Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.2

Template epSOS-eDispensation

Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.2 - epSOS-eD

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.2

Classification CDA document level template

Relationship Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)

Context Pathname /

Version valid from 2012‑05‑03 status Under develeopment

Open/Closed Open (other than defined elements are allowed)

Description

epSOS eDispensation Template

The implementers must be familiar with the context of the project, as it shall not be repeated in this document. The implementers must also be familiar with the content of the following documents:

CDA Release 2.0 Normative Web Edition, May, 2005
HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), HL7, April 1, 2007.
Integrating the Healthcare Enterprise, Patient Care Coordination Technical Framework, Volume 1 and Volume 2- Revision 5, IHE International, August 10, 2009.
Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules- Trial Implementation Supplement, August 10, 2009.
HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, HL7, July 16, 2008.

It must also be noted that although the guidelines are based on the above documents, they contain specific developments particular to the project epSOS. This document can be used as a standalone to develop the syntax of the epSOS documents; however in order to achieve the full functionality of the epSOS Semantic Services, they are to be used within the context of the deliverable 3.9.1.

Item DT Card Conf Desc Label

hl7:ClinicalDocument

CDA header

(epSOS-eD)

hl7:realmCode

1 .. 1

(epSOS-eD)

@code

1 .. 1

Example

<realmCode code="UV"/>

hl7:typeId

1 .. 1

The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

The @root and @extension values of this element are specified as shown in the example below.

(epSOS-eD)

@extension

1 .. 1

POCD_HD000040

@root

1 .. 1

2.16.840.1.113883.1.3

Example

<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>

hl7:templateId

1 .. 1

Template ID for epSOS eDispensation document

(epSOS-eD)

@root

1 .. 1

1.3.6.1.4.1.12559.11.10.1.3.1.1.2

Example

<templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.2"/>

hl7:id

1 .. 1

The ClinicalDocument/id element is an instance identifier data type. The root attribute is an OID. The root uniquely identifies the scope of the extension. The root and extension attributes uniquely identify the document.

R1.11.3

Example

<id extension="a621" root="2.16.840.1.113883.2.4.3.11.60.22.9999"/>

hl7:code

1 .. 1

Determines the document type "epSOS eDispensation"

R1.11.6

@code

1 .. 1

60593-1

@codeSystem

1 .. 1

2.16.840.1.113883.6.1 (LOINC)

Example

<code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed.extended Document"/>

hl7:title

1 .. 1

ClinicalDocument/title is used for display purposes.

R1.11.7

Example

<title>epSOS eDispensation Maria Bakker November 13, 2011</title>

hl7:effectiveTime

TS.DATETIME.MIN

1 .. 1

The element contains the date and time at which this document was created as an electronic document.

R1.11.1

Example

<effectiveTime value="20111113125600"/>

hl7:confidentialityCode

1 .. 1

ClinicalDocument/confidentialityCode shall be present shall be present in accordance with the HL7 CDA R2 standard.

R1.11.8

CONF

The value of @code shall be drawn from value set epSOSConfidentiality (DYNAMIC)

Example

<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>

hl7:languageCode

1 .. 1

Document Language Code

The language code SHALL be in the form nn-CC.
The nn portion SHALL be an ISO-639-1 language code in lower case derived by the Value Set epSOSLanguage.
The CC portion SHALL be an ISO-3166 country code in upper case derived by the value Set epSOSCountry

R.11.10

Example

<languageCode code="en-GB"/>

Schematron assert role error

test matches(@code,'[a-z]{2}-[A-Z]{2}')

Message The language code SHALL be in the form nn-CC where nn is ISO-639-1 epSOSLanguage and CC is ISO-3166 epSOSCountry

Included from epSOS CDA setId (DYNAMIC) 0 .. 1

hl7:setId

0 .. 1

This attribute “represents an identifier that is common across all document revisions”.

In the case of the NCP transcoding /translation this is the ID that remains unchanged among all the existing transformations.

Implementers are recommended to use this attribute.

