The nationality of the patient.

This extension SHALL be used when needed to express the nationality of the patient.

The birth place for a patient.

This extension SHALL be used when needed to express the place of birth of the patient.

An identifier for this patient.

Typically, when SSIN is available it is used. Organizations will most likely want to also include a local identifier, using its own system. A type can be added if needed. When an identifier is given, a consumer SHALL NOT ignore it.

An identifier for this patient according to SSIN (NISS-INSZ.)

When needed to express a SSIN, it SHALL be done according to these guidelines. Other ways to identify a patient using coding systems remain also possible.

A name associated with the individual.

It is RECOMMENDED to give at least one familyname and at least one given name when possible and define an 'official' use. When names are given, a consumer SHALL NOT ignore it.

A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted.

It is RECOMMENDED to at least add one phone or email address with clear indication using the .use element whether it is home use, private use,...

This is primarily the administrative gender. The gender might not match the biological sex as determined by genetics or the individual's preferred identification. Note that for both humans and particularly animals, there are other legitimate possibilities than male and female, though the vast majority of systems and contexts only support male and female. Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific sex or gender aspect of interest (anatomical, chromosomal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. Where such defaulting occurs, rule enforcement should allow for the variation between administrative and biological, chromosomal and other gender aspects. For example, an alert about a hysterectomy on a male should be handled as a warning or overridable error, not a "hard" error. See the Patient Gender and Sex section for additional information about communicating patient gender and sex.

Special remarks for KMEHR users:

Please note gender in KMEHR is typically expressed using CD-SEX. The two values that do not map directly to the HL7 dataset are 'undefined' (use 'other') and 'changed' (use the actual gender)

The date of birth for the individual.

It is RECOMMENDED to give the birthdate when available.

Indicates if the individual is deceased or not.

It is RECOMMENDED to include deceased information when applicable

An address for the individual.

It is RECOMMENDED to include an address when available. When needed to express the availablity of a Patient at home (e.g. only Wednesdays), another solution will be defined.

This field contains a patient's most recent marital (civil) status.

It is RECOMMENDED to include this when available. In a Belgian context, the concept ‘civil state’ , Dutch ‘burgerlijke stand’, French ‘état civil’ is more typically used and this might imply a more neutral concept to the reader. In HL7 semantics however this concept is described as ‘marital status’ and it SHALL be understood as the same concept.

Indicates whether the patient is part of a multiple (boolean) or indicates the actual birth order (integer). Care SHOULD be given when exchanging Patient instances in a purely administrative flow.

A contact party (e.g. guardian, partner, friend) for the patient.

It is RECOMMENDED to include this when available and considered relevant for the patientcare. (e.g. a parent of a young patient)

Contact covers all kinds of contact parties: family members, business contacts, guardians, caregivers. Not applicable to register pedigree and family ties beyond use of having contact.

Special remarks for KMEHR users:

A contact person for the patient is not part of the 'patient' element itself in KMEHR. As such, the base resource of this is considered sufficient here. The KMEHR standard defines a contact as a separate element using a value from the KMEHR CD-ITEM table and an appropriate value from CD-CONTACT-PERSON to describe the relation to the patient in the KMEHR message. When needed, using FHIR, the contactperson is included in the FHIR resource Patient. Use cases implementing this contact SHALL be aware not all information of CD-CONTACT-PERSON is covered by the base valueset. The codesystem ‘https://www.ehealth.fgov.be/standards/fhir/core/CodeSystem/CD-CONTACT-PERSON’ SHALL be used to refer to any codes previously used in a KMEHR context that cannot be covered by the base HL7 valueset.

A language which may be used to communicate with the patient about his or her health.

It is RECOMMENDED to include this when available.

If no language is specified, this implies that the default local language is spoken. If you need to convey proficiency for multiple modes, then you need multiple Patient.Communication associations. For animals, language is not a relevant field, and should be absent from the instance. If the Patient does not speak the default local language, then the Interpreter Required Standard can be used to explicitly declare that an interpreter is required.

Special remarks for KMEHR users:

The 'usuallanguage' element in a KMEHR message only refers to the use of W3C language codes. As such, the language codes as proposed in the FHIR standard should not present any interoperability issue. Note the KMEHR element implies it is the language usally used by the patient. As such, when this element from KMEHR would be mapped to a FHIR resource, the communication.preferred Boolean SHOULD be used.

