Build French Medical Synthesis Document (VSM — HL7 CDA R2 / CI-SIS)

Skill: Assemble a patient summary into a Volet de Synthèse Médicale (VSM) CDA for the DMP

Region: France Category: Health care Does: Takes a structured patient summary and assembles the Volet de Synthèse Médicale (VSM) as an HL7 CDA R2 document conforming to the CI-SIS (Cadre d'Interopérabilité des Systèmes d'Information de Santé), identified by the patient INS-i, for deposit into the DMP within Mon espace santé via the ANS. Spec: ANS — CI-SIS / HL7 CDA R2 VSM template; INS identity (current version)

The VSM is the medical synthesis (problems, treatments, allergies, antecedents) authored by the treating physician and fed to the patient's DMP (Dossier Médical Partagé) inside Mon espace santé. It is a structured CDA R2 document under the CI-SIS, with the patient identified by the qualified INS (matricule INS + OID). Element names below follow the CDA/CI-SIS VSM template, not a verbatim XSD.

When this applies

• A treating physician (médecin traitant) or care team needs to publish or update a patient's medical synthesis to the DMP.
• Identity must be the INS qualifiée (Identité Nationale de Santé), retrieved from the téléservice INSi and matched to the NIR-derived matricule.
• The document is sent through a CI-SIS / DMP-compatible LPS (logiciel professionnel de santé) and authenticated by a CPS card / Pro Santé Connect.

Structure (VSM → CDA R2 / CI-SIS)

ClinicalDocument (CDA R2)
   templateId           CI-SIS VSM template OID
   recordTarget/patient INS-i: id matricule + OID INS, nom de naissance, sexe, date naissance
   author               PS: RPPS/identifiant national, Pro Santé Connect / CPS
   custodian            établissement / structure (FINESS/SIRET)
   structuredBody
      section Antécédents
      section Allergies et intolérances
      section Problèmes / pathologies en cours (codés CIM-10 / SNOMED)
      section Traitements en cours (médicaments — CIP/ATC)
      section Facteurs de risque, vaccinations

Data rules

• The INS-i identity (matricule + OID, nom de naissance, prénom, sexe, date et lieu de naissance) must be qualifiée before the document is published; an unqualified identity must not be used.
• Author and custodian carry RPPS (practitioner) and FINESS/SIRET (structure); authentication via CPS / Pro Santé Connect.
• Clinical content is coded with reference terminologies (CIM-10, SNOMED CT, CIP/ATC for drugs) per CI-SIS jeux de valeurs.
• The CDA must validate against the CI-SIS VSM template (schematron/MOS) before submission; UTF-8 encoding and required header elements present.
• A new VSM replaces/updates the previous one in the DMP (versioning via setId/versionNumber); the patient retains masking rights.

Worked example (outline)

ClinicalDocument templateId=CI-SIS VSM
recordTarget INS: 1 85 05 75 116 084 (matricule INS, OID 1.2.250.1.213.1.4.8),
   nom naissance MARTIN, F, 1985-05-12
author RPPS 10100000001 (via Pro Santé Connect)
custodian FINESS 750000001
Problèmes: Diabète type 2 (CIM-10 E11)
Traitements: Metformine 1000 mg (CIP ...)
Allergies: Pénicilline

Validated against the CI-SIS VSM template and deposited into the patient's DMP in Mon espace santé via the ANS-referenced service.

Validation checklist

• Patient identified by INS qualifiée (matricule + OID, nom de naissance)
• Author RPPS and custodian FINESS/SIRET present; CPS / Pro Santé Connect auth
• CDA R2 header and required sections complete (problèmes, traitements, allergies, antécédents)
• Clinical content coded with CI-SIS terminologies (CIM-10 / SNOMED / CIP-ATC)
• Document validates against the CI-SIS VSM template (schematron)
• Correct setId/versionNumber for update vs replacement in DMP
• Submitted via a DMP/Mon espace santé-compatible LPS

Last updated: 2026-06-04 — confirm the current CI-SIS VSM CDA template, INS rules, terminologies, and DMP/Mon espace santé integration requirements against current ANS (ans.gouv.fr) guidance before use.