(epSOS-eD)

hl7:versionNumber

0 .. 1

(epSOS-eD)

Included from epSOS CDA recordTarget (DYNAMIC) 1 .. 1 Mandatory

hl7:recordTarget

1 .. 1

(epSOS-eD)

@typeCode

0 .. 1

RCT

@contextControlCode

0 .. 1

hl7:patientRole

1 .. 1

(epSOS-eD)

@classCode

0 .. 1

PAT

hl7:id

1 .. *

Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)

R1.4 / R1.4.1 / R1.4.2

@extension

1 .. 1

@nullFlavor

0 .. 1

UNC

When the @root is impossible to know, e.g. for insurance numbers, @nullFlavor SHALL be 'UNC' while @extension contains the id

Example

<id nullFlavor="UNC" extension="EHIC"/>

hl7:addr

1 .. 1

The patient address <addr> element is required. If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present. Optionalities and Cardinalities of the address sub-parts shall be interpreted according to this rule.

R1.5

@nullFlavor

0 .. 1

Choice min 0 element(s) and max * element(s). Elements to choose from:

hl7:streetAddressLine
hl7:city
hl7:postalCode
hl7:state
hl7:country

hl7:streetAddressLine

ADXP

1 .. *

Patient's Number of Street/Patient's Number of Street

R1.5.1/R1.5.2

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:city

ADXP

1 .. *

Patient's City

R1.5.3

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:postalCode

ADXP

1 .. *

Patient's Postal Code

R1.5.4

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:state

ADXP

1 .. *

Patient's State or Province

R1.5.5

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:country

ADXP

1 .. *

Patient's Country

R1.5.6

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:telecom

TEL

1 .. *

Patient’s telephone number / Patient e-mail address. The patient telephone or e-mail <telecom> element is required. If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present Optionalities and Cardinalities of the following two items shall be interpreted according to this rule: e.g. is not expected to have two nullFlavored telecom elements.

R1.6.1 / R1.6.2

@use

0 .. 1

CONF

The value of @use shall be drawn from value set epSOSTelecomAddress (DYNAMIC)

@nullFlavor

0 .. 1

hl7:patient

1 .. 1

(epSOS-eD)

@classCode

0 .. 1

PSN

@determinerCode

0 .. 1

INSTANCE

hl7:name

1 .. *

Patient Name

R1.1

Choice min 1 element(s) and max * element(s). Elements to choose from:

hl7:family
hl7:prefix
hl7:given

hl7:family

ENXP

1 .. *

Patient's Family Name/Surname

R1.1.1

hl7:prefix

ENXP

0 .. *

Patient's Prefix

R1.1.2

Constraint If the attribute qualifier is used for this element it should be derived from epSOSEntityNamePartQualifier 2.16.840.1.113883.5.43

hl7:given

ENXP

1 .. *

Patient's Given Name

R1.1.3

hl7:administrativeGenderCode

1 .. 1

Patient's Gender

R1.2

CONF

The value of @code shall be drawn from value set epSOSAdministrativeGender (DYNAMIC)

hl7:birthTime

1 .. 1

Patient's Date of Birth

R1.3

hl7:guardian

1 .. *

The guardians of a patient shall be recorded in the <guardian> element beneath the /ClinicalDocument/recordTarget/patientRole/patient XML - <patient> element. Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact. The classCode attribute shall be present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or other relations respectively.

The relationship between the patient and the guardian or other contact should be recorded in the <code> element. The code attribute is required and comes from the HL7 PersonalRelationshipRoleType vocabulary (epSOSPersonalRelationship value set).

The address of the guardian or other contact should be present, and shall be represented as any other address would be in CDA.

The phone number of the guardian or other contact should be present, and shall be represented as 480 any other phone number would be in CDA.

The name of the guardian or other contact shall be present, and shall be represented as any other name would be in CDA.

