Business requirements for health summary records – Part 1: Requirements

A health summary record (HSR) is a health record extract comprising a standardised collection of clinical and contextual information (retrospective, concurrent, prospective) that provides a snapshot in time of a subject-of-care’s health information and healthcare.

This document defines and describes HSRs based on a comprehensive review of a series of HSR initiatives and implementations worldwide. It summarises the business requirements driving the development of HSRs, the content that is common across HSRs, and issues associated with HSRs. Future activities are also recommended for the ISO’s Technical Committee on health informatics (TC 215) to support international standardisation of HSRs.

This document focuses primarily on requirements that are unique to HSRs. It does not attempt to articulate, other than at a high level, requirements that are generally applicable to all health records or all electronic health records.

Main sections:

· Scope

· Examples of health summary records

· Nature and definition of health summary records

· Purposes of health summary records

· Common use cases for health summary records

· Business requirements for health summary records

· Data and information management requirements for health summary records

· Standardisation of health summary records

· Recommendations