AU Patient Summary Implementation Guide
1.0.0-ballot - Ballot

AU Patient Summary Implementation Guide - Downloaded Version 1.0.0-ballot See the Directory of published versions

## Change Log

Page standards status: Informative

### Release 1.0.0-ballot

- Publication date: 2025-02-16
- Publication status: Ballot for Working Standard
- Based on FHIR version: 4.0.1

This change log documents the significant updates and resolutions implemented from version 0.3.0-ballot to 1.0.0-ballot. The changes in this update are for ballot.

#### Changes in this version

- changed AU PS Consumer guidance to align wording with the handle obligation (replace "consume resources" with "handle") in General Requirements page AU PS: FHIR-52616.
- added plain language text clarifying the meaning of SHALL:handle obligation for AU PS Consumers in General Requirements page AU PS: FHIR-53033.
- changed Generation and Access page to retain only options in line with current community interest au-fhir-ps #91.
- updated mapping of AUCDI element Date/time of onset of first reaction in the Adverse reaction risk summary data group to be AllergyIntolerance.onset[x] AU PS: FHIR-53631.
- AU PS AllergyIntolerance:
  - changed AllergyIntolerance.reaction.manifestation binding to Adverse Reaction Clinical Manifestation (preferred) AU Base: FHIR-47076
  - removed SHOULD:display obligation on AllergyIntolerance.patient.reference for the AU PS Consumer IPS: FHIR-51258
  - changed AllergyIntolerance.code obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed AllergyIntolerance.patient obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed AllergyIntolerance.patient.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115
- AU PS Bundle:
  - changed obligations for all mandatory elements for the AU PS Producer from SHALL:able-to-populate to SHALL:populate AU PS: FHIR-51440
- AU PS Composition:
  - changed Composition.section[all slices].code cardinality from 0..1 to 1..1, and added Must Support and obligation SHALL:handle for the AU PS Consumer IPS: FHIR-51231
  - changed Composition.section.code to remove use of the CodeableConceptIPS IPS: FHIR-51231
  - removed the cardinality constraint on Composition.section[all slices].extension:section-note, changing it from 0..1 to 0..* IPS: FHIR-50271
  - removed SHOULD:display obligation on Composition.identifier, Composition.type, and Composition.subject.reference for the AU PS Consumer IPS: FHIR-51258
  - changed Composition.section[all slices].title and Composition.section[all slices].text obligations from SHALL:populate-if-known to SHALL:populate for the AU PS Producer IPS: FHIR-51259
  - added Composition.section.title and Composition.section.text with associated Must Support and obligations in each section slice AU PS: FHIR-51871
  - changed Composition.section.entry obligation for the AU PS Producer from SHOULD:populate-if-known to SHOULD:populate in the following sections AU PS: FHIR-51834:
    - Patient Summary Immunizations Section (Composition.section:sectionImmunizations)
    - Patient Summary Results Section (Composition.section:sectionResults)
    - Patient Summary History of Procedures Section (Composition.section:sectionProceduresHx)
    - Patient Summary Medical Devices Section (Composition.section:sectionMedicalDevices)
  - changed obligations for the following elements for the AU PS Producer from SHALL:able-to-populate to SHALL:populate IPS: FHIR-51972:
    - Composition.author
    - Composition.title
    - Composition.event:careProvisioningEvent.code
  - changed the following elements to use CodeableConceptIPS AU PS: FHIR-52953:
    - Composition.event:careProvisioningEvent.code
    - Composition.section[all slices].code
    - Composition.section:sectionProblems.emptyReason
    - Composition.section:sectionAllergies.emptyReason
    - Composition.section:sectionMedications.emptyReason
- AU PS Condition:
  - changed Condition.bodySite to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - removed SHOULD:display obligation on Condition.subject.reference for the AU PS Consumer IPS: FHIR-51258
  - changed Condition.code obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Condition.subject obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Condition.subject.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115
- AU PS Consumer ActorDefinition:
  - changed requirement for recommended AU PS Composition sections from SHOULD to SHALL to implement the profiles referenced by Composition.section.entry AU PS: FHIR-52345
- AU PS Encounter:
  - changed Encounter.serviceType to use CodeableConceptIPS AU PS: FHIR-51872
  - changed Encounter.participant.type to use CodeableConceptIPS AU PS: FHIR-51872