Healthcare Service Identification

The Healthcare Service Identification information is represented in structures under the /ClinicalDocument/author XML element

R1.7.A

@classCode

1 .. 1

GUARD

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

Example

<guardian classCode="GUARD"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4"/> <addr> <streetAddressLine>2222 Home Street</streetAddressLine> <city>London</city> <state>London</state> <postalCode>A1B 2C3</postalCode> <country>UK</country> </addr> <telecom value="tel:+452070256161"/> <telecom value="mailto:jsmith@myprovider.co.uk"/> <guardianPerson> <name> <given>John</given> <family>Español Smith</family> </name> </guardianPerson> </guardian>

hl7:templateId

1 .. 1

Template id for Patient's Guardian

R1.7.A

@root

1 .. 1

1.3.6.1.4.1.19376.1.5.3.1.2.4

hl7:addr

1 .. 1

The guardian’s address <addr> element is required. If there is no information, the nullFlavor attribute shall have a value of 'UNK' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present

R1.7.A

@nullFlavor

0 .. 1

UNK

hl7:streetAddressLine

ADXP

1 .. *

Guardian's Number of Street/Guardian's Number of Street

R1.7.A.3.1/R1.7.A.3.2

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:city

ADXP

1 .. *

Guardian's City

R1.7.A.3.3

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:postalCode

ADXP

1 .. *

Guardian's Postal Code

R1.7.A.3.4

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:state

ADXP

1 .. *

Guardian's State or Province

R1.7.A.3.5

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:country

ADXP

1 .. *

Guardian's Country

R1.7.A.3.6

@nullFlavor

0 .. 1

Use nullFlavor if unknown or if no information is applicable

hl7:telecom

TEL

1 .. *

Guardian’s telephone number / Patient e-mail address. The guardian telephone or e-mail <telecom> element is required. If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present Optionalities and Cardinalities of the following two items shall be interpreted according to this rule: e.g. is not expected to have two nullFlavored telecom elements.

R1.7.A.4.1/R1.7.A.4.2

@use

0 .. 1

CONF

The value of @use shall be drawn from value set epSOSTelecomAddress (DYNAMIC)

@nullFlavor

0 .. 1

hl7:guardianPerson

1 .. 1

R1.7.A

hl7:name

1 .. *

Patient Guardian's Name

R1.7.A

Choice min 1 element(s) and max * element(s). Elements to choose from:

hl7:family
hl7:given

hl7:family

ENXP

1 .. *

Patient Guardian's Family Name/Surname

R1.7.A.1

hl7:given

ENXP

1 .. *

Patient Guardian's Given Name

R1.7.A.2

hl7:languageCommunication

0 .. *

(epSOS-eD)

hl7:templateId

1 .. 1

Template id for LanguageCommunication

(epSOS-eD)

@root

1 .. 1

1.3.6.1.4.1.19376.1.5.3.1.2.1

hl7:languageCode

0 .. 1

Patient’s preferred language

R1.7

CONF

The value of @code shall be drawn from value set epSOSLanguage (DYNAMIC)

Included from epSOS CDA author (DYNAMIC) 1 .. * Required

hl7:author

1 .. *

(epSOS-eD)

@typeCode

0 .. 1

AUT

@contextControlCode

0 .. 1

hl7:functionCode

0 .. 1

R1.10.6

CONF

The value of @code shall be drawn from value set epSOSHealthcareProfessionalRoles (DYNAMIC)

hl7:assignedAuthor

1 .. 1

(epSOS-eD)

@classCode

0 .. 1

ASSIGNED

hl7:id

1 .. *

HP ID number

R1.10.5

hl7:code

0 .. 1

HP Specialty

R1.10.7

hl7:telecom

TEL

0 .. *

Attribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLScheme

R1.10.8 / R1.10.8.1 / R1.10.8.2

@use

0 .. 1

CONF

The value of @use shall be drawn from value set epSOSTelecomAddress (DYNAMIC)

Choice min 1 element(s) and max 1 element(s). Elements to choose from:

hl7:assignedPerson
assignedAuthoringDevice containing hl7:code from template CDA Device (DYNAMIC)

hl7:assignedPerson

(epSOS-eD)

@classCode

0 .. 1

PSN

@determinerCode

0 .. 1

INSTANCE

hl7:name

0 .. 1

HP Name

(epSOS-eD)

Example

<name> <given>John</given> <family>Español Smith</family> </name>

Choice min 1 element(s) and max * element(s). Elements to choose from:

hl7:family
hl7:given
hl7:prefix
hl7:suffix

hl7:family

ENXP

1 .. *

HP Family Name/Surname

R1.10.1

hl7:given

ENXP

1 .. *

HP Given Name

R1.10.2

hl7:prefix

ENXP

1 .. *

HP Prefix

R1.10.3

hl7:suffix

ENXP

1 .. *

HP Suffix

R1.10.4

assignedAuthoringDevice

(epSOS-eD)

