International Patient Summary composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.

Specifies that this composition refer to a Patient Summary (Loinc "60591-5")

Who or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the IPS the subject is always the patient.

Identifies who is responsible for the information in the IPS, not necessarily who typed it in.

The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" IPS Vs. an "automatically generated" IPS.

The provision of healthcare over a period of time this IPS is documenting.

The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report:

• the currently active medications;
• the current and past medications considered relevant by the authoring GP;
• the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.

In all those cases however medications are documented in the Patient Summary as medication statements. This section requires either an entry indicating the subject is known not to be on any relevant medication; either an entry indicating that no information is available about medications; or entries summarizing the subject's relevant medications.

This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.

The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient.

The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:

1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)
2. Therapeutic procedure: e.g. dialysis;
3. Surgical procedure: e.g. appendectomy

The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.

The medical devices section contains narrative text and coded entries describing the patient history of medical device use.

This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.

The History of Past Illness section contains a description of the conditions the patient suffered in the past.

The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.

The plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.

The social history section contains a description of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)

The history of pregnancy section shall contain information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies.

The advance directives section contains a narrative description of patient's advance directive.