DECOR Information for Project: International Patient Summary (IPS) (hl7ips-)

Templates

HTML Name Effective Date Version Label
Templates with direct association to a transaction
html draft International Patient Summary 2.16.840.1.113883.10.22.1.1 2017‑04‑11
The International Patient Summary is a "Minimal and non-exhaustive Patient Summary, specialty-agnostic, condition-independent, but readily usable by all clinicians for the unsched...
Transaction Direction Schematron
IPS Created rotate stationary hl7ips-hl7ips1.sch
CDA Header Level Template
html ref CDA AssignedEntity 2.16.840.1.113883.10.12.153
ref
ad1bbr-
 		2005‑09‑07
Template CDA AssignedEntity (prototype, directly derived from POCD_RM000040 MIF)
html ref CDA Organization 2.16.840.1.113883.10.12.151
ref
ad1bbr-
 		2005‑09‑07
Template CDA Organization (prototype, directly derived from POCD_RM000040 MIF)
html ref CDA Person 2.16.840.1.113883.10.12.152
ref
ad1bbr-
 		2005‑09‑07
Template CDA Person (prototype, directly derived from POCD_RM000040 MIF)
html ref epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102
ref
epsos-
 		2013‑12‑20
A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedA...
html draft IPS CDA author 2.16.840.1.113883.10.22.2.2 2017‑04‑11
A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedA...
html draft IPS CDA custodian 2.16.840.1.113883.10.22.2.3 2017‑04‑11
The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. This information is required ...
html draft IPS CDA documentationOf  2.16.840.1.113883.10.22.2.6 2017‑04‑12
The documentationOf relationship in an International Patient Summary contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care...
html draft IPS CDA legalAuthenticator 2.16.840.1.113883.10.22.2.4 2017‑04‑11
The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that ...
html draft IPS CDA Organization 2.16.840.1.113883.10.22.9.1 2017‑04‑11
This is a reusable template providing essential information for describing / identifying an organization.
html draft IPS CDA Person 2.16.840.1.113883.10.22.9.3 2017‑04‑12
Person name
html draft IPS CDA recordTarget 2.16.840.1.113883.10.22.2.1 2017‑04‑11
The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole ...
html draft IPS CDA relatedDocument 2.16.840.1.113883.10.22.2.7 2017‑04‑12
An IPS may have three types of parent document: A superseded version that the present instance of the document wholly repla...
html draft IPS Patient Contacts 2.16.840.1.113883.10.22.2.5 2017‑04‑12
The IPS may record several kinds of patient contacts, including parents, relatives, caregivers, and others related in some way to the patient. A patient contact may be an individual or an organization...
CDA Section Level Template
html draft IPS Advance Directives Section 2.16.840.1.113883.10.22.3.12 2017‑04‑13
The advance directive section shall contain a narrative description of patient's advance directive. The optional author and informant elements are used when ne...
html draft IPS Allergies and Intolerances Section 2.16.840.1.113883.10.22.3.2 2016‑11‑11
This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that c...
html draft IPS Functional Status Section 2.16.840.1.113883.10.22.3.8 2017‑04‑13
The functional status section shall contain 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...
html draft IPS History of Past Illness Section 2.16.840.1.113883.10.22.3.7 2017‑04‑12
The History of Past Illness section contains a narrative description and coded entries of the conditions the patient suffered in the past.  The optional author and informant elements are used when nec...
html draft IPS History of Pregnancy Section 2.16.840.1.113883.10.22.3.11 2017‑04‑13
The history of pregnancy section shall contain information about whether the patient is currently pregnant (optional with the Expected Delivery Date) or not. I...
html draft IPS History of Procedures Section 2.16.840.1.113883.10.22.3.4 2017‑03‑27
The History of Procedures Section contains a description of the  patient past procedures that are pertinent to the scope of this document. Procedu...
html draft IPS Immunizations Section 2.16.840.1.113883.10.22.3.5 2017‑04‑05
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...
html draft IPS Medical Devices Section 2.16.840.1.113883.10.22.3.6 2017‑04‑11
The medical devices section contains narrative text and coded entries describing the patient history of medical device use. Medical devices include, but are not limited to, implanted devices and devi...