  - changed Encounter.reasonCode to use CodeableConceptIPS AU PS: FHIR-51872
- AU PS Immunization:
  - changed Immunization.site and Immunization.route to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - removed SHOULD:display obligation on Immunization.patient.reference for the AU PS Consumer IPS: FHIR-51258
  - changed Immunization.vaccineCode obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Immunization.patient obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Immunization.patient.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115
  - removed SHOULD:display obligation on Immunization.vaccineCode coding slices amtVaccineCode and airVaccineCode for the AU PS Consumer AU PS: FHIR-53077
  - changed Immunization.status obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53116
- AU PS Medication:
  - changed Medication to add a comment that the IPS guidance preferencing the use of Medication resource is not adopted by AU PS at this time AU PS: FHIR-51876
  - added profile specific implementation guidance that this resource SHALL NOT be used to represent no known current medications for a patient and MedicationStatement SHOULD be used instead AU PS: FHIR-52274
  - applied technical correction to add obligations SHALL:populate-if-known for the AU PS Producer, and SHALL:handle for the AU PS Consumer to Medication.code coding slices pbs and amt AU PS: FHIR-53374
  - changed Medication.ingredient.item[x] binding to Medication Ingredient (preferred) AU Base: FHIR-44781
- AU PS MedicationRequest:
  - changed MedicationRequest.dosageInstruction.route to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - changed MedicationRequest.doNotPerform to constrain out 'true' IPS: FHIR-51483
  - removed SHOULD:display obligation on MedicationRequest.subject.reference for the AU PS Consumer IPS: FHIR-51258
  - changed MedicationRequest.medication:medicationCodeableConcept to use CodeableConceptIPS IPS: FHIR-51970
  - changed MedicationRequest.medication[x] to add a comment that the IPS guidance preferencing the use of Medication resources, with use of medicationCodeableConcept only when no other information than a simple code is available, is not adopted by AU PS at this time AU PS: FHIR-51876
  - changed MedicationRequest.medication[x] obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate (change applied to MedicationRequest.medication[x]:medicationCodeableConcept and MedicationRequest.medication[x]:medicationReference) AU PS: FHIR-52411
  - changed MedicationRequest.subject obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed MedicationRequest.reasonCode to use CodeableConceptIPS AU PS: FHIR-52953
  - changed MedicationRequest.subject.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115
  - added profile specific implementation guidance that this resource SHALL NOT be used to represent no known current medications for a patient and MedicationStatement SHOULD be used instead AU PS: FHIR-52274
  - removed SHOULD:display obligation on MedicationRequest.medication[x]:medicationCodeableConcept coding slices pbs and amt for the AU PS Consumer AU PS: FHIR-53077
  - changed MedicationRequest.status obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53116
  - changed MedicationRequest.intent obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53116
- AU PS MedicationStatement:
  - changed MedicationStatement.dosage.route to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - removed SHOULD:display obligation on MedicationStatement.subject.reference for the AU PS Consumer IPS: FHIR-51258
  - changed MedicationStatement.medication[x] to add a comment that the IPS guidance preferencing the use of Medication resources, with use of medicationCodeableConcept only when no other information than a simple code is available, is not adopted by AU PS at this time AU PS: FHIR-51876
  - changed MedicationStatement.medication[x] obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate (change applied to MedicationStatement.medication[x]:medicationCodeableConcept and MedicationStatement.medication[x]:medicationReference) AU PS: FHIR-52411
  - changed MedicationStatement.subject obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed MedicationStatement.subject.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115
  - removed SHOULD:display obligation on MedicationStatement.medication[x]:medicationCodeableConcept coding slices pbs and amt for the AU PS Consumer AU PS: FHIR-53077
  - changed MedicationStatement.reasonCode to use CodeableConceptIPS AU PS: FHIR-52953
  - added profile specific implementation guidance for representing no known current medications for a patient AU PS: FHIR-52274
