AU Patient Summary Implementation Guide
0.4.0-draft - Draft

AU Patient Summary Implementation Guide - Local Development build (v0.4.0-draft) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Example Bundle: Bundle - Patient Summary for Joyce Johnson as of 28 OCT 2024 (with electronic signature)

Document Details

Profile: AU PS Bundle

Final Document at 2024-10-28 11:57:10+1100 by Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100 for Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

Document Subject

Profile: AU PS Patient

Joyce JOHNSON Female, DoB: 1985-02-06 ( IHI: Austalian Healthcare Identifier - Individual#8003608500314679)

Other Id: | Medicare Number/29545401611
Contact Detail | ph: 0270108012(Home) ph: 0491571804(Mobile) 139 River Lane Palmvale NSW 2484 AU
Links: | General Practitioner: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100
Australian Indigenous Status | australian-indigenous-status-1 4: Neither Aboriginal nor Torres Strait Islander origin

Document Content

## Allergies and Intolerances

No known allergies.

## Medication Summary

Medicine | Dose | Status | Last Updated | Comment
--- | --- | --- | --- | ---
Prenatal vitamins | 1 tablet daily | Active | 28/10/2024 | Pt prefers Blackmores
Insulin (Humulin N) | 10 units subcutaneously in the morning and evening | Active | 28/10/2024 |
Insulin (Humulin R) | 5 units subcutaneously before each meal | Active | 28/10/2024 |
Metformin | 500mg twice daily | Active | 28/10/2024 |

## Problem list

Problem/Diagnosis | Status | Comment
--- | --- | ---
Gestational diabetes | Active | Recent diagnosis, referring to Endo & Dietitian
Anaemia | Active |

## History of Immunizations

Vaccine | Date of administration | Comment
--- | --- | ---
Diphtheria + tetanus + pertussis 5 component adolescent/adult vaccine injection, 0.5 mL syringe | 05/10/2024 |
Influenza vaccine | 05/05/2024 |
Influenza vaccine | 15/05/2023 | Pt reported localised redness and swelling post previous flu vax last year. Monitor for rxn.
COVID-19 mRNA-1273 Vaccine (Moderna) injection, 0.5 mL syringe | 15/05/2023 |

## Pregnancy Information

Pregnancy confirmed 12/06/2024. Estimated Date of Delivery 03/02/2025.

## Social History

Joyce is a 39-year-old woman who is currently pregnant and lives with her partner in a stable home environment. She works in an office-based job, which involves prolonged periods of sitting, but she attempting to increase her activity outside of work through regular walks and light exercise. She has a strong support system, including her partner, family, and close friends. Joyce does not smoke and does not consume alcohol during pregnancy. She follows a generally balanced diet but occasionally consumes convenience foods due to her busy work schedule. She has access to healthcare services and attends routine antenatal appointments as recommended. She reports moderate stress related to work responsibilities and preparing for the baby’s arrival but manages it through mindfulness techniques and social support. Financially, she and her partner are stable, with plans in place for parental leave and childcare. She has no history of substance use and is not exposed to occupational hazards that would pose a risk to her pregnancy. Overall, Joyce maintains a healthy and supportive lifestyle, with good access to medical care and a positive outlook on her pregnancy.

## Additional Resources Included in Document

Entry 2 - fullUrl = urn:uuid:85822a88-55b1-460c-bb7b-e8fc22d8568f

Resource Patient:

> Profile: AU PS Patient

> Joyce JOHNSON Female, DoB: 1985-02-06 ( IHI: Austalian Healthcare Identifier - Individual#8003608500314679)

> Other Id: | Medicare Number/29545401611
> Contact Detail | ph: 0270108012(Home) ph: 0491571804(Mobile) 139 River Lane Palmvale NSW 2484 AU
> Links: | General Practitioner: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100
> Australian Indigenous Status | australian-indigenous-status-1 4: Neither Aboriginal nor Torres Strait Islander origin

Entry 3 - fullUrl = urn:uuid:0baac8a9-69b8-4e99-9460-03df08f92c98

Resource AllergyIntolerance:

> Profile: AU PS AllergyIntolerance

> clinicalStatus: Active

> code: No known allergy

> patient: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

Entry 4 - fullUrl = urn:uuid:05292a9c-2bc9-43a7-b935-0a61ede063da

Resource MedicationStatement:

> Profile: AU PS MedicationStatement

> status: recorded

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> effective: 2024 --> (ongoing)

> dateAsserted: 2024-10-24

> ### Dosages

> - | Text | Timing | Route
> * | 500mg twice daily | 2 per 1 day | Oral route

> > Profile: AU PS Medication

> > code: Metformin

Entry 5 - fullUrl = urn:uuid:166c2afe-c6fb-4928-88f0-1c1a1e5e65cd

Resource MedicationStatement:

> Profile: AU PS MedicationStatement

> status: recorded

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> effective: 2024 --> (ongoing)

> dateAsserted: 2024-10-24

> note:

> > Pt prefers Blackmores

> ### Dosages

> - | Text | Route
> * | 1 tablet daily | Oral route

Entry 6 - fullUrl = urn:uuid:7193cc2f-d03e-42cb-ab55-4130904505d5

Resource MedicationStatement:

> Profile: AU PS MedicationStatement

> status: recorded

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> effective: 2024 --> (ongoing)

> dateAsserted: 2024-10-24

> ### Dosages

> - | Text
> * | 10 units subcutaneously in the morning and evening

Entry 7 - fullUrl = urn:uuid:1c4dd2b6-a9ee-4ba3-9b37-c1aff277c417

Resource MedicationStatement:

> Profile: AU PS MedicationStatement

> status: recorded

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> effective: 2024 --> (ongoing)

> dateAsserted: 2024-10-24

> ### Dosages

> - | Text
> * | 5 units subcutaneously before each meal

Entry 8 - fullUrl = urn:uuid:cb647933-b18c-42ef-a1c8-ae137921ba83

Resource Condition:

> Profile: AU PS Condition

> clinicalStatus: Active

> category: Problem

> code: Gestational diabetes

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> note:

> > Recent diagnosis, referring to Endo & Dietitian

Entry 9 - fullUrl = urn:uuid:78f75926-3ee1-44a7-9424-6178d905af63

Resource Condition:

> Profile: AU PS Condition

> clinicalStatus: Active

> category: Problem

> code: Anaemia

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

Entry 10 - fullUrl = urn:uuid:784ae7d5-22df-442d-b932-0c001720136c

Resource Immunization:

> Profile: AU PS Immunization

> status: Completed

> vaccineCode: Diphtheria + tetanus + pertussis 5 component adolescent/adult vaccine injection, 0.5 mL syringe

> patient: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> occurrence: 2024-10-05

Entry 11 - fullUrl = urn:uuid:ad82d71b-ca1c-4db6-a726-cc70cf638306

Resource Observation:

> Profile: Observation Pregnancy - Expected Delivery Date (IPS)

> status: Final

> category: Imaging

> code: Estimated date of delivery

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> effective: 2024-06-12

> value: 2025-02-03

Entry 12 - fullUrl = urn:uuid:f85ad223-7bed-46f3-893d-e89d6082f9a9

Resource Observation:

> Profile: Observation Pregnancy - Status (IPS)

> status: Final

> category: Social History

> code: Pregnancy status

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> effective: 2024-06-12

> value: Pregnant

> hasMember: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

Entry 13 - fullUrl = urn:uuid:afead11c-3bee-4020-af4f-44040abfa961

Resource PractitionerRole:

> Profile: AU PS PractitionerRole

> identifier: Medicare Provider Number/2448681J

> practitioner: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> organization: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> code: General Practitioner

> specialty: General medical practice

Entry 14 - fullUrl = urn:uuid:0c0e2c4f-a748-4cc7-afde-f09bdc2d6fa9

Resource Practitioner:

> Profile: AU PS Practitioner

> identifier: HPI-I/8003618233385011

> name: Ginger BURROWS

> telecom: ph: 0270105673(Work), ginger.burrows@bungabbeemc.example.com.au

> address: 189 Bay Esp Bungabbee NSW 2480

Entry 15 - fullUrl = urn:uuid:14292353-98f0-43b3-a25b-406baf3f9175

Resource Organization:

> Profile: AU PS Organization

> identifier: HPI-O/8003624900039170, ABN/81156248664

> type: General practice medical clinic service

> name: Bungabbee Medical Clinic

> > contact

> > telecom: ph: 0255506327(Work), info@bungabbeemc.example.com.au

> > address: 158 Toby Ave Bungabbee NSW 2480

Entry 16 - fullUrl = urn:uuid:62eb70e3-e814-4785-80d3-8aa45b1fc367

Resource Immunization:

> Profile: AU PS Immunization

> status: Completed

> vaccineCode: Panvax

> patient: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> occurrence: 2023-05-15

> primarySource: true

> note:

> > Pt reported localised redness and swelling post previous flu vax last year. Monitor for rxn.

Entry 17 - fullUrl = urn:uuid:2f3537b2-f50c-4a2a-ab92-30fdcfe5fd96

Resource Immunization:

> Profile: AU PS Immunization

> Vaccine Vial Serial Number: SERIAL1234

> status: Completed

> vaccineCode: Panvax

> lotNumber: lot001

> patient: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> occurrence: 2024-05-05

> primarySource: true

Entry 18 - fullUrl = urn:uuid:97767fb5-3be7-4d16-9ee8-76c47a4ab0ce

Resource Immunization:

> Profile: AU PS Immunization

> Vaccine Vial Serial Number: vNo1111

> status: Completed

> vaccineCode: COVID-19 mRNA-1273 Vaccine (Moderna) injection, 0.5 mL syringe

> manufacturer: No display for Immunization.manufacturer (reference: ->display: string (PrimitiveType/Bundle.entry[17].resource.manufacturer.reference.display): native = string -> ModernaTX, Inc.)

> lotNumber: RX00000F

> patient: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> occurrence: 2023-05-15

> primarySource: true

Entry 19 - fullUrl = urn:uuid:8924f910-53b3-4125-b0f2-58d0068f8983

Resource Observation:

> Profile: AU PS Smoking Status

> status: Final

> category: Social History

> code: Smoking status

> subject: Bundle: identifier = UUID:b1398367-c580-412f-a34e-a09bab5d0bf2; type = document; timestamp = 2024-11-07 10:02:11+1100

> effective: 2024-10-28

> value: Lifetime non-smoker