html draft IPS Medication Summary Section 2.16.840.1.113883.10.22.3.1 2016‑11‑11
The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depen...
html draft IPS Plan of Care Section 2.16.840.1.113883.10.22.3.9 2017‑04‑13
The care plan section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the conditio...
html draft IPS Problems Section 2.16.840.1.113883.10.22.3.3 2017‑02‑15
The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient. This section can record different kinds of  problems as, but not limited to,  chr...
html draft IPS Results Section 2.16.840.1.113883.10.22.3.14 2017‑04‑30
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, oth...
html draft IPS Social History Section 2.16.840.1.113883.10.22.3.10 2017‑04‑13
The social history section contains a description of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) The opti...
html draft IPS Translation Section 2.16.840.1.113883.10.22.3.15 2017‑07‑12
Template CDA Section to carry the translations of a Parent Section
CDA Entry Level Template
html ref CDA Author (Body) 2.16.840.1.113883.10.12.318
ref
ad1bbr-
 		2005‑09‑07
Template CDA Author (prototype, directly derived from POCD_RM000040 MIF)
html ref CDA Device 2.16.840.1.113883.10.12.315
ref
ad1bbr-
 		2005‑09‑07
Template CDA Device (prototype, directly derived from POCD_RM000040 MIF)
html ref CDA Device 2.16.840.1.113883.3.1937.777.11.10.129
ref
epsos-
 		2013‑12‑20
Template CDA Device (prototype, directly derived from POCD_RM000040 MIF)
html ref CDA Informant (Body) 2.16.840.1.113883.10.12.319
ref
ad1bbr-
 		2005‑09‑07
Template CDA Informant Body (prototype, directly derived from POCD_RM000040 MIF)
html ref CDA Performer (Body) 2.16.840.1.113883.10.12.323
ref
ad1bbr-
 		2005‑09‑07
Template CDA Performer (Body) (prototype, directly derived from POCD_RM000040 MIF)
html ref CDA RelatedEntity 2.16.840.1.113883.10.12.316
ref
ad1bbr-
 		2005‑09‑07
Template CDA RelatedEntity (prototype, directly derived from POCD_RM000040 MIF)
html draft IPS Allergy and Intolerance Concern 2.16.840.1.113883.10.22.4.5 2016‑11‑11
This template reflects an ongoing concern on behalf of the person that placed the allergy on a patient’s allergy list. A concern may refer to one or more allergies or intolerances. There are different...
html draft IPS Allergy Certainty Observation 2.16.840.1.113883.10.22.10 2018‑02‑07 12:00:44
This observation represents the certainty associated with a propensity, or potential risk, of a reaction to the identified substance.
html draft IPS Allergy or Intolerance 2.16.840.1.113883.10.22.4.1 2016‑11‑10
This template reflects a discrete observation about a patient's allergy or intolerance. Because it is a discrete observation, it will have a statusCode of "completed". The eff...
html draft IPS Allergy Status Observation 2.16.840.1.113883.10.22.4.21 2017‑05‑24
This subordinated observation used by the allergy observation records information about the current status of an allergy or intolerance, for example, whether it is active, in remission, resolved, et c...
html draft IPS Body Author 2.16.840.1.113883.10.22.4.14 2017‑03‑02
This template represents the Author Participation (including the author timestamp). CDA R2 requires that Author and Author timestamp be asserted in the document header. From there, authorship propagat...
html draft IPS CDA Device 2.16.840.1.113883.10.22.9.2 2017‑04‑12
This template provides basic information about a device
html draft IPS Certainty Observation 2.16.840.1.113883.10.22.4.19 2017‑03‑29
This observation represents the verification status to support the clinical status of the condition.
html draft IPS Comment Activity 2.16.840.1.113883.10.22.4.22 2017‑04‑05
Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. F...
html draft IPS Criticality Observation 2.16.840.1.113883.10.22.4.18 2017‑03‑27
This observation represents the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual. When the ...
html rejected IPS Entry Comment 2.16.840.1.113883.3.1937.777.13.10.28 2017‑04‑07 10:00:14 0
This entry allows for a comment to be supplied with each entry. For CDA this structure is usually included in the target act using the <entryRelationship> element defined in the CDA Schema, but can al...
html cancelled IPS Entry Problem Status Observation 2.16.840.1.113883.3.1937.777.13.10.56 2017‑05‑02 18:36:45
(CCD) Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element define...
