Structure for SUMEHR (Summarized Electronic Health Record)

Patient Identification

Id

Patient Presentation

Name

Forenames

Sex

Birth date

Usual language

Contact person

Author

Health care practitioner Id

GMD relationship

Risks

Allergies

Adverse drug reactions

Social factors

Other factors

Relevant personal antecedents

[ICPC2, ICD10, Other Code, Begin date, End date, text, links]

Actual problems list

[ICPC2, ICD10, Other Code, Begin date, text, links]

Actual medications

[CNK or other Id, Various administration informations, Begin date, text, links]

Vaccination status

Administrated [CNK or other Id, Date]

To be administrated [CNK or other Id, Date]

Contextual comment

Stop

(no supplementary items for the moment)

Special related software functions :

- At the end of a working session, changes in the EHR content have to trigger a notification whether Sumehr informations are concerned by these changes.

- Before exporting a Sumehr, a contextual comment could be edited.

Target for homologation : export of Sumehr (Kmehr message level 4) for any given patient and import of Sumehr for a new patient (creation of the record and structured integration of Sumehr content)

Sources : SSMG (DM transmissible), WVVH (Kerndossier), Sumehr task force, C-Care proposal, DMMG proposal.