Sumehr

Definition

	The Summarized Electronic Health Record is the minimal set of data that a physician needs to understand the medical status of the patient in a few minutes and to ensure the continuity of care.
	Specification from the Label working group

How to build a sumehr message ?

Once your header is ready, you should build the transaction element as follows:

bold means mandatory italic means optional

id(s)	Each transaction must have an id which is its sequential position within the folder according to the ID-KMEHR convention. The unique number of your transaction within the Belgian healthcare Telematics system is obtained by the concatenation of the header.id, a dot, the folder.id, a dot,the transaction.id. In addition to this, you can always add your own local transaction identifiers.
cd(s)	You must use the value sumehr from CD-TRANSACTION. You can always add your own local codes.
date	This is the date when the summary has been produced.
time	This is the time when the summary has been produced.
author	This is the the person assuming the responsibility of medical content of the sumher record. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person. If you do not know the ID-HCPARTY, please apply the same rule as for the message.sender.
iscomplete	By definition, a sumehr record must be complete. Therefore, the value must be true.
isvalidated	By definition, a sumehr record must be validated. Therefore, the value must be true.
item(s)	The following items from CD-ITEM must be used to compose a sumehr transaction.
	Item Purpose adr to specify an adverse drug reaction allergy to specify an allergy socialrisk to specify a social risk factor risk to specify other risk factors gmdmanager to identify the manager of the global medical record, using a hcparty element. contactperson to specify a contact person ntbr to specify if the patient is not to be ressuscitated, using a boolean content. The patient should not be ressuscitated if the value is 'true'. bloodtransfusionrefusal to specify if the patient refuses blood transfusion, using a boolean content. The patient should not receive blood if the value is 'true'. vaccine to describe each vaccine administration cd(s) The item must have a cd with the value vaccine from CD-ITEM. content The vaccine item can make use of the medication specialised element medication cd must refer to a national CNK code or a HYRCV vaccine code tradename specifies the commercial name as free text presentation specifies the galenic form using a value from CD-DRUG-PRESENTATION strength specifies the strength of an administration unit using a decimal and a unit from CD-UNIT route specifies the administration route using a value of from CD-DRUG-ROUTE batch specifies the serial number of the batch as free text. or text if the product can not be described more precisely beginmoment specifies the date (and time) when the vaccine has been (or will be) administrated. This can be used for planning. lifecycle must specify if the doses has been administrated or if it is planned for later, using a value from CD-LIFECYCLE. medication to describe the actual medications (one item per product) cd(s) The item must have a cd with the value medication from CD-ITEM. content The vaccine item must use the medication specialised element medication cd must refer to a national CNK code or inn specifies the international non-proprietary name as free text tradename specifies the commercial name as free text presentation specifies the galenic form using a value from CD-DRUG-PRESENTATION strength specifies the strength of an administration unit using a decimal and a unit from CD-UNIT route specifies the administration route using a value of from CD-DRUG-ROUTE batch specifies the serial number of the batch as free text. ... beginmoment specifies the date (and time) when the treatment starts. endmoment specifies the date (and time) when the treatment ends. healthcareelement to describe the actual problems (one item per problem) cd(s) The item must have a cd with the value healthcareelement from CD-ITEM. content The healthcareelement can make use of text elements or a combination of one or several cd(s) that refer to ICD10 codes or ICPC2 codes beginmoment specifies the date (and time) when the problem started. healthcareelement to describe the patient's relevant antecedents (one item per antecedent) cd(s) The item must have a cd with the value healthcareelement from CD-ITEM. content The healthcareelement can make use of text elements or a combination of one or several cd(s) that refer to ICD10 codes or ICPC2 codes beginmoment specifies the date (and time) when the problem started. endmoment this can be used to specify when the problem finished. lifecycle must be used to differentiate this item from actual problems, using the value inactive from CD-LIFECYCLE.

Examples

• Sumehr