Transaction: Clinical Summary

General information

STATUS:

Published

OWNER:

eHealth Platform

STANDARD:

KMEHR

VERSION:

2.0

DATE:

2011-07-01

DEFINITION:

This transaction is a part of the ‘Software migration format’ . The reader is recommended to consult this page before any further reading.

The transaction corresponds to a summary of the clinical elements stored in the medical file of the patient within the software. This transaction is strongly related to the SumEHR transaction since the content of a SumEHR should be the content of the ‘clinical summary’ transaction reduced to ‘relevant care elements’.

However, each software is free to choose to export medical items in this transaction or in the contact reports. Items that are not related to a specific contact will typically be in the clinical summary.

General information

STATUS:

Published

OWNER:

eHealth Platform

STANDARD:

KMEHR

VERSION:

2.0

DATE:

2011-07-01

DEFINITION:

This transaction is a part of the ‘Software migration format’ . The reader is recommended to consult this page before any further reading.

Guidelines

Generalities

This transaction requires a level 3-4 of kmehr normalization: content are preferably coded however some textual contents are still allowed.

Transaction elements

Element list
Element	Purpose
id	id of the transaction according to the ID-KMEHR conventions.
cd	You must use the value ‘clinicalsummary’ from CD-TRANSACTION. You can always add your own local codes.
date	This is the date of the last update of the summary.
time	This is the time of the last update of the summary.
author	This is the person assuming the responsibility of the medical content of the record. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person. It must contain the ID-HCPARTY of this healthcare professional and it should contain its INSS number.
iscomplete	Expresses if the summary is completed.
isvalidated	Expresses if the summary is validated.

Structure overview

A clinical summary is mainly composed of standardized items (from CD-ITEM ). It can additionally contain a textual part that allows one to export the elements that cannot be expressed throughout recognized items. The structuration within headings is free. It could for instance follow the visualization proposed by the software.

Items

Any item from CD-ITEM can be used to compose a clinical summary transaction, but we suggest using the items listed below. When using any of these items, the described item structure should be used.

