Patient - FHIR v5.0.0 (original) (raw)

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

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8.1 Resource Patient - Content

Patient Administration Work Group	Maturity Level: N	Normative (from v4.0.0)	Security Category: Patient	Compartments: Patient, Practitioner, RelatedPerson

Demographics and other administrative information about an individual or animal receiving care or other health-related services.

8.1.1 Scope and Usage

This Resource covers data about patients and animals involved in a wide range of health-related activities, including:

• Curative activities
• Psychiatric care
• Social services
• Pregnancy care
• Nursing and assisted living
• Dietary services
• Tracking of personal health and exercise data
• Tracking financial services (e.g. insurance subscriber/policy holder)

The data in the Resource covers the "who" information about the patient: its attributes are focused on the demographic information necessary to support the administrative, financial and logistic procedures. A Patient record is generally created and maintained by each organization providing care for a patient. A patient or animal receiving care at multiple organizations may therefore have its information present in multiple Patient Resources.

Not all concepts are included within the base resource (such as race, ethnicity, organ donor status, nationality, etc.), but may be found in profiles defined for specific jurisdictions (e.g., US Meaningful Use Program) or standard extensions. Such fields vary widely between jurisdictions and often have different names and valuesets for the similar concepts, but they are not similar enough to be able to map and exchange.

8.1.2 References to this Resource

• Implements: ParticipantLiving
• Resource References: Account, ActivityDefinition, AdverseEvent, AllergyIntolerance, Annotation... Show 83 more, Appointment, AppointmentResponse, ArtifactAssessment, AuditEvent, Basic, BiologicallyDerivedProduct, BiologicallyDerivedProductDispense, BodyStructure, CarePlan, CareTeam, ChargeItem, Claim, ClaimResponse, ClinicalImpression, Communication, CommunicationRequest, Composition, Condition, Consent, Contract, Coverage, CoverageEligibilityRequest, CoverageEligibilityResponse, DetectedIssue, DeviceAssociation, DeviceDispense, DeviceRequest, DeviceUsage, DiagnosticReport, DocumentReference, Encounter, EncounterHistory, EnrollmentRequest, EpisodeOfCare, EvidenceReport, ExplanationOfBenefit, FamilyMemberHistory, Flag, GenomicStudy, Goal, Group, GuidanceResponse, ImagingSelection, ImagingStudy, Immunization, ImmunizationEvaluation, ImmunizationRecommendation, InventoryItem, InventoryReport, Invoice, List, MeasureReport, MedicationAdministration, MedicationDispense, MedicationRequest, MedicationStatement, MolecularSequence, NutritionIntake, NutritionOrder, Observation, itself, PaymentReconciliation, Permission, Person, PlanDefinition, Procedure, Provenance, QuestionnaireResponse, RelatedPerson, RequestOrchestration, Requirements, ResearchSubject, RiskAssessment, Schedule, ServiceRequest, Signature, Specimen, Subscription, SupplyDelivery, SupplyRequest, Task, Transport and VisionPrescription
• Extension References: AuditEvent agent OnBehalfOf, Consent Transcriber, Consent Witness, Contact detail reference, DocumentReference Source Patient... Show 8 more, FamilyMemberHistory Patient Record, Goal acceptance, List For Extension, Procedure Directed By, QuestionnaireResponse Attester, QuestionnaireResponse Author, Receiving person and initiating person

8.1.3Resource Content

• Structure
• UML
• XML
• JSON
• Turtle
• R4 Diff
• All

JSON Template

{ "resourceType" : "Patient", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // An identifier for this patient "[active](patient-definitions.html#Patient.active "Whether this patient record is in active use. Many systems use this property to mark as non-current patients, such as those that have not been seen for a period of time based on an organization's business rules.

