Transaction: Contact report




eHealth Platform








The contact report documents a consultation, emergency visit, a home visit...


This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).

Transaction elements


id of the transaction according to the ID-KMEHR conventions.


You must use the value ‘contactreport’ from CD-TRANSACTION. You can always add your own local codes.


This is the date of the last update of the summary.


This is the time of the last update of the summary.


This is the person assuming the responsibility of the medical content of the record. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person. It must contain the ID-HCPARTY of this healthcare professional and it should contain its INSS number.


Expresses if the summary is completed.


Expresses if the summary is validated.

Structure overview

You have the choice between:

  •     text(s) : to transfer your contact report as free text,
  •     lnk(s) : to encapsulate your contact report as a multimedia object (Word document for example),
  •     heading(s) and/or item(s) : to further structure your contact report.


We recommend the use of the following headings from CD-HEADING.

history Patient's history (antecedents)
clinical Clinical investigation
technical Technical investigation
assessment Current diagnoses and hypotheses
clinicalplan Clinical plan of action
technicalplan Technical plan of action
treatment Proposed treatment

Each heading can contain:

  •     text(s) : to transfer your paragraph as free text,
  •     lnk(s) : to encapsulate your paragraph as a multimedia object (Word document for example),
  •     item(s): to further structure your paragraph.


Most items of CD-ITEM are useful.

Item type (cd) Item purpose Item structure
encounternumber your local admission number Any national standard dictionary could be used to code the content of the items but at this stage of the specification, we recommend to transfer the content of the items as free text.
encountertype hospitalisation, emergency, etc ...
encounterdatetime admission date and time
encounterlocation to document institution, site, unit, room and bed
encounterresponsible responsible of the encounter (can be used to identify the individual and/or the medical department in charge of the patient)
transactionreason reason for admission
encounterorigin origin of the patient before admission (ambulance, home, ...)
referrer the type of entity that referred the patient to the organisatio
admissiontype type of admission process: (planned admission, emergency, ...)
dischargedatetime date and time of the death
dischargetype the type of discharge
dischargedestination the destination after discharge
healthissue to specify current problem(s), diagnoses, hypotheses but also antecedents.
allergy allergy
adr adverse drug reaction
vaccine vaccine administration
medication pharmaceutical treatment
treatment treatment other than pharmaceutical
habits usage of alcohol, tobacco, drug, ...
complaint patient's complaint
clinical results of clinical investigations
technical results of technical investigations
risk factor like communicable disease, work hazard, ...
socialrisk like unemployed, junky, ...
Name XML
contact_level4_1-0 xml