrowsingp1.atform:avai1.ab1.eathttps:/www.iso.org/obp3.1 Hea1.thcare3.1.1hea1.thcarecare,services,orsupp1.iesre1.atedtothehea1.thofanindividua1.