It is often used to filter patient lists to exclude inactive patients

Deceased patients may also be marked as inactive for the same reasons, but may be active for some time after death (this element modifies the meaning of other elements)")" : <boolean>, // Whether this patient's record is in active use "name" : [{ HumanName }], // A name associated with the patient "telecom" : [{ ContactPoint }], // A contact detail for the individual "gender" : "<code>", // male | female | other | unknown "birthDate" : "<date>", // The date of birth for the individual // deceased[x]: Indicates if the individual is deceased or not. One of these 2: "deceasedBoolean" : <boolean>, "deceasedDateTime" : "<dateTime>", "address" : [{ Address }], // An address for the individual "maritalStatus" : { CodeableConcept }, // Marital (civil) status of a patient // multipleBirth[x]: Whether patient is part of a multiple birth. One of these 2: "multipleBirthBoolean" : <boolean>, "multipleBirthInteger" : <integer>, "photo" : [{ Attachment }], // Image of the patient "contact" : [{ // A contact party (e.g. guardian, partner, friend) for the patient "relationship" : [{ CodeableConcept }], // The kind of relationship "name" : { HumanName }, // I A name associated with the contact person "telecom" : [{ ContactPoint }], // I A contact detail for the person "address" : { Address }, // I Address for the contact person "gender" : "<code>", // male | female | other | unknown "organization" : { Reference(Organization) }, // I Organization that is associated with the contact "period" : { Period } // The period during which this contact person or organization is valid to be contacted relating to this patient }], "communication" : [{ // A language which may be used to communicate with the patient about his or her health "[language](patient-definitions.html#Patient.communication.language "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-AU" for Australian English.")" : { CodeableConcept }, // R! The language which can be used to communicate with the patient about his or her health "preferred" : <boolean> // Language preference indicator }], "generalPractitioner" : [{ Reference(Organization|Practitioner| PractitionerRole) }], // Patient's nominated primary care provider "managingOrganization" : { Reference(Organization) }, // Organization that is the custodian of the patient record "link" : [{ // Link to a Patient or RelatedPerson resource that concerns the same actual individual "other" : { Reference(Patient|RelatedPerson) }, // R! The other patient or related person resource that the link refers to "type" : "<code>" // R! replaced-by | replaces | refer | seealso }] }

JSON Template

{ "resourceType" : "Patient", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // An identifier for this patient "[active](patient-definitions.html#Patient.active "Whether this patient record is in active use. Many systems use this property to mark as non-current patients, such as those that have not been seen for a period of time based on an organization's business rules.

It is often used to filter patient lists to exclude inactive patients

Deceased patients may also be marked as inactive for the same reasons, but may be active for some time after death (this element modifies the meaning of other elements)")" : <boolean>, // Whether this patient's record is in active use "name" : [{ HumanName }], // A name associated with the patient "telecom" : [{ ContactPoint }], // A contact detail for the individual "gender" : "<code>", // male | female | other | unknown "birthDate" : "<date>", // The date of birth for the individual // deceased[x]: Indicates if the individual is deceased or not. One of these 2: "deceasedBoolean" : <boolean>, "deceasedDateTime" : "<dateTime>", "address" : [{ Address }], // An address for the individual "maritalStatus" : { CodeableConcept }, // Marital (civil) status of a patient // multipleBirth[x]: Whether patient is part of a multiple birth. One of these 2: "multipleBirthBoolean" : <boolean>, "multipleBirthInteger" : <integer>, "photo" : [{ Attachment }], // Image of the patient "contact" : [{ // A contact party (e.g. guardian, partner, friend) for the patient "relationship" : [{ CodeableConcept }], // The kind of relationship "name" : { HumanName }, // I A name associated with the contact person "telecom" : [{ ContactPoint }], // I A contact detail for the person "address" : { Address }, // I Address for the contact person "gender" : "<code>", // male | female | other | unknown "organization" : { Reference(Organization) }, // I Organization that is associated with the contact "period" : { Period } // The period during which this contact person or organization is valid to be contacted relating to this patient }], "communication" : [{ // A language which may be used to communicate with the patient about his or her health "[language](patient-definitions.html#Patient.communication.language "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-AU" for Australian English.")" : { CodeableConcept }, // R! The language which can be used to communicate with the patient about his or her health "preferred" : <boolean> // Language preference indicator }], "generalPractitioner" : [{ Reference(Organization|Practitioner| PractitionerRole) }], // Patient's nominated primary care provider "managingOrganization" : { Reference(Organization) }, // Organization that is the custodian of the patient record "link" : [{ // Link to a Patient or RelatedPerson resource that concerns the same actual individual "other" : { Reference(Patient|RelatedPerson) }, // R! The other patient or related person resource that the link refers to "type" : "<code>" // R! replaced-by | replaces | refer | seealso }] }

