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Patient Summary
To ensure interoperability, certain standardizations are followed. All data is encrypted. "MyHealth@EU" periodically publishes the Master Value Catalogue, which includes standards and definitions to ensure that health information is consistent and understandable across all participating systems and organizations. This catalogue incorporates codings from various Value Sets, such as ICD-10 for diagnoses, SNOMED CT for clinical terms, ATC for drug classification, and EDQM Standard Terms for the descriptions of pharmaceutical products.
Figure 3.1:
Patient Clinical Data
Patient Clinical Data comprises five mandatory sections that must always be included in a Patient Summary Health History:
- Allergies (and intolerances)
- Current problems and diagnoses
- Medical devices (implanted or external)
- Major interventions
- List of current medications
They also include several optional modules, such as:
- Vaccinations
- Problems that no longer exist
- Social history (e.g., smoking, alcohol consumption)
- Pregnancy history (for women)
Figure 3.2:
Figure 3.3:
Figure 3.4:
