IPS Bundle example with Immunization - International Patient Summary Implementation Guide v2.0.0-ballot

This page is part of the International Patient Summary Implementation Guide (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

Example Bundle: IPS Bundle example with Immunization

Document Details

Generated Narrative: Bundle Patient Summary as of December 11, 2017 14:30

Language: en-GB

Final Document at 2017-12-11 14:30:00+0100 by Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100 for Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

Document Subject

Generated Narrative: Patient 2b90dd2b-2dab-4c75-9bb9-a355e07401e1-with-immunization

Martha DeLarosa Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)

Active:

true

Contact Detail

+31788700800
Laan Van Europa 1600 Dordrecht 3317 DB NL

mother:

Martha Mum
Promenade des Anglais 111 Lyon 69001 FR
+33-555-20036

Document Content

Active Problems

Hot flushes

Medication

Medication	Strength	Form	Dosage	Comment
Anastrozole	1 mg	tablet	once daily	treatment for breast cancer
Black Cohosh Extract		pil		herbal supplement

Allergies and Intolerances

Allergy to penicillin, high criticality, active No known food allergies

History of Past Illness

Breast cancer Stage II with no evidence of recurrence following treatment

Plan of Treatment

Continue hormone medication with Anastrozole for total of 5 years and monitor for potential breast cancer recurrence

Results

Blood typing
Blood group	A+
C Ab [Presence] in Serum or Plasma	Positive
E Ab [Presence] in Serum or Plasma	Positive
Little c Ab [Presence] in Serum or Plasma	Negative

Hemoglobin A1c monitoring
Hemoglobin A1c/Hemoglobin.total in Blood by HPLC	7.5 %

Bacteriology
Methicillin resistant Staphylococcus aureus
Healthy carrier of MRSA

Immunizations

Marie Lux-Brennard (Apr 17, 1998)

Vaccin anti diphtérie-coqueluche-tétanos-poliomyélite, Jun 3, 1998, 10:00:00 PM

Voie intramusculaire, Cuisse droite

Additional Resources Included in Document

Entry 1 - fullUrl = urn:uuid:30551ce1-5a28-4356-b684-1e639094ad4d

Resource Composition:

Generated Narrative: Composition 30551ce1-5a28-4356-b684-1e639094ad4d

identifier: urn:oid:2.16.724.4.8.10.200.10/3f69e0a5-2177-4540-baab-7a5d0877428f
status: Final
type: Patient summary Document
date: 2017-12-11 14:30:00+0100
author: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
title: Patient Summary as of December 11, 2017 14:30
attester
mode: Legal
time: 2017-12-11 14:30:00+0100
party: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
attester
mode: Legal
time: 2017-12-11 14:30:00+0100
party: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
custodian: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
relatesTo
No display for RelatedArtifact (type: appends)
Events
- Period Detail
* ?? --> 2017-12-11 14:30:00+0100 No display for Composition.event.detail (concept: care provision)

Entry 2 - fullUrl = urn:uuid:2b90dd2b-2dab-4c75-9bb9-a355e07401e1

Resource Patient:

Generated Narrative: Patient 2b90dd2b-2dab-4c75-9bb9-a355e07401e1-with-immunization
Martha DeLarosa Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)
Active: true
Contact Detail
+31788700800
Laan Van Europa 1600 Dordrecht 3317 DB NL
mother:
Martha Mum
Promenade des Anglais 111 Lyon 69001 FR
+33-555-20036

Entry 3 - fullUrl = urn:uuid:1c616b24-3895-48c4-9a02-9a64110351ef

Resource Practitioner:

Generated Narrative: Practitioner 1c616b24-3895-48c4-9a02-9a64110351ef-with-immunization

identifier: urn:oid:2.16.528.1.1007.3.1/129854633
active: true
name: Beetje van Hulp
Qualifications
- Code
* Doctor of Medicine

Entry 4 - fullUrl = urn:uuid:890751f4-2924-4636-bab7-efffc7f3cf15

Resource Organization:

Generated Narrative: Organization 890751f4-2924-4636-bab7-efffc7f3cf15-with-immunization

identifier: urn:oid:2.16.528.1.1007.3.3/564738757
active: true
name: Anorg Aniza Tion BV / The best custodian ever
Contacts
- Telecom Address
* +31-51-34343400 Houttuinen 27 Dordrecht 3311 CE NL (work)

Entry 5 - fullUrl = urn:uuid:c64139e7-f02d-409c-bf34-75e8bf23bc80

Resource Condition:

Generated Narrative: Condition c64139e7-f02d-409c-bf34-75e8bf23bc80-with-immunization

identifier: urn:oid:1.2.3.999/c87bf51c-e53c-4bfe-b8b7-aa62bdd93002
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem
severity: Moderate severity
code: Menopausal flushing (finding)
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
onset: 2015
recordedDate: 2016-10

Entry 6 - fullUrl = urn:uuid:c220e36c-eb67-4fc4-9ba1-2fabc52acec6

Resource MedicationStatement:

Generated Narrative: MedicationStatement c220e36c-eb67-4fc4-9ba1-2fabc52acec6-with-immunization

identifier: urn:oid:1.2.3.999/b75f92cb-61d4-469a-9387-df5ef70d25f0
status: recorded
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2015-03 --> (ongoing)
dosage

Entry 7 - fullUrl = urn:uuid:47524493-846a-4a26-bae2-4ab03e60f02e

Resource MedicationStatement:

Generated Narrative: MedicationStatement 47524493-846a-4a26-bae2-4ab03e60f02e-with-immunization

identifier: urn:oid:1.2.3.999/9e312d6b-c6b6-439a-a730-6efaa5dcf8bc
status: recorded
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2016-01 --> (ongoing)
Dosages
- Route
* Oral use