Patient's nominated care provider.

Take note this does not automatically imply any legal form of therapeutic link or consent relationship with this GP. It is RECOMMENDED to include this when available if the flow is in any way medical. Please note this is an element of the Reference datatype. This means when it is available it will contain either a relative or absolute URL where this GP can be found. Alternatively, there is only an internal reference and the GP is included as a ‘contained resource’ (cfr. the HL7 FHIR specifications in what cases this applies).

This may be the primary care provider (in a GP context), or it may be a patient nominated care manager in a community/disability setting, or even organization that will provide people to perform the care provider roles. It is not to be used to record Care Teams, these should be in a CareTeam resource that may be linked to the CarePlan or EpisodeOfCare resources. Multiple GPs may be recorded against the patient for various reasons, such as a student that has his home GP listed along with the GP at university during the school semesters, or a "fly-in/fly-out" worker that has the onsite GP also included with his home GP to remain aware of medical issues.

Jurisdictions may decide that they can profile this down to 1 if desired, or 1 per type.

Special remarks for KMEHR users:

The general practioner is in many KMEHR use cases known by being the author or sender of the message. This is however a functionally different concept from the generalPractioner as it is defined in the FHIR resource. (Consult the published definition on the HL7 webpage) It is also possible in KMEHR to add a general practioner via an item and using the correct value from CD-ITEM. That way is functionally closer to the general practioner referenced here. Note in the FHIR base definition of this element that the scope of this element might be wider then just the general practicioner.

Organization that is the custodian of the patient record.

This SHOULD be included when available.Please note this is an element of the Reference datatype. This means when it is available it will contain either a relative or absolute URL where this Organization can be found. Alternatively, there is only an internal reference and the Organization is included as a ‘contained resource’ (cfr. the HL7 FHIR specifications in what cases this applies).

There is only one managing organization for a specific patient record. Other organizations will have their own Patient record, and may use the Link property to join the records together (or a Person resource which can include confidence ratings for the association).

Special remarks for KMEHR users:

The reference to the managing organization is the organization that is the custodian of the patient record. As there is no explicit ‘author of this record’ – like in a KMEHR message – this element functionally refers to the organization in charge. (Which might also be a GP practice of an individual.)

Demographics and other administrative information about an individual or animal receiving care or other health-related services.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

An Extension

The nationality of the patient.

This extension SHALL be used when needed to express the nationality of the patient.

The birth place for a patient.

This extension SHALL be used when needed to express the place of birth of the patient.

The gender the patient identifies with. The Patient's gender identity is used as guidance (e.g. for staff) about how to interact with the patient.

Gender at the time of birth

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

An identifier for this patient.

Typically, when SSIN is available it is used. Organizations will most likely want to also include a local identifier, using its own system. A type can be added if needed. When an identifier is given, a consumer SHALL NOT ignore it.

Patients are almost always assigned specific numerical identifiers.

An identifier for this patient according to SSIN (NISS-INSZ.)

When needed to express a SSIN, it SHALL be done according to these guidelines. Other ways to identify a patient using coding systems remain also possible.

Patients are almost always assigned specific numerical identifiers.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Whether this patient record is in active use. Many systems use this property to mark as non-current patients, such as those that have not been seen for a period of time based on an organization's business rules.

It is often used to filter patient lists to exclude inactive patients

Deceased patients may also be marked as inactive for the same reasons, but may be active for some time after death.

If a record is inactive, and linked to an active record, then future patient/record updates should occur on the other patient.

Need to be able to mark a patient record as not to be used because it was created in error.

A name associated with the individual.

It is RECOMMENDED to give at least one familyname and at least one given name when possible and define an 'official' use. When names are given, a consumer SHALL NOT ignore it.

A patient may have multiple names with different uses or applicable periods. For animals, the name is a "HumanName" in the sense that is assigned and used by humans and has the same patterns.

Need to be able to track the patient by multiple names. Examples are your official name and a partner name.

A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted.

It is RECOMMENDED to at least add one phone or email address with clear indication using the .use element whether it is home use, private use,...

A Patient may have multiple ways to be contacted with different uses or applicable periods. May need to have options for contacting the person urgently and also to help with identification. The address might not go directly to the individual, but may reach another party that is able to proxy for the patient (i.e. home phone, or pet owner's phone).

People have (primary) ways to contact them in some way such as phone, email.

Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes.

This is primarily the administrative gender. The gender might not match the biological sex as determined by genetics or the individual's preferred identification. Note that for both humans and particularly animals, there are other legitimate possibilities than male and female, though the vast majority of systems and contexts only support male and female. Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific sex or gender aspect of interest (anatomical, chromosomal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. Where such defaulting occurs, rule enforcement should allow for the variation between administrative and biological, chromosomal and other gender aspects. For example, an alert about a hysterectomy on a male should be handled as a warning or overridable error, not a "hard" error. See the Patient Gender and Sex section for additional information about communicating patient gender and sex.

Special remarks for KMEHR users:

Please note gender in KMEHR is typically expressed using CD-SEX. The two values that do not map directly to the HL7 dataset are 'undefined' (use 'other') and 'changed' (use the actual gender)

The gender of a person used for administrative purposes.

Needed for identification of the individual, in combination with (at least) name and birth date.

The date of birth for the individual.

It is RECOMMENDED to give the birthdate when available.

At least an estimated year should be provided as a guess if the real DOB is unknown There is a standard extension "patient-birthTime" available that should be used where Time is required (such as in maternity/infant care systems).

Age of the individual drives many clinical processes.

An Extension

The time of day that the Patient was born. This includes the date to ensure that the timezone information can be communicated effectively.

Indicates if the individual is deceased or not.

It is RECOMMENDED to include deceased information when applicable

If there's no value in the instance, it means there is no statement on whether or not the individual is deceased. Most systems will interpret the absence of a value as a sign of the person being alive.

The fact that a patient is deceased influences the clinical process. Also, in human communication and relation management it is necessary to know whether the person is alive.

An address for the individual.

It is RECOMMENDED to include an address when available. When needed to express the availablity of a Patient at home (e.g. only Wednesdays), another solution will be defined.

Note: address is intended to describe postal addresses for administrative purposes, not to describe absolute geographical coordinates. Postal addresses are often used as proxies for physical locations (also see the Location resource).

Special remarks for KMEHR users:

Note when .use and .type are used they SHALL use the FHIR defined valuesets as per their required binding level in the FHIR specification. In a KMEHR address, the use was defined by CD-ADDRESS but those values can be found in the FHIR valueset. KMEHR values 'careadress', 'other' and 'vacation' are not directly present in the FHIR address-use table but can be mapped to the value 'temp' in FHIR. In those cases, it is RECOMMENDED to also add a .period. In KMEHR, an address might be expressed using free text or a totally structured approach where the streetname and housenumber are put in separate fields. FHIR prefers a more pragmatic approach where the ‘text’ element is used to print on labels. Also, streetname and number are not separate fields as in KMEHR but in a structural approach are given as one or moren ‘line’ elements. It is however RECOMMENDED to use the Streetname, Housenumber and Postbox extensions to express them seperately. Note the FHIR address also allows to optionally define whether the address is a physical, postal or ‘both’ address using the .type field.

May need to keep track of patient addresses for contacting, billing or reporting requirements and also to help with identification.

This field contains a patient's most recent marital (civil) status.

It is RECOMMENDED to include this when available. In a Belgian context, the concept ‘civil state’ , Dutch ‘burgerlijke stand’, French ‘état civil’ is more typically used and this might imply a more neutral concept to the reader. In HL7 semantics however this concept is described as ‘marital status’ and it SHALL be understood as the same concept.

Most, if not all systems capture it.

Indicates whether the patient is part of a multiple (boolean) or indicates the actual birth order (integer). Care SHOULD be given when exchanging Patient instances in a purely administrative flow.

Where the valueInteger is provided, the number is the birth number in the sequence. E.g. The middle birth in triplets would be valueInteger=2 and the third born would have valueInteger=3 If a boolean value was provided for this triplets example, then all 3 patient records would have valueBoolean=true (the ordering is not indicated).

For disambiguation of multiple-birth children, especially relevant where the care provider doesn't meet the patient, such as labs.

A contact party (e.g. guardian, partner, friend) for the patient.

It is RECOMMENDED to include this when available and considered relevant for the patientcare. (e.g. a parent of a young patient)

Contact covers all kinds of contact parties: family members, business contacts, guardians, caregivers. Not applicable to register pedigree and family ties beyond use of having contact.