html draft IPS Immunization 2.16.840.1.113883.10.22.4.15 2017‑03‑08
An Immunization entry describes immunization substance administrations that have actually occurred. 
html draft IPS Immunization Medication Information 2.16.840.1.113883.10.22.4.16 2017‑03‑08
The Immunization Medication Information represents product information about the immunization substance. The vaccine manufacturer and vaccine lot number are typically recorded in the medical record an...
html draft IPS Internal Reference 2.16.840.1.113883.10.22.4.31 2017‑05‑02
This template is used to reference (point to) information contained in other entries within the same document.
html draft IPS Laboratory Result Observation 2.16.840.1.113883.10.22.4.13 2017‑03‑21
This template constrains the results of a clinical laboratory observation. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test...
html draft IPS Manufactured Material 2.16.840.1.113883.10.22.4.3 2016‑11‑10
This entry provides details about the medicinal product. Due to the current absence of global product id...
html draft IPS Medical Device 2.16.840.1.113883.10.22.4.26 2017‑04‑11
The medical devices entry content module describes the kind of device that is, or has been used by the patient
html draft IPS Medication Information (detail) 2.16.840.1.113883.10.22.4.2 2016‑11‑10
This entry describes the consumable subject of the medication statement. All the information about the  medication is provided in the included IPS Manufactured Material template.
html draft IPS Medication Statement 2.16.840.1.113883.10.22.4.4 2016‑11‑11
An IPS Medication entry describes a medication statement, that is a substance administration that has actually occurred (e.g., pills ingested or injections given) or are intended to ...
html draft IPS ObservationMedia 2.16.840.1.113883.10.22.4.23 2017‑04‑06
Template CDA ObservationMedia for IPS (prototype, directly derived from POCD_RM000040 MIF) This element is intended to carry a small multimedia content, like an image or a graph to be rendered in the ...
html draft IPS Pathology Result Observation 2.16.840.1.113883.10.22.4.11 2017‑03‑21
This template constrains the results of an  anatomic pathology observation. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a tes...
html draft IPS Pregnancy Expected Delivery Date Observation 2.16.840.1.113883.10.22.4.29 2017‑04‑13
This observation records the Pregnancy Expected Delivery Date for pregnant patients, expressed as a time stamp. The code reflects the method (operationalisation) of how the date was ...
html draft IPS Pregnancy Outcome Observation 2.16.840.1.113883.10.22.4.28 2017‑04‑13
A pregnancy outcome observation records a summary over all pregnancies.
html draft IPS Pregnancy Status Observation 2.16.840.1.113883.10.22.4.27 2017‑04‑13
A pregnancy status observation records whether the patient is currently pregnant or not. If pregnant, an Expected Delivery Date may be specified as an subordinate observation.
html draft IPS Problem Concern Entry 2.16.840.1.113883.10.22.4.7 2017‑02‑15
This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list.  The purpose of the concern act is that of supporting the tra...
html draft IPS Problem Entry 2.16.840.1.113883.10.22.4.8 2017‑02‑15
This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also refer...
html draft IPS Problem Status Observation 2.16.840.1.113883.10.22.4.20 2017‑03‑29
This subordinated observation used by the problem observation records information about the current status of a condition, for example, whether it is active, in remission, resolved, et cetera.
html draft IPS Procedure Entry 2.16.840.1.113883.10.22.4.17 2017‑03‑27
The procedure entry is used to record procedures that have occurred, or which are planned for in the future.
html draft IPS Radiology Result Observation 2.16.840.1.113883.10.22.4.12 2017‑03‑21
This template represents an observation produced as one of the results of a radiology or other imaging study performed on a patient.  In most cases, in the context of a patient summary this observatio...
html draft IPS Reaction Manifestation 2.16.840.1.113883.10.22.4.6 2016‑11‑15
This clinical statement represents the response to an undesired symptom, finding, etc. due to administered or exposed substance. This reaction may be an undesired symptom, finding, etc. or it could be...
html draft IPS Result Observation 2.16.840.1.113883.10.22.4.10 2017‑03‑02