Entry 8 - fullUrl = urn:uuid:976d0804-cae0-45ae-afe3-a19f3ceba6bc

Resource Medication:

Generated Narrative: Medication 976d0804-cae0-45ae-afe3-a19f3ceba6bc-with-immunization

code: Product containing anastrozole (medicinal product)

Entry 9 - fullUrl = urn:uuid:8adc0999-9468-4ac9-9557-680fa133d626

Resource Medication:

Generated Narrative: Medication 8adc0999-9468-4ac9-9557-680fa133d626-with-immunization

code: Black Cohosh Extract herbal supplement

Entry 10 - fullUrl = urn:uuid:72884cad-ebe6-4f43-a51a-2f978275f132

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance 72884cad-ebe6-4f43-a51a-2f978275f132-with-immunization

identifier: urn:oid:1.2.3.999/3a462598-009c-484a-965c-d6b24a821424
clinicalStatus: Active
verificationStatus: Confirmed
type: Allergy
category: Medication
criticality: High Risk
code: Substance with penicillin structure and antibacterial mechanism of action (substance)
patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
onset: 2010

Entry 11 - fullUrl = urn:uuid:c4597aa2-688a-401b-a658-70acc6de28c6

Resource Condition:

Generated Narrative: Condition c4597aa2-688a-401b-a658-70acc6de28c6-with-immunization

identifier: urn:oid:1.2.3.999/66d4a8c7-9081-43e0-a63f-489c2ae6edd6
clinicalStatus: Remission
verificationStatus: Confirmed
category: Problem
severity: Severe
code: Malignant tumor of breast
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
onset: 2015-01
abatement: 2015-03

Entry 12 - fullUrl = urn:uuid:45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7

Resource Organization:

Generated Narrative: Organization 45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7-with-immunization

active: true
type: Other
name: Laboratoire de charme

Entry 13 - fullUrl = urn:uuid:aa11a2be-3e36-4be7-b58a-6fc3dace2741

Resource Observation:

Generated Narrative: Observation aa11a2be-3e36-4be7-b58a-6fc3dace2741-with-immunization

status: Final
category: Laboratory
code: ABO and Rh group [Type] in Blood
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2015-10-10 09:15:00+0100
performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
value: Blood group A Rh(D) positive

Entry 14 - fullUrl = urn:uuid:6e39ccf3-f997-4a2b-8f28-b4b71c778c70

Resource Observation:

Generated Narrative: Observation 6e39ccf3-f997-4a2b-8f28-b4b71c778c70-with-immunization

status: Final
category: Laboratory
code: C Ab [Presence] in Serum or Plasma
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2015-10-10 09:35:00+0100
performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
value: Positive

Entry 15 - fullUrl = urn:uuid:b4916505-a06b-460c-9be8-011609282457

Resource Observation:

Generated Narrative: Observation b4916505-a06b-460c-9be8-011609282457-with-immunization

status: Final
category: Laboratory
code: E Ab [Presence] in Serum or Plasma
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2015-10-10 09:35:00+0100
performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
value: Positive

Entry 16 - fullUrl = urn:uuid:a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4

Resource Observation:

Generated Narrative: Observation a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4-with-immunization

status: Final
category: Laboratory
code: little c Ab [Presence] in Serum or Plasma
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2015-10-10 09:35:00+0100
performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
value: Negative

Entry 17 - fullUrl = urn:uuid:2639657a-c19a-48e2-82cc-471e13b8ad94

Resource Observation:

Generated Narrative: Observation 2639657a-c19a-48e2-82cc-471e13b8ad94-with-immunization

status: Final
category: Laboratory
code: Blood typing
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2015-10-10
performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
hasMember:
Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

Entry 18 - fullUrl = urn:uuid:cc354e00-a419-47ea-8b6c-1768b2a01646

Resource Observation:

Generated Narrative: Observation cc354e00-a419-47ea-8b6c-1768b2a01646-with-immunization

status: Final
category: Laboratory
code: Hemoglobin A1c/Hemoglobin.total in Blood by HPLC
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2017-11-10 08:20:00+0100
performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
value: 7.5 % (Details: UCUM code% = '%')
note: Above stated goal of 7.0 %

Entry 19 - fullUrl = urn:uuid:26bee0a9-5997-4557-ab9d-c6adbb05b572

Resource Observation:

Generated Narrative: Observation 26bee0a9-5997-4557-ab9d-c6adbb05b572-with-immunization

status: Final
category: Laboratory
code: Bacteria identified in Isolate
subject: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
effective: 2017-12-10 08:20:00+0100
performer: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
value: Methicillin resistant Staphylococcus aureus
note: Healthy carrier of MRSA

Entry 20 - fullUrl = urn:uuid:c7781f44-6df8-4a8b-9e06-0b34263a47c5

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance c7781f44-6df8-4a8b-9e06-0b34263a47c5-with-immunization

clinicalStatus: Active
code: No known food allergy (situation)
patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100

Entry 21 - fullUrl = urn:uuid:40b7b6a0-c043-423a-9959-be3707e728b2

Resource Immunization:

Generated Narrative: Immunization 40b7b6a0-c043-423a-9959-be3707e728b2

Language: fr-LU
status: Completed
vaccineCode: Vaccin anti diphtérie-coqueluche-tétanos-poliomyélite
lotNumber: AXK23RWERS
expirationDate: 2000-06-01
patient: Bundle: identifier = urn:oid:2.16.724.4.8.10.200.10#175bd032-8b00-4728-b2dc-748bb1501aed; type = document; timestamp = 2017-12-11 14:30:00+0100
occurrence: 1998-06-04 00:00:00+0200
primarySource: true
site: Cuisse droite
route: Voie intramusculaire
ProtocolApplieds
- TargetDisease
* Pertussis