Special remarks for KMEHR users:

A contact person for the patient is not part of the 'patient' element itself in KMEHR. As such, the base resource of this is considered sufficient here. The KMEHR standard defines a contact as a separate element using a value from the KMEHR CD-ITEM table and an appropriate value from CD-CONTACT-PERSON to describe the relation to the patient in the KMEHR message. When needed, using FHIR, the contactperson is included in the FHIR resource Patient. Use cases implementing this contact SHALL be aware not all information of CD-CONTACT-PERSON is covered by the base valueset. The codesystem ‘https://www.ehealth.fgov.be/standards/fhir/core/CodeSystem/CD-CONTACT-PERSON’ SHALL be used to refer to any codes previously used in a KMEHR context that cannot be covered by the base HL7 valueset.

Need to track people you can contact about the patient.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The nature of the relationship between the patient and the contact person.

Used to determine which contact person is the most relevant to approach, depending on circumstances.

A language which may be used to communicate with the patient about his or her health.

It is RECOMMENDED to include this when available.

If no language is specified, this implies that the default local language is spoken. If you need to convey proficiency for multiple modes, then you need multiple Patient.Communication associations. For animals, language is not a relevant field, and should be absent from the instance. If the Patient does not speak the default local language, then the Interpreter Required Standard can be used to explicitly declare that an interpreter is required.

Special remarks for KMEHR users:

The 'usuallanguage' element in a KMEHR message only refers to the use of W3C language codes. As such, the language codes as proposed in the FHIR standard should not present any interoperability issue. Note the KMEHR element implies it is the language usally used by the patient. As such, when this element from KMEHR would be mapped to a FHIR resource, the communication.preferred Boolean SHOULD be used.

If a patient does not speak the local language, interpreters may be required, so languages spoken and proficiency are important things to keep track of both for patient and other persons of interest.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.

The structure aa-BB with this exact casing is one the most widely used notations for locale. However not all systems actually code this but instead have it as free text. Hence CodeableConcept instead of code as the data type.

A human language.

Most systems in multilingual countries will want to convey language. Not all systems actually need the regional dialect.

Patient's nominated care provider.

Take note this does not automatically imply any legal form of therapeutic link or consent relationship with this GP. It is RECOMMENDED to include this when available if the flow is in any way medical. Please note this is an element of the Reference datatype. This means when it is available it will contain either a relative or absolute URL where this GP can be found. Alternatively, there is only an internal reference and the GP is included as a ‘contained resource’ (cfr. the HL7 FHIR specifications in what cases this applies).

This may be the primary care provider (in a GP context), or it may be a patient nominated care manager in a community/disability setting, or even organization that will provide people to perform the care provider roles. It is not to be used to record Care Teams, these should be in a CareTeam resource that may be linked to the CarePlan or EpisodeOfCare resources. Multiple GPs may be recorded against the patient for various reasons, such as a student that has his home GP listed along with the GP at university during the school semesters, or a "fly-in/fly-out" worker that has the onsite GP also included with his home GP to remain aware of medical issues.

Jurisdictions may decide that they can profile this down to 1 if desired, or 1 per type.

Special remarks for KMEHR users:

The general practioner is in many KMEHR use cases known by being the author or sender of the message. This is however a functionally different concept from the generalPractioner as it is defined in the FHIR resource. (Consult the published definition on the HL7 webpage) It is also possible in KMEHR to add a general practioner via an item and using the correct value from CD-ITEM. That way is functionally closer to the general practioner referenced here. Note in the FHIR base definition of this element that the scope of this element might be wider then just the general practicioner.

Organization that is the custodian of the patient record.

This SHOULD be included when available.Please note this is an element of the Reference datatype. This means when it is available it will contain either a relative or absolute URL where this Organization can be found. Alternatively, there is only an internal reference and the Organization is included as a ‘contained resource’ (cfr. the HL7 FHIR specifications in what cases this applies).

There is only one managing organization for a specific patient record. Other organizations will have their own Patient record, and may use the Link property to join the records together (or a Person resource which can include confidence ratings for the association).

Special remarks for KMEHR users:

The reference to the managing organization is the organization that is the custodian of the patient record. As there is no explicit ‘author of this record’ – like in a KMEHR message – this element functionally refers to the organization in charge. (Which might also be a GP practice of an individual.)

Need to know who recognizes this patient record, manages and updates it.

Link to another patient resource that concerns the same actual patient.