Additional definitions: Master Definition XML + JSON,XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

8.1.3.1Terminology Bindings

Path	ValueSet	Type	Documentation
Patient.gender	AdministrativeGender	Required	The gender of a person used for administrative purposes.
Patient.maritalStatus	MaritalStatusCodes	Extensible	This value set defines the set of codes that can be used to indicate the marital status of a person.
Patient.contact.relationship	PatientContactRelationship	Extensible	The nature of the relationship between the patient and the contact person.
Patient.contact.gender	AdministrativeGender	Required	The gender of a person used for administrative purposes.
Patient.communication.language	AllLanguages (a valid code from Tags for the Identification of Languages )	Required	This value set includes all possible codes from BCP-47 (see http://tools.ietf.org/html/bcp47)
	Common Languages	starter
Patient.link.type	LinkType	Required	The type of link between this Patient resource and another Patient/RelatedPerson resource.

8.1.3.2 Constraints

UniqueKey	Level	Location	Description	Expression
pat-1	Rule	Patient.contact	SHALL at least contain a contact's details or a reference to an organization	name.exists() or telecom.exists() or address.exists() or organization.exists()

Notes:

• multipleBirth can be either expressed as a Boolean (just indicating whether the patient is part of a multiple birth) or as an integer, indicating the actual birth order.
• Patient records may only be in one of two statuses: in use (active=true) and not in use (active=false). A normal record is active, i.e. it is in use. Active is set to 'false' when a record is created as a duplicate or in error. A record does not need to be linked to be inactivated.
• The link element is used to assert that two or more Patient resources are both about the same actual patient. See below for further discussion
• There should be only one preferred language (Language.preference = true) per mode of expression.
• The Contact for a Patient has an element organization, this is for use with guardians or business related contacts where just the organization is relevant.

8.1.4 Patient ids and Patient resource ids

A Patient record's Resource Id can never change. For this reason, the identifiers with which humans are concerned (often called MRN - Medical Record Number, or UR - Unit Record) should not be used for the resource's id, since MRN's may change, i.e. as a result of having duplicate records of the same patient. Instead they should be represented in the _Patient.identifier_list where they can be managed. This is also useful for the case of institutions that have acquired multiple numbers because of mergers of patient record systems over time.

Where there is a need to implement an automated MRN Identifier created for a patient record, this could be achieved by providing an identifier in the patient with an appropriate assigner, MRN Type and/or system but with no value assigned. Internal business rules can then detect this and replace/populate this identifier with 1 or more identifiers (as required).

8.1.5 Merging records Trial Use

There are two common approaches for resolving duplicate patient records: merging and linking. Linking duplicate patients is described in the Linking Patients section, or merging duplicate patients as described in the $merge operation page.

8.1.6 Linking Patients

The link element is used to assert that patient resources refer to the same patient. This element is used to support the following scenarios where multiple patient records exist:

8.1.6.1 Duplicate Patient records

Managing Patient registration is a well-known difficult problem. Around 2% of registrations are in error, mostly duplicate records. Sometimes the duplicate record is caught fairly quickly and retired before much data is accumulated. In other cases, substantial amounts of data may accumulate.
There are two common approaches for resolving duplicate patient records: merging and linking. Merging duplicate patients is described in the $merge operation page.
Linking duplicate records can be accomplished by using a link of type 'replaced-by' where the record containing such a link is marked as a duplicate and the link points forward to a record that should be used instead. Note that the record pointed to may in its turn have been identified as created in error and forward to yet another Patient resource. Records that replace another record may use a link type of 'replaces' pointing to the old record.

8.1.6.2 Patient record in a Patient index

A Patient record may be present in a system that acts as a Patient Index: it maintains a (summary of) patient data and a list of one or more servers that are known to hold a more comprehensive and/or authoritative record of the same patient. The link type 'refer' is used to denote such a link. Note that linked records may contain contradictory information. The record referred to does not point back to the referring record.

8.1.6.3 Distributed Patient record

In a distributed architecture, multiple systems keep separate patient records concerning the same patient. These records are not considered duplicates, but contain a distributed, potentially overlapping view of the patient's data. Each such record may have its own focus or maintaining organization and there need not be a sense of one record being more complete or more authoritative than another. In such cases, links of type 'see also' can be used to point to other patient records. It is not a requirement that such links are bilateral.