This generic template is the basic set of constraints, which apply to any kind of observation grouped in a Result Organizer. The IPS Result Observation template is generic. It is further specialized b...
html draft IPS Result Organizer 2.16.840.1.113883.10.22.4.9 2017‑03‑02
This template provides a mechanism for grouping result observations. It contains information applicable to all of the contained result observations. The Result Organizer code categorizes the contained...
html draft IPS Severity Observation 2.16.840.1.113883.10.22.4.25 2017‑04‑07
This clinical statement represents the subjective assessment of the severity of the condition as evaluated by the clinician. The Severity Observation can be associated with a Reactio...
html draft IPS Social History Alcohol Use 2.16.840.1.113883.10.22.4.35 2017‑06‑29
This template is a specialization of the Social History Observation that may be used to represent alcohol consumption habits.
html draft IPS Social History Tobacco Use 2.16.840.1.113883.10.22.4.34 2017‑06‑20
This template is a specialization of the Social History Observation that may be used to represent smoking or tobacco habits.
html draft IPS Specimen Collection 2.16.840.1.113883.10.22.4.30 2017‑04‑14
Specimen Collection is used when a set of laboratory or pathology observations  produced on one or more specimens need to be associated with the minimal characteristics of the specimen(s): specimen so...
html draft IPS Subordinate SubstanceAdministration 2.16.840.1.113883.10.22.4.33 2017‑06‑15
This entry is used by a main substanceAdministration act to provide dosage information as the frequency of intakes or the amount of the medication given.
html ref UV Use Period 2.16.840.1.113883.10.21.9.1
ref
pharmcda-
 		2017‑05‑02
This element encodes the start and stop time of the medication regimen. This an interval of time (xsi:type='IVL_TS'), and must be specified as shown. This is an additional constraint placed upon CDA ...
html ref UV Use Period 2.16.840.1.113883.10.21.9.1
ref
pharmcda-
 		2017‑01‑02
HL7 V2/V3 Datatype Level Template
html draft IPS Address 2.16.840.1.113883.10.22.11 2018‑04‑04 15:41:36
Reusable address template
html rejected IPS Address 2.16.840.1.113883.10.22.12 2018‑04‑04 15:41:43
Reusable address template, for use in US Realm CDA Header.
html rejected IPS Address 2.16.840.1.113883.10.22.13 2018‑04‑04 15:42:34
Reusable address template, for use in US Realm CDA Header.
Template type not specified
html ref epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111
ref
epsos-
 		2013‑12‑20

Template Summary

Templates 77

Templates per Scenario

Templates for scenario IPS Originated hl7ips-scenario-1 as of 2017‑04‑07 11:10:54

Transaction Representing template Link as of
IPS Created hl7ips-document-template-1 International Patient Summary 2017‑04‑11

Item Labels per Template

Label Template id Template name Link as of
IHE PCC link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
IHE PCC link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
IHE PCC / R1.10.8 / R1.10.8.1 / R1.10.8.2 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
IPSSubordSBADM link11 hl7ips-entry-template-33 IPS Subordinate SubstanceAdministration 2.16.840.1.113883.10.22.4.33 2017‑06‑15
R1.10.1 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.2 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.3 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.4 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.5 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.6 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.7 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.9 link11 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102 2013‑12‑20
R1.10.9.1 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.2 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.3 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.3.1 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.3.2 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.3.3 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.3.4 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.3.5 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20
R1.10.9.4 / R1.10.9.4.1 / R1.10.9.4.2 link11 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111 2013‑12‑20

Data sets, codes, OIDs and Rules: this information is used for rendering and validation purposes.