There is no assumption that linked patient records have mutual links.

There are multiple use cases:

• Duplicate patient records due to the clerical errors associated with the difficulties of identifying humans consistently, and
• Distribution of patient information across multiple servers.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The other patient resource that the link refers to.

Referencing a RelatedPerson here removes the need to use a Person record to associate a Patient and RelatedPerson as the same individual.

The type of link between this patient resource and another patient resource.

The type of link between this patient resource and another patient resource.

Demographics and other administrative information about an individual or animal receiving care or other health-related services.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

An Extension

The nationality of the patient.

This extension SHALL be used when needed to express the nationality of the patient.

The birth place for a patient.

This extension SHALL be used when needed to express the place of birth of the patient.

The gender the patient identifies with. The Patient's gender identity is used as guidance (e.g. for staff) about how to interact with the patient.

Gender at the time of birth

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

An identifier for this patient.

Typically, when SSIN is available it is used. Organizations will most likely want to also include a local identifier, using its own system. A type can be added if needed. When an identifier is given, a consumer SHALL NOT ignore it.

Patients are almost always assigned specific numerical identifiers.

An identifier for this patient according to SSIN (NISS-INSZ.)

When needed to express a SSIN, it SHALL be done according to these guidelines. Other ways to identify a patient using coding systems remain also possible.

Patients are almost always assigned specific numerical identifiers.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Whether this patient record is in active use. Many systems use this property to mark as non-current patients, such as those that have not been seen for a period of time based on an organization's business rules.

It is often used to filter patient lists to exclude inactive patients

Deceased patients may also be marked as inactive for the same reasons, but may be active for some time after death.

If a record is inactive, and linked to an active record, then future patient/record updates should occur on the other patient.

Need to be able to mark a patient record as not to be used because it was created in error.

A name associated with the individual.

It is RECOMMENDED to give at least one familyname and at least one given name when possible and define an 'official' use. When names are given, a consumer SHALL NOT ignore it.

A patient may have multiple names with different uses or applicable periods. For animals, the name is a "HumanName" in the sense that is assigned and used by humans and has the same patterns.

Need to be able to track the patient by multiple names. Examples are your official name and a partner name.

A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted.

It is RECOMMENDED to at least add one phone or email address with clear indication using the .use element whether it is home use, private use,...

A Patient may have multiple ways to be contacted with different uses or applicable periods. May need to have options for contacting the person urgently and also to help with identification. The address might not go directly to the individual, but may reach another party that is able to proxy for the patient (i.e. home phone, or pet owner's phone).

People have (primary) ways to contact them in some way such as phone, email.

Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes.

This is primarily the administrative gender. The gender might not match the biological sex as determined by genetics or the individual's preferred identification. Note that for both humans and particularly animals, there are other legitimate possibilities than male and female, though the vast majority of systems and contexts only support male and female. Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific sex or gender aspect of interest (anatomical, chromosomal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. Where such defaulting occurs, rule enforcement should allow for the variation between administrative and biological, chromosomal and other gender aspects. For example, an alert about a hysterectomy on a male should be handled as a warning or overridable error, not a "hard" error. See the Patient Gender and Sex section for additional information about communicating patient gender and sex.

Special remarks for KMEHR users:

Please note gender in KMEHR is typically expressed using CD-SEX. The two values that do not map directly to the HL7 dataset are 'undefined' (use 'other') and 'changed' (use the actual gender)

The gender of a person used for administrative purposes.

Needed for identification of the individual, in combination with (at least) name and birth date.

The date of birth for the individual.

It is RECOMMENDED to give the birthdate when available.

At least an estimated year should be provided as a guess if the real DOB is unknown There is a standard extension "patient-birthTime" available that should be used where Time is required (such as in maternity/infant care systems).

Age of the individual drives many clinical processes.

unique id for the element within a resource (for internal references)

An Extension

The time of day that the Patient was born. This includes the date to ensure that the timezone information can be communicated effectively.

The actual value

Indicates if the individual is deceased or not.

It is RECOMMENDED to include deceased information when applicable

If there's no value in the instance, it means there is no statement on whether or not the individual is deceased. Most systems will interpret the absence of a value as a sign of the person being alive.

The fact that a patient is deceased influences the clinical process. Also, in human communication and relation management it is necessary to know whether the person is alive.

An address for the individual.