8.1.7 Patient vs. Person vs. Patient.Link vs. Linkage

The Person resource on the surface appears to be very similar to the Patient resource, and the usage for it is very similar to using the Patient.Link capability.
The intention of the Person resource is to be able to link instances of resources together that are believed to be the same individual. This includes across resource types, such as RelatedPerson, Practitioner, Patient and even other Person resources.
The Patient Link however is only intended to be used for Patient resources.

The primary use case for the Person resource is to be able to support person registries that do not necessarily have a healthcare context, and are able to identify and quantify confidence levels that this is the same person.
This could include consumer portals where the maintainer of the person information is the actual person themselves.
A system could use the Person entry to cross check changes to information applied to one part of a record to values in another system; e.g., when moving, a consumer updates his contact numbers and address in his person record, and then a Patient Administration system is able to see that this data is changed and prompt the organization to follow up with the patient that was linked to the person record if they want their details updated, or if they no longer need services and they should be cancelled, as they've moved from the area.

The Linkage resource and the Patient.link property conceptually perform similar functions in FHIR, both provide an assertion of linkages between multiple resource instances that are referring to the same underlying individual.
When a Patient resource is linked/merged then it needs to have an internal indication that there is another patient resource that should be considered when referencing other records, which is achieved using the patient.link property.
Not detecting/checking for a potential linkage could mean that related clinical records are not discovered, potentially impacting patient safety. (which is why using the Linkage resource is not appropriate, as its use in this manner would force the use of either another query to potentially locate other patient resources to consider, or use _revinclude)

8.1.8 Patient.contact vs. RelatedPerson

The contact element on the Patient resource should be used for storing the details of people to contact. This information always travels with the Patient resource, and cannot be used as the target of a reference. Where related people need to be referenced by other resources (e.g. CarePlan.participant, Encounter.participant, DocumentReference.author, Appointment.participant), the RelatedPerson resource must be used.

It is not expected that these records will be used for recording the primary care provider; this information should be stored in the Patient.generalPractitioner field.

8.1.9 Patient Gender and Sex

Many systems and organizations only provide for a single attribute that aspires to represent all aspects of a patient's gender and sex with a single value. However, there are many considerations around sex and gender documentation and interoperability. Listed below are various social and biological attributes that are relevant in the healthcare setting, as well as information on how each can be communicated. Each of these attributes may be useful to address different use cases, and it is up to the implementer to identify which attribute or combination of attributes are most appropriate.

• Administrative Gender - in order to interoperate with systems that use a single generic property, the basic Patient.gender property represents an administrative gender: the gender that the patient is considered to have for administration and record keeping purposes. This property is often used as an input to patient matching algorithms. Systems should not infer any specific clinical meaning from Patient.gender without pre-coordination with exchange partners.
• Gender Identity - a gender the patient has indicated they consider themselves to be. The gender identity can influence how the patient prefers to be addressed by care providers and other individuals. The standard genderIdentity extension may be used to communicate this property. When determining how to address the patient, the pronouns extension may also be applicable.
• Sex Parameter for Clinical Use (SPCU) - a parameter that provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc.. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population. The standard sexParameterForClinicalUse extension may be used to communicate this property.
• Clinical Observations about sex characteristics - a testable observation about a biological property of the patient. This could include karyotypic sex, genetic sex, chromosomal sex, gonadal sex, ductal sex, hormone levels, or various other phenotypic attributes. Clinical observations about sex characteristics should be represented using Observation, qualified with the appropriate clinical codes from LOINC, SNOMED, or other relevant clinical terminologies. These observations may serve as supporting information for the Sex Parameters for Clinical Use categorization.
• Recorded Sex or Gender (RSG) - recorded sex or gender information includes the various sex and gender concepts that are often used in existing systems but are known NOT to represent a gender identity, sex parameter for clinical use, or attributes related to sexuality, such as sexual orientation, sexual activity, or sexual attraction. Examples of recorded sex or gender concepts include administrative gender, administrative sex, legal sex, and sex assigned at birth. When exchanging these concepts, refer to the guidance in the Gender Harmony Implementation Guide.
• Legal Sex - a sex value documented on a legal document, such as a passport, driver's license, birth certificate, or other document. Regional and national entities often categorize citizens using a single legal sex value. The legal sex of a patient can vary from region to region and country to country. A single patient may have multiple legal sex values at the same time in different jurisdictions, or even on different legal documents within a single jurisdiction. In cases where the Patient.gender administrative property is not sufficient to communicate legal sex, refer to the guidance in the Gender Harmony Implementation Guide .
• Sex assigned at Birth - the sex assigned at birth is a sex or gender value assigned to a patient at birth. This value is often documented on the birth registration. Some jurisdictions allow variations such as not yet determined, unknown, or undifferentiated, while others do not. Some jurisdictions also allow birth registration information to be updated. The sex assigned at birth may often be a poor approximation of the patient's current sex for clinical use, especially for adult patients. See sexParameterForClinicalUse as a way to communicate a patient's current sex for clinical use. Refer to the guidance in the Gender Harmony Implementation Guide for options to exchange this concept.