Item list
Item type (cd)	Cardinality	Item purpose	Item structure
gmdmanager	0-1	Specifies the manager of the DMG/GMD if the DMG manager exists.	content (hcparty) The GMD manager is described by an hcparty element whose id element must contain a INAMI/RIZIV number. If the GMD owner is a physical person, it also contains a familyname and firstname elements. If the GMD owner is a medical practice, it also contains a name element.
gmdmanager	0-1		[beginmoment] First signature date (if available)
contactperson An additional cd element with a value from CD-CONTACT-PERSON may be used to describe the link with the patient.	0-*	Specifies a patient related person (family, etc ...)	content(person) The contact person is described by a person element. It is recommended to export the software local ID of the person (in order to support the identification of the person across the record if there is no official identifier available).
contacthcparty	0-*	Specifies a healthcare professional contact.	content(hcparty) The healthcare professional is described by, at least, one hcparty element. This HCParty should contain the INAMI/RIZIV number of the healthcare professional (if available). The role of the contact must be described within the cd element by a value from CD-HCPARTY or by a local code. It is recommended to export the software local ID of the healthcare professional (in order to support the identification of the healthcare professional across the record if there is no official identifier available).
insurancystatus	1	Specifies the insurancy status of the patient	content (insurance)
patientwill	0-*	Specifies a therapeutic limitation expressed for the patient (specified only if registered).	content (cd+) [content (text+)] The therapeutic limitations are described using the values of CD-PATIENTWILL.
patientwill	0-*		recorddatetime Date and time of item registration
adr	0-*	Specifies an adverse drug reaction.	content (text+) [content (cd+)] This item contains textual content with the label of the risk at least. It should also contain one cd elements content corresponding to the available codifications. Recommended codifications: IBUI , ICPC-2, ICD-10.
adr	0-*	Specifies an adverse drug reaction.	recorddatetime Date and time of item registration
allergy	0-*	Specifies an allergy.	same structure as 'adr'
socialrisk	0-*	Specifies a social risk factor.	same structure as 'adr'
familyrisk	0-*	Specifies a risk related to the family history	same structure as 'adr'
professionalrisk	0-*	Specifies a professional risk	same structure as 'adr'
risk	0-*	Specifies other risk factors.	same structure as 'adr'
healthcareelement	0-*	Specifies either a 'current problem' or a 'passive care element'	content (text+) [content (cd+)] For each healthcare element, an item is provided. This item contains at least a textual content with the label of the risk. It should also contain one cd elements content corresponding to the available codifications. Recommended codifications: IBUI, ICPC-2, ICD-10.
			[beginmoment] Specifies when the problem started.
			[endmoment] Specifies when the problem ended. This field is only mandatory for a an antecedent.
			lifecycle Must be used to distinguish between problems (value ‘ active’ from CD-LIFECYCLE) and relevant passive care elements (value ‘inactive’).
			isrelevant Must be used to distinguish between relevant and irrelevant healthcare elem ents. If the field is set to ‘true’, the healthcare elements is ‘relevant’. ‘ Active’ healthcare elements are necessarily ‘relevant’.
			recorddatetime Date and time of item registration
medication	0-*	Specifies a patient's medication.	content (text) Textual description of the medication as given by the GP (may correspond to the medicinal product description if available).
			[content (medicinalproduct\| substanceproduct \| compoundprescription)] This content should correspond to the last medicinal product or substance product prescribed for this medication item (when available). The element medicinalproduct supports the identification the prepacked medicinal product by a code from CD-DRUG-CNK(element intendeddcc) and a textual description (element intendedname) whereas the element substanceproduct describes the INN or substance based cluster prescribed by using a value from CD-INNCLUSTER. The element compoundprescription is a textual description of a compound prescription. If the information regarding the delivery of the medicinal product packag e/substance product package is available, it can be put in the delivereddcc/deliveredname elements.
			[content (cd)] Value from CD-ATCcorresponding to the medication.
			[beginmoment] Specifies when the treatment starts.
			[endmoment] Specifies when the treatment ends.
			instructionforpartient Should be built from the detailed posology related items when available. Holds the S/ part of a prescription as written by the pharmacist.
			isrelevant Must be used to distinguish between relevant and irrelevant medications. If the field is set to ‘true’, the medication is ‘relevant’.
			lifecycle Lifecycle of the medication according with from CD-LIFECYCLE. Allowed values : ‘active’ or ‘inactive’.
			[temporality] Specifies if the treatment is ‘acute’ or ‘chronic’ according to the values of CD-TEMPORALITY.
			recorddatetime Date and time of item registration
			All the item elements (such as posology, frequency) described in pharmaceutical prescription 2.0 may also be used.
vaccine	0-*	Specifies a planned or administrated vaccine	content (cd+) Description of indications for the vaccine, using values from CD-VACCINE INDICATION.
			[content (text)] Textual description of the vaccine as given by the GP (may correspond to the medicinal product description if available).
			[content (medicinalproduct \| substanceproduct)] This content should correspond to the medicinal product administrated for this vaccine (when available). The element medicinalproduct supports the identification the prepacked medicinal product by a code from CD-DRUG-CNK(element intendeddcc) and a textual description (element intendedname) whereas the element substanceproduct describes the INN or substance based cluster prescribed by using a value from CD-INNCLUSTER.
			beginmoment Specifies when the vaccine has been administrated or is planned.
			lifecycle Specifies if the vaccine is ‘planned’ or ‘administrated’
			recorddatetime Date and time of item registration
careplansubscription	0-*	Specifies a subscription to a care plan.	content(cd) Description of a care plan, by using a code from the CD-CAREPATH or CD-CLINICALPLAN.
			[content (text)] Textual description of the prevention plan subscription as given by the GP.
			isrelevant Must be used to distinguish between relevant and irrelevant care plan subscriptions. If the field is set to ‘true’, the care plan subscription is ‘relevant’.
			lifecycle Lifecycle of the prevention plan subscription according with from CD-LIFECYCLE .
			[beginmoment] Specifies when this subscription to a prevention plan was registered.
			[endmoment] Specifies when the subscription to a prevention plan was or will be ended.
			recorddatetime Date and time of item registration.