It is RECOMMENDED to include an address when available. When needed to express the availablity of a Patient at home (e.g. only Wednesdays), another solution will be defined.

Note: address is intended to describe postal addresses for administrative purposes, not to describe absolute geographical coordinates. Postal addresses are often used as proxies for physical locations (also see the Location resource).

Special remarks for KMEHR users:

Note when .use and .type are used they SHALL use the FHIR defined valuesets as per their required binding level in the FHIR specification. In a KMEHR address, the use was defined by CD-ADDRESS but those values can be found in the FHIR valueset. KMEHR values 'careadress', 'other' and 'vacation' are not directly present in the FHIR address-use table but can be mapped to the value 'temp' in FHIR. In those cases, it is RECOMMENDED to also add a .period. In KMEHR, an address might be expressed using free text or a totally structured approach where the streetname and housenumber are put in separate fields. FHIR prefers a more pragmatic approach where the ‘text’ element is used to print on labels. Also, streetname and number are not separate fields as in KMEHR but in a structural approach are given as one or moren ‘line’ elements. It is however RECOMMENDED to use the Streetname, Housenumber and Postbox extensions to express them seperately. Note the FHIR address also allows to optionally define whether the address is a physical, postal or ‘both’ address using the .type field.

May need to keep track of patient addresses for contacting, billing or reporting requirements and also to help with identification.

This field contains a patient's most recent marital (civil) status.

It is RECOMMENDED to include this when available. In a Belgian context, the concept ‘civil state’ , Dutch ‘burgerlijke stand’, French ‘état civil’ is more typically used and this might imply a more neutral concept to the reader. In HL7 semantics however this concept is described as ‘marital status’ and it SHALL be understood as the same concept.

Most, if not all systems capture it.

Indicates whether the patient is part of a multiple (boolean) or indicates the actual birth order (integer). Care SHOULD be given when exchanging Patient instances in a purely administrative flow.

Where the valueInteger is provided, the number is the birth number in the sequence. E.g. The middle birth in triplets would be valueInteger=2 and the third born would have valueInteger=3 If a boolean value was provided for this triplets example, then all 3 patient records would have valueBoolean=true (the ordering is not indicated).

For disambiguation of multiple-birth children, especially relevant where the care provider doesn't meet the patient, such as labs.

Image of the patient.

Guidelines:

• Use id photos, not clinical photos.
• Limit dimensions to thumbnail.
• Keep byte count low to ease resource updates.

Many EHR systems have the capability to capture an image of the patient. Fits with newer social media usage too.

A contact party (e.g. guardian, partner, friend) for the patient.

It is RECOMMENDED to include this when available and considered relevant for the patientcare. (e.g. a parent of a young patient)

Contact covers all kinds of contact parties: family members, business contacts, guardians, caregivers. Not applicable to register pedigree and family ties beyond use of having contact.

Special remarks for KMEHR users:

A contact person for the patient is not part of the 'patient' element itself in KMEHR. As such, the base resource of this is considered sufficient here. The KMEHR standard defines a contact as a separate element using a value from the KMEHR CD-ITEM table and an appropriate value from CD-CONTACT-PERSON to describe the relation to the patient in the KMEHR message. When needed, using FHIR, the contactperson is included in the FHIR resource Patient. Use cases implementing this contact SHALL be aware not all information of CD-CONTACT-PERSON is covered by the base valueset. The codesystem ‘https://www.ehealth.fgov.be/standards/fhir/core/CodeSystem/CD-CONTACT-PERSON’ SHALL be used to refer to any codes previously used in a KMEHR context that cannot be covered by the base HL7 valueset.

Need to track people you can contact about the patient.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The nature of the relationship between the patient and the contact person.

Used to determine which contact person is the most relevant to approach, depending on circumstances.

A name associated with the contact person.

Contact persons need to be identified by name, but it is uncommon to need details about multiple other names for that contact person.

A contact detail for the person, e.g. a telephone number or an email address.

Contact may have multiple ways to be contacted with different uses or applicable periods. May need to have options for contacting the person urgently, and also to help with identification.

People have (primary) ways to contact them in some way such as phone, email.

Address for the contact person.

Need to keep track where the contact person can be contacted per postal mail or visited.

Administrative Gender - the gender that the contact person is considered to have for administration and record keeping purposes.

The gender of a person used for administrative purposes.

Needed to address the person correctly.