Contains inherited template rules CDA Device (DYNAMIC) with overridden cardinality

hl7:representedOrganization

1 .. 1

R1.10.9

Contains inherited template rules epSOS CDA Organization (DYNAMIC) with overridden cardinality 1 .. 1

Included from epSOS CDA custodian (DYNAMIC) 1 .. 1 Required Mandatory

hl7:custodian

1 .. 1

(epSOS-eD)

@typeCode

0 .. 1

CST

hl7:assignedCustodian

1 .. 1

(epSOS-eD)

@classCode

0 .. 1

ASSIGNED

hl7:representedCustodianOrganization

1 .. 1

R1.10.9

@classCode

0 .. 1

ORG

@determinerCode

0 .. 1

INSTANCE

Contains inherited template rules epSOS CDA Organization (DYNAMIC) with overridden cardinality 1 .. 1

hl7:legalAuthenticator

1 .. 1

The person taking responsibility for the medical content of the document. In Spain this is the regional authority in healthcare. This regional authority healthcare organization will send this to the NCP. The definition of the legal authenticator may vary accoriding to the rules set up in the framework agreement particular to each state. It may be a person or a regional authority, or an NCP.

R1.11.9

Example

<legalAuthenticator> <time value="20111013150937"/> <signatureCode code="S"/> <assignedEntity> <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/> <representedOrganization> <name>Healthcare Facility's name</name> <addr> <country>NL</country> <streetName>Duinweg</streetName> <houseNumber>23</houseNumber> <postalCode>7364 RX</postalCode> <city>Amsterdam</city> </addr> </representedOrganization> </assignedEntity> </legalAuthenticator>

hl7:time

1 .. 1

Time of signing the document

R1.11.9

hl7:signatureCode

0 .. 1

Signature code

R1.11.9

CONF

The value of @code shall be drawn from value set ParticipationSignature (DYNAMIC)

Error: Cannot find value set "ParticipationSignature"

hl7:assignedEntity

0 .. 1

The regional authority that is responsible for the legal authentication of the CDA document

R1.11.9

hl7:id

1 .. 1

Unique identification of ligal authenticator

R1.11.9

hl7:representedOrganization

1 .. 1

The healthcare facility where the health professional works

R1.11.9

hl7:name

1 .. *

Healthcare Facility's name

R1.11.9

hl7:addr

1 .. 1

Healthcare Facility's Country

R1.11.9

hl7:participant
where
[@typeCode='IND']

1 .. *

Contact person of the patient.

(epSOS-eD)

@typeCode

1 .. 1

IND

Participant typeCode

Example

<participant typeCode="IND"> <associatedEntity classCode="CON">  </associatedEntity> </participant>

Contains inherited template rules epSOS CDA Contact Person (DYNAMIC) with overridden cardinality 1 .. *

hl7:participant
where
[hl7:functionCode [@code='PCP'] [@codeSystem='2.16.840.1.113883.5.88']]

1 .. *

Preferred Health Professional to contact about patient.

(epSOS-eD)

@typeCode

1 .. 1

CON

Example

<participant typeCode="IND"> <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/> <associatedEntity classCode="CON">  </associatedEntity> </participant>

Contains inherited template rules epSOS CDA Preferred HP or Legal Organization (DYNAMIC) with overridden cardinality 1 .. *

hl7:functionCode

1 .. 1

(epSOS-eD)

@code

1 .. 1

PCP

@codeSystem

1 .. 1

2.16.840.1.113883.5.88

hl7:component

1 .. 1

(epSOS-eD)

hl7:structuredBody

1 .. 1

(epSOS-eD)

@classCode

0 .. 1

DOCBODY

hl7:component

1 .. *

(epSOS-eD)

@typeCode

0 .. 1

COMP

Contains inherited template rules Section Dispensation (DYNAMIC) with overridden cardinality 1 .. * Required

Template epSOS-eDispensation