For veterinary use, the animal extension also includes the genderStatus which indicates sterility information.

8.1.10 Mother and newborn relationships

There are several ways to represent the relationship between a mother and a child. This is due to the when it is recorded and the purpose for which it is recorded:

• To express the family relationship and legal responsibility thereof for administrative purposes: use the Patient/RelatedPerson structure.
  This structure is consistent over time.
• To relate the encounters of a mother and her baby in a maternity encounter, for administrative and billing purposes: use the encounter.partof property
• To collect information about the patient's relatives that might be relevant to the patient's medical condition: use the FamilyMemberHistory resource

During a maternity encounter, the Patient and Encounter resources for the mother will be present. After the child is born, new Patient, Encounter and RelatedPerson (for the mother) records will be created. The Child's encounter should reference the Mother's encounter using the partOf property.
The Patient/RelatedPerson structure should also be created for ongoing usage, as shown in this example:

8.1.11 Patient Matching using an MPI

A Master Patient Index (MPI ) is a service used to manage patient identification in a context where multiple patient databases exist. Healthcare applications and middleware use the MPI to match patients between the databases, and as new patient details are encountered. MPIs are highly specialized applications, often tailored extensively to the institution's particular mix of patients. MPIs can also be run on a regional and national basis.

To ask an MPI to match a patient, clients call the patient $match operation, which processes a parameters resource containing a complete or fragment of a patient resource, along with some other control parameters.
This provided patient resource does not need to pass full validation (mandatory fields, or invariants) as the resource will not be stored, it does however need to be a parsable instance.
The MPI can then use the properties of the resource as MPI inputs, and process them using an internal MPI algorithm of some kind to determine the most appropriate matches in the patient set. It does not have to use all the properties provided, and may ignore others provided quietly.
A specific profile (with the required fields/invariants) can be used to define what parameters the MPI algorithm requires.

POST [base]/Patient/$match [some headers including content-type xml or json] [parameters body with patient resource inside]

The response from an MPI $match operation is a set of patient records, ordered from most likely to least likely. If there are not patient matches, the MPI SHALL return an empty search set with no error, but may include an operation outcome with further advice. All patient records should have a score from 0 to 1, where 1 is the most certain match, along with an extension "match-grade" that indicates the MPI's position on the match quality:

The match-grade extension has one of the following codes:

The purpose of using an MPI search versus a regular search is that the MPI search is really intended to target and find a specific single patient for recording information about reducing errors through incorrectly selecting the wrong patient. Often MPIs won't return data if there is insufficient search parameter data, such as a partial surname.
This compares to a regular search which can be used for finding lists of patients, such as to locate a group of patients that share a property in common, such as live in a specific location, or fit within an age range for performing population analysis.

A formal definition for the MPI $match operation is published.

8.1.12 Veterinary Care

Veterinary care is very much within the scope of FHIR, and the Patient resource can be used to communicate information about animal patients. To support this, there is a standard patient-animal extension which can be used for recording details about species, breed, and gender status. This extension is not intended to cover all relevant properties for veterinary care, and the use of additional domain-relevant extensions is expected for areas such as laboratory, zoological and livestock care.

The veterinary client ("owner") is represented using the RelatedPerson resource.

8.1.13 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.