Organization on behalf of which the contact is acting or for which the contact is working.

For guardians or business related contacts, the organization is relevant.

The period during which this contact person or organization is valid to be contacted relating to this patient.

A language which may be used to communicate with the patient about his or her health.

It is RECOMMENDED to include this when available.

If no language is specified, this implies that the default local language is spoken. If you need to convey proficiency for multiple modes, then you need multiple Patient.Communication associations. For animals, language is not a relevant field, and should be absent from the instance. If the Patient does not speak the default local language, then the Interpreter Required Standard can be used to explicitly declare that an interpreter is required.

Special remarks for KMEHR users:

The 'usuallanguage' element in a KMEHR message only refers to the use of W3C language codes. As such, the language codes as proposed in the FHIR standard should not present any interoperability issue. Note the KMEHR element implies it is the language usally used by the patient. As such, when this element from KMEHR would be mapped to a FHIR resource, the communication.preferred Boolean SHOULD be used.

If a patient does not speak the local language, interpreters may be required, so languages spoken and proficiency are important things to keep track of both for patient and other persons of interest.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.

The structure aa-BB with this exact casing is one the most widely used notations for locale. However not all systems actually code this but instead have it as free text. Hence CodeableConcept instead of code as the data type.

A human language.

Most systems in multilingual countries will want to convey language. Not all systems actually need the regional dialect.

Indicates whether or not the patient prefers this language (over other languages he masters up a certain level).

This language is specifically identified for communicating healthcare information.

People that master multiple languages up to certain level may prefer one or more, i.e. feel more confident in communicating in a particular language making other languages sort of a fall back method.

Patient's nominated care provider.

Take note this does not automatically imply any legal form of therapeutic link or consent relationship with this GP. It is RECOMMENDED to include this when available if the flow is in any way medical. Please note this is an element of the Reference datatype. This means when it is available it will contain either a relative or absolute URL where this GP can be found. Alternatively, there is only an internal reference and the GP is included as a ‘contained resource’ (cfr. the HL7 FHIR specifications in what cases this applies).

This may be the primary care provider (in a GP context), or it may be a patient nominated care manager in a community/disability setting, or even organization that will provide people to perform the care provider roles. It is not to be used to record Care Teams, these should be in a CareTeam resource that may be linked to the CarePlan or EpisodeOfCare resources. Multiple GPs may be recorded against the patient for various reasons, such as a student that has his home GP listed along with the GP at university during the school semesters, or a "fly-in/fly-out" worker that has the onsite GP also included with his home GP to remain aware of medical issues.

Jurisdictions may decide that they can profile this down to 1 if desired, or 1 per type.

Special remarks for KMEHR users:

The general practioner is in many KMEHR use cases known by being the author or sender of the message. This is however a functionally different concept from the generalPractioner as it is defined in the FHIR resource. (Consult the published definition on the HL7 webpage) It is also possible in KMEHR to add a general practioner via an item and using the correct value from CD-ITEM. That way is functionally closer to the general practioner referenced here. Note in the FHIR base definition of this element that the scope of this element might be wider then just the general practicioner.

Organization that is the custodian of the patient record.

This SHOULD be included when available.Please note this is an element of the Reference datatype. This means when it is available it will contain either a relative or absolute URL where this Organization can be found. Alternatively, there is only an internal reference and the Organization is included as a ‘contained resource’ (cfr. the HL7 FHIR specifications in what cases this applies).

There is only one managing organization for a specific patient record. Other organizations will have their own Patient record, and may use the Link property to join the records together (or a Person resource which can include confidence ratings for the association).

Special remarks for KMEHR users:

The reference to the managing organization is the organization that is the custodian of the patient record. As there is no explicit ‘author of this record’ – like in a KMEHR message – this element functionally refers to the organization in charge. (Which might also be a GP practice of an individual.)

Need to know who recognizes this patient record, manages and updates it.

Link to another patient resource that concerns the same actual patient.

There is no assumption that linked patient records have mutual links.

There are multiple use cases:

• Duplicate patient records due to the clerical errors associated with the difficulties of identifying humans consistently, and
• Distribution of patient information across multiple servers.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The other patient resource that the link refers to.

Referencing a RelatedPerson here removes the need to use a Person record to associate a Patient and RelatedPerson as the same individual.

The type of link between this patient resource and another patient resource.

The type of link between this patient resource and another patient resource.