Return PS of country A

Patient Data

Identification

National Health Care patient ID (country of affiliation):
National Health Care patient ID (country of treatment):
Other Identifier:

Personal Information

Full Name

Given name:
Family Name/Surname:
Prefix:
Suffix:

Date of Birth:

Gender:

Contact Information

Address

Street:
Number of Street:
City:
Postal Code:
State or Province:
Country:

Telecom

Telephone No:
Email:

Preferred HP to contact

Full Name

Given Name:
Family Name/Surname:
Prefix:
Suffix:

Telephone No:

Email:

Legal Organization to contact

Organization Name:
Telephone No:
Email:

Contact Person/legal guardian

Role of that person:

Full Name

Given Name:
Family Name/Surname:
Prefix:
Suffix:

Telephone No:

Email:

Insurance Information

Insurance Number:

Clinical Data

Alerts

Allergy

Allergy description:
Allergy code:
Onset Date:
Agent description:
Agent Code:

Medical Alert Information

Health Care Alert code:
Health Care Alert description:

History of Past Illness

Problem/Diagnosis

Problem/diagnosis Description:
Problem/diagnosis Id (Code):
Problem Status:
Problem Severity:
Onset Time:
End date:
Resolution Circumstances:

Vaccination

Vaccine brand name:
Vaccine description:
Vaccine code:
Vaccination date:

Surgical Procedure

Procedure description:
Procedure Id (code):
Procedure Date:

Medical Problems

Problem/Diagnosis

Problem/diagnosis Description:
Problem/diagnosis Id (Code):
Problem Status:
Problem Severity:
Onset Time:
End date:
Resolution Circumstances:

Surgical Procedure

Procedure description:
Procedure Id (code):
Procedure Date:

Medical Devices and Implants

Medical Devices and Implants Description:
Device Code:
Implant Date:

Treatments

Treatment description:
Treatment code:
Onset time:

Care plan

Recommendations Description:
Recommendations Id (code):

Disability or function

Invalidity description:
Onset time:

Medication

Prescription

Prescription identification:

Medicinal product code:

Date of issue of prescription:

Brand name:

Active ingredient:

Active ingredient code:

Strength:

Medicinal product package size:

Pharmaceutical dose form:

Number of packages:

Number of units per intake:

Frequency of intakes:

Duration of treatment:

Date of onset of treatment:

Route of administration:

Instructions to patient:

Advice to dispenser:

Prescriber

Prescriber Profession:

Prescriber Speciality:

Timestamp of Prescribing:

Prescriber Identification:

Prescriber Full Name

Given Name:
Family Name/Surname:
Prefix:
Suffix:

Prescriber Telecom

Telephone No:
Email:

Prescriber Healthcare Facility

Identifier:

Name:

Healthcare Facility Telecom

Telephone No:
Email:

Prescriber Credentialing Organization

Identifier:
Name:

Surgical Procedure

Procedure description:
Procedure Id (code):
Procedure Date:

Problem/Diagnosis

Problem/diagnosis Description:
Problem/diagnosis Id (Code):
Problem Status:
Problem Severity:
Onset Time:
End date:
Resolution Circumstances:

Physical Findings

Vital Signs Observations

Blood Pressure

Systolic Blood Pressure:	mm[Hg]
Diastolic Blood Pressure:	mm[Hg]

Date when blood pressure was measured:

Diagnostic Tests

Blood Group

Result of Blood Group:
Date:

Vaccination

Vaccine brand name:
Vaccine description:
Vaccine code:
Vaccination date:

Allergy

Allergy description:
Allergy code:
Allergy Severity:
Onset Date:
Agent description:
Agent Code:

Pregnancy History

Expected date of delivery:

Social History

Social History Observations

Social History Observations related to: smoke, alcohol and diet:
Date range of observation:

Document Data

Identification:

Type:

Confidentiality:

Language:

Country A:

Topicality

Date Created:

Author

Author Identification:

Author Full Name

Given Name:
Family Name/Surname:
Prefix:
Suffix:

Author Healthcare Facility

Identifier:
Name: