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 07 NOV 2024 (with digital signature)

Document Details

Profile: AU PS Bundle

Final Document at 2024-11-07 10:02:10+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

Type | Substance | Date/time of onset of first reaction | Manifestation | Severity of reaction | Comment
--- | --- | --- | --- | --- | ---
Allergy | Prawns | 18:50 02/11/2024 | Itchy throat | Mild | Pt stated had prawns with dinner and noticed itchy throat, never experienced this before

## Medication Summary

Medicine | Dose | Clinical Indication | 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 |
Trimethoprim | 300mg daily for 3 days | Urinary tract infection (UTI) | Active | 04/11/2024 |

## Problem list

Problem/Diagnosis | Status | Comment
--- | --- | ---
Gestational diabetes | Active | Recent diagnosis, referring to Endo & Dietitian
Anaemia | Active |
Urinary tract infection (UTI) | Active | Patient reported symptoms of UTI. MSU to confirm

## 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 |
Influenza vaccine | 01/06/2022 |
Covid vaccine - Pfizer | 02/02/2022 |
Covid vaccine - Pfizer | 20/07/2021 |
Influenza vaccine | 17/05/2021 |
Covid vaccine - Pfizer | 27/04/2021 |
Influenza vaccine | 03/05/2020 |

## Past Medical History (Problems)

Problem/Diagnosis | Status | Onset Date | Comment
--- | --- | --- | ---
Appendicitis | Resolved | 03/2000 |
Upper respiratory tract infection | Resolved | 10/2022 |
First degree burn, Upper shoulders and back | Resolved | 02/01/2005 | Severe sunburn, upper shoulders and back

## Pregnancy Information

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

## Result History

Test Name | Test Result | Date
--- | --- | ---
Glucose Tolerance Test (GTT) Fasting | 5.3 mmol/L | 21/10/2024
Glucose Tolerance Test (GTT) 1 hour | 10.0 mmol/L | 21/10/2024
Glucose Tolerance Test (GTT) 2 hour | 8.6 mmol/L | 21/10/2024
Haemoglobin A1c | 5.8 % | 14/06/2024

## Social History

Lifetime non-smoker 28/10/2024

## 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:f7bd83e4-2a4e-40be-8467-8a29b667ef46

Resource AllergyIntolerance:

> Profile: AU PS AllergyIntolerance

> clinicalStatus: Active

> verificationStatus: Unconfirmed

> type: Allergy

> code: Prawns

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

> onset: 2024-11-02 18:50:00+1100

> recordedDate: 2024-11-04

> note:

> > Pt stated had prawns with dinner and noticed itchy throat, never experienced this before

> ### Reactions

> - | Manifestation | Severity
> * | No display for AllergyIntolerance.reaction.manifestation (concept: ) | Mild

Entry 4 - fullUrl = urn:uuid:cbe37f4b-e84b-4f34-8490-f21da27f1aa9

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: 2024-11-04 --> (ongoing)

> dateAsserted: 2024-11-04

> ### Dosages

> - | Text | Timing | Route
> * | 300mg daily for 3 days | 3 per 1 day | Oral route

> > Profile: AU PS Medication

> > code: Trimethoprim

Entry 5 - 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 6 - 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 7 - 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 8 - 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 9 - 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 10 - fullUrl = urn:uuid:07034a67-66ce-4d29-95ab-1ef7e964a873

Resource Condition:

> Profile: AU PS Condition

> clinicalStatus: Active

> verificationStatus: Provisional

> category: Problem

> code: Urinary tract infection (UTI)

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

> note:

> > Patient reported symptoms of UTI. MSU to confirm.

Entry 11 - 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 12 - fullUrl = urn:uuid:289aff01-0b3e-4614-aee8-378d074fc3d2

Resource Condition:

> Profile: AU PS Condition

> clinicalStatus: Resolved

> category: Problem

> code: Appendicitis

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

Entry 13 - fullUrl = urn:uuid:e6db9bbe-60c3-4f89-8f65-25c58771fe41

Resource Condition:

> Profile: AU PS Condition

> clinicalStatus: Resolved

> category: Problem

> code: Upper respiratory tract infection

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

Entry 14 - fullUrl = urn:uuid:dc422222-8b3a-4dd5-96b5-b7e0cf43b477

Resource Condition:

> Profile: AU PS Condition

> clinicalStatus: Resolved

> category: Problem

> code: First degree burn, Upper shoulders and back

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

> note:

> > Severe sunburn, upper shoulders and back

Entry 15 - 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 16 - 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 17 - 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 18 - 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 19 - 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 20 - 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 21 - fullUrl = urn:uuid:46624cc1-7d2e-4367-aa82-85d097ac423f

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: 2022-06-01

> primarySource: true

Entry 22 - fullUrl = urn:uuid:5711e015-890f-489d-9f8f-49d9a7ff95cd

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: 2021-05-17

> primarySource: true

Entry 23 - 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 24 - 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 25 - fullUrl = urn:uuid:c4e7d351-cd85-435d-9fa5-2db04108651f

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: 2020-05-03

> primarySource: true

Entry 26 - 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[25].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 27 - fullUrl = urn:uuid:40a0b552-b0ea-4283-b33e-a5d2e26ed20f

Resource Immunization:

> Profile: AU PS Immunization

> Vaccine Vial Serial Number: vNo1111

> status: Completed

> vaccineCode: Pfizer Comirnaty

> manufacturer: No display for Immunization.manufacturer (reference: ->display: string (PrimitiveType/Bundle.entry[26].resource.manufacturer.reference.display): native = string -> Pfizer Australia Ltd)

> lotNumber: 300000000P

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

> occurrence: 2021-07-20

> primarySource: true

> site: Left upper arm

Entry 28 - fullUrl = urn:uuid:fac8c42e-4d2a-4cf5-bcc6-831c60e8230e

Resource Immunization:

> Profile: AU PS Immunization

> identifier: Uniform Resource Identifier (URI)/urn:uuid:475db616-dfd5-43f3-b935-9f582233a38d

> status: Completed

> vaccineCode: Pfizer Comirnaty

> manufacturer: No display for Immunization.manufacturer (reference: ->display: string (PrimitiveType/Bundle.entry[27].resource.manufacturer.reference.display): native = string -> Pfizer Australia Ltd)

> lotNumber: 500000000P

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

> occurrence: 2022-02-02

> primarySource: true

> site: Left upper arm

Entry 29 - fullUrl = urn:uuid:eb1f812e-41c6-4f8d-b9de-573428a94994

Resource Immunization:

> Profile: AU PS Immunization

> status: Completed

> vaccineCode: Pfizer Comirnaty

> manufacturer: No display for Immunization.manufacturer (reference: ->display: string (PrimitiveType/Bundle.entry[28].resource.manufacturer.reference.display): native = string -> Pfizer Australia Ltd)

> lotNumber: 200000000P

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

> occurrence: 2021-04-27

> primarySource: true

> site: Left upper arm

Entry 30 - fullUrl = urn:uuid:5f1b9790-4892-4af3-9b76-3cb4f854a5b1

Resource Observation:

> Profile: AU PS Pathology Result Observation

> status: Final

> category: Laboratory

> code: Glucose Tolerance Test (GTT) 2 hour

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

> effective: 2024-10-21

> performer: ?rref?

> value: 8.6 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 31 - fullUrl = urn:uuid:1bbd2e05-161d-4030-975c-0cca3ef97cdb

Resource Observation:

> Profile: AU PS Pathology Result Observation

> status: Final

> category: Laboratory

> code: Glucose Tolerance Test (GTT) Fasting

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

> effective: 2024-10-21

> performer: ?rref?

> value: 5.3 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 32 - fullUrl = urn:uuid:27060cbf-e30e-4091-bd64-7d4ef40916ac

Resource Observation:

> Profile: AU PS Pathology Result Observation

> status: Final

> category: Laboratory

> code: Glucose Tolerance Test (GTT) 1 hour

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

> effective: 2024-10-21

> performer: ?rref?

> value: 10 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 33 - fullUrl = urn:uuid:fc061f59-5410-41e9-945e-3f59664e8611

Resource Observation:

> Profile: AU PS Pathology Result Observation

> status: Final

> category: Laboratory

> code: Haemoglobin A1c

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

> effective: 2024-06-14

> performer: ?rref?

> value: 5.8 % (Details: UCUM code% = '%')

Entry 34 - 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

Entry 35 - fullUrl = urn:uuid:40c3b2a7-e673-4f83-8dd8-2b112a88775e

Resource Device:

> identifier: `http://example.com/CIS-ID`/12345

> manufacturer: Some Clinical Information System Manufacturer

> modelNumber: 2.0.1

> type: Clinical information system