  - changed MedicationStatement.status obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53116
- AU PS Organization:
  - applied technical correction to add obligations SHALL:populate-if-known for the AU PS Producer, and SHALL:handle and SHOULD:display for the AU PS Consumer to Organization.telecom.system AU PS: FHIR-52835
  - applied technical correction to add obligations SHALL:populate-if-known for the AU PS Producer, and SHALL:handle and SHOULD:display for the AU PS Consumer to Organization.telecom.value AU PS: FHIR-52835
  - changed Organization.type to use CodeableConceptIPS AU PS: FHIR-52953
  - removed SHOULD:display obligation on the following elements for the AU PS Consumer AU PS: FHIR-52836:
    - Organization.telecom.system
    - Organization.telecom.value
- AU PS Pathology Result Observation:
  - changed Observation.interpretation to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - removed SHOULD:display obligation on Observation.subject.reference for the AU PS Consumer IPS: FHIR-51258
  - changed Observation.code obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Observation.subject obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed the following elements to use CodeableConceptIPS AU PS: FHIR-52953:
    - Observation.category:lab
    - Observation.category:specificDiscipline
    - Observation.dataAbsentReason
    - Observation.interpretation
    - Observation.referenceRange.type
    - Observation.component.code
    - Observation.value[x]:valueCodeableConcept
    - Observation.component.dataAbsentReason
  - changed Observation.subject.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115
- AU PS Patient:
  - changed Patient.contact.relationship to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - added SHOULD:able-to-populate obligation on Patient.name.text for the AU PS Producer AU PS: FHIR-51877
  - added a comment to Patient.name.text strongly recommending population of this element based on IPS guidance AU PS: FHIR-51877
  - changed Patient.communication.language to use CodeableConceptIPS AU PS: FHIR-52953
  - applied technical correction to invariants inv-pat-1 and inv-pat-2 to ensure terminology validation applies to the correct sub-extension values when multiple extension instances are present AU Base: FHIR-53536
  - removed SHOULD:display obligation on the following elements for the AU PS Consumer AU PS: FHIR-52836:
    - Patient.telecom.system
    - Patient.telecom.value
    - Patient.telecom.use
- AU PS PractitionerRole:
  - applied technical correction to add obligations SHALL:populate-if-known for the AU PS Producer, and SHALL:handle and SHOULD:display for the AU PS Consumer to PractitionerRole.telecom.system AU PS: FHIR-52837
  - applied technical correction to add obligations SHALL:populate-if-known for the AU PS Producer, and SHALL:handle and SHOULD:display for the AU PS Consumer to PractitionerRole.telecom.value AU PS: FHIR-52837
  - removed SHOULD:display obligation on the following elements for the AU PS Consumer AU PS: FHIR-52836:
    - PractitionerRole.telecom.system
    - PractitionerRole.telecom.value
- AU PS Procedure:
  - changed Procedure.bodySite to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - removed SHOULD:display obligation on Procedure.subject.reference for the AU PS Consumer IPS: FHIR-51258
  - changed Procedure.code obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Procedure.subject obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Procedure.reasonCode to use CodeableConceptIPS AU PS: FHIR-52953
  - changed Procedure.subject.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115
  - changed Procedure.status obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53116
- AU PS RelatedPerson:
  - removed SHOULD:display obligation on the following elements for the AU PS Consumer AU PS: FHIR-52836:
    - RelatedPerson.name.use
    - RelatedPerson.name.family
    - RelatedPerson.name.given
- AU PS Smoking Status:
  - changed Observation.valueCodeableConcept to remove use of the CodeableConceptIPS IPS: FHIR-51257
  - removed SHOULD:display obligation on Observation.subject.reference for the AU PS Consumer IPS: FHIR-51258
  - changed Observation.code obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed Observation.subject obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-52411
  - changed the following elements to use CodeableConceptIPS AU PS: FHIR-52953:
    - Observation.category
    - Observation.category:socialHistory
    - Observation.value[x]
    - Observation.dataAbsentReason
  - changed Observation.subject.reference obligation for the AU PS Producer from SHALL:populate-if-known to SHALL:populate AU PS: FHIR-53115