International Patient Summary Implementation Guide
1.1.0 - STU 1 Update 1 International flag

This page is part of the International Patient Summary Implementation Guide (v1.1.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

IPS Structure

Page standards status: Informative

The International Patient Summary Structure

The IPS is composed by the following sections described below.

Figure 2: The IPS composition

Figure 2: The IPS composition

Sections description

Medication Summary

The medication summary section contains a description of the patient’s medications relevant for the scope of the patient summary.

The actual content could depend on the jurisdiction, it could report:

  • the currently active medications;
  • the current and past medications considered relevant by the authoring GP;
  • the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.

In all those cases however medications are documented in the Patient Summary as medication statements.

The entries of this section must be one of the choices below:

  • an entry stating that the patient is known not to be under any relevant medication;
  • an entry stating that no information is available about the patient’s potential medications;
  • one or more entries enumerating the patient’s relevant medication (one entry per medication).

Allergies and Intolerances

This section documents the relevant allergies or intolerances (conditions) for a patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.

Problem List

The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient.

Immunizations

The Immunizations Section defines a patient’s current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient’s immunization status. The section includes current immunization status and the entire clinically pertinent immunization history that is known.

History of Procedures

The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of the IPS.

Procedures may refer for example to:

  1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)
  2. Therapeutic procedure: e.g. dialysis;
  3. Surgical procedure: e.g. appendectomy

Medical Devices

The medical devices section contains narrative text and coded entries describing the patient history of medical device use.

Diagnostic Results

This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, and others, radiology results.

This section includes entry choices to carry result observations (using Observation or referenced observations in DiagnosticReport) from:

  • laboratory
  • pathology
  • radiology

A generic result entry is also supported.

Vital Signs

The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included

Past history of illnesses

The History of Past Illness section contains a description of the conditions the patient suffered in the past

Pregnancy (status and history summary)

The pregnancy status and history is comprised of

  • an entry as an Observation of the pregnancy status, and optionally, a member Observation of the Estimated Delivery Date
  • an entry as an Observation of the pregnancy history (summary)

Social History

The social history is as of now comprised of

  • tobacco use
  • alcohol use

Plan of Care

The plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.

Functional Status

The functional status section contains a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.

Advance Directives

The advance directives section contains a narrative description of patient’s advance directives.

List of Profiles

The profiles that have been defined for this implementation guide are listed here.

Following are the profiles that have been defined for each section. (R) denotes a required section (i.e. must be present in an IPS), (S) denotes a recommended section, the others are optional: