Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.1

Template epSOS-ePrescription

Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.1 - epSOS-eP

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.1

Version valid from 2013‑12‑20 status Under develeopment

Classification CDA Document Level Template

Context Pathname /

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

Description

epSOS ePrescription 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.

Used by / Uses

Used by / Uses 8 templates

Uses Template id	as	Name	Version
2.16.840.1.113883.3.1937.777.10.10.110	Include	epSOSCDAId	DYNAMIC
2.16.840.1.113883.3.1937.777.10.10.108	Include	epSOSCDAsetId	DYNAMIC
2.16.840.1.113883.3.1937.777.10.10.100	Include	epSOSCDArecordTarget	DYNAMIC
2.16.840.1.113883.3.1937.777.10.10.103	Include	epSOSCDAauthorPrescriber	DYNAMIC
2.16.840.1.113883.3.1937.777.10.10.104	Include	epSOSCDAcustodian	DYNAMIC
2.16.840.1.113883.3.1937.777.10.10.109	Include	epSOSCDAlegalAuthenticator	DYNAMIC
2.16.840.1.113883.3.1937.777.10.10.107	Include	epSOSCDArelatedDocument	DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.1	Containment	SectionPrescription	DYNAMIC

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

Item DT Card Conf Description Label

hl7:ClinicalDocument

CDA header

(epSOS-eP)

hl7:realmCode

1 .. 1

(epSOS-eP)

hl7:typeId

II.EPSOS

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-eP)

@root

1 .. 1

2.16.840.1.113883.1.3

@extension

1 .. 1

POCD_HD000040

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

hl7:templateId

II.EPSOS

1 .. 1

Template ID for epSOS ePrescription document

(epSOS-eP)

@root

1 .. 1

1.3.6.1.4.1.12559.11.10.1.3.1.1.1

Example <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.1"/>

Included from 2.16.840.1.113883.3.1937.777.10.10.110 epSOS CDA Id (DYNAMIC) 1..1 Mandatory

hl7:id

1 .. 1

The ClinicalDocument/id element is an instance identifier data type. The root attribute is an OID. If there is a value in @extension, then the root uniquely identifies the scope of the extension. If there is no value in @extension then @root SHALL uniquely identify the document

UUIDs SHALL be represented in the form XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX, where each X is a character from the set [A-Fa-f0-9].

OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0, or starts with a nonzero digit. More formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+.

R1.11.3

Example <id extension="a621" root="2.16.840.1.113883.3.1937.777.10.9999"/>

hl7:code

CV.EPSOS

1 .. 1

Determines the document type "epSOS ePrescription"

R1.11.6

@displayName

1 .. 1

@code

1 .. 1

57833-6

@codeSystem

1 .. 1

2.16.840.1.113883.6.1 (LOINC)

Example <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/>

hl7:title

1 .. 1

ClinicalDocument/title is used for display purposes.

R1.11.7

Example <title>epSOS ePrescription Maria Bakker November 13, 2011</title>

hl7:effectiveTime

TS.EPSOS.TZ

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+0200"/>

hl7:confidentialityCode

CE.EPSOS

1 .. 1

ClinicalDocument/confidentialityCode 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 1.3.6.1.4.1.12559.11.10.1.3.1.42.31 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 2.16.840.1.113883.3.1937.777.10.10.108 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-eP)

hl7:versionNumber

0 .. 1

(epSOS-eP)

Included from 2.16.840.1.113883.3.1937.777.10.10.100 epSOS CDA recordTarget (DYNAMIC) 1..1 Mandatory

hl7:recordTarget

1 .. 1

(epSOS-eP)

@typeCode

0 .. 1

RCT

@contextControlCode

0 .. 1

hl7:patientRole

1 .. 1

(epSOS-eP)

@classCode

0 .. 1

PAT

hl7:id

II.EPSOS

1 .. *

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

R1.4 / R1.4.1 / R1.4.2

hl7:addr

AD.EPSOS

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.

R1.5

@nullFlavor

0 .. 1

hl7:streetAddressLine

0 .. *

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

R1.5.1 / R1.5.2

hl7:city

0 .. 1

Patient's City

R1.5.3

hl7:postalCode

0 .. 1

Patient's Postal Code

R1.5.4

hl7:state

0 .. 1

Patient's State or Province

R1.5.5

hl7:country

0 .. 1

Patient's Country. When used addr.country it is always bound to the epSOSCountry value set

R1.5.6

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 1.3.6.1.4.1.12559.11.10.1.3.1.42.40 epSOSTelecomAddress (DYNAMIC)

@nullFlavor

0 .. 1

hl7:patient

1 .. 1

(epSOS-eP)

@classCode

0 .. 1

PSN

@determinerCode

0 .. 1

INSTANCE

hl7:name

1 .. *

Patient Name

R1.1

hl7:family

1 .. *

Patient's Family Name/Surname

R1.1.1

hl7:prefix

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

1 .. *

Patient's Given Name

R1.1.3

hl7:administrativeGenderCode

CE.EPSOS

1 .. 1

Patient's Gender

R1.2

@nullFlavor

0 .. 1

UNK

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.34 epSOSAdministrativeGender (DYNAMIC)

hl7:birthTime

1 .. 1

Patient's Date of Birth. The patient date of birth may be a partial date such as only the year.

R1.3

hl7:guardian

0 .. *

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 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 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.

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

II.EPSOS

1 .. 1

Template id for IHE PCC Patient Contacts

R1.7.A

@root

1 .. 1

1.3.6.1.4.1.19376.1.5.3.1.2.4

hl7:addr

AD.EPSOS

1 .. 1

The guardian’s 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

R1.7.A

@nullFlavor

0 .. 1

hl7:streetAddressLine

0 .. *

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

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

hl7:city

0 .. 1

Guardian's City

R1.7.A.3.3

hl7:postalCode

0 .. 1

Guardian's Postal Code

R1.7.A.3.4

hl7:state

0 .. 1

Guardian's State or Province

R1.7.A.3.5

hl7:country

0 .. 1

Guardian's Country. When used addr.country it is always bound to the epSOSCountry value set

R1.7.A.3.6

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 1.3.6.1.4.1.12559.11.10.1.3.1.42.40 epSOSTelecomAddress (DYNAMIC)

@nullFlavor

0 .. 1

hl7:guardianPerson

1 .. 1

R1.7.A

hl7:name

1 .. *

Patient Guardian's Name

IHE PCC

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

hl7:family
hl7:given

hl7:family

1 .. *

Patient Guardian's Family Name/Surname

R1.7.A.1

hl7:given

1 .. *

Patient Guardian's Given Name

R1.7.A.2

hl7:languageCommunication

1 .. *

This element is derived from the IHE template LanguageCommunication (1.3.6.1.4.1.19376.1.5.3.1.2.1), however this template does not need the element preferenceInd because the language is already said to be the "preferred language".

(epSOS-eP)

hl7:languageCode

1 .. 1

Patient’s preferred language

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

R1.7

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 2.16.840.1.113883.3.1937.777.10.10.103 epSOS CDA author prescriber (DYNAMIC) 1..* Mandatory

hl7:author

1 .. *

(epSOS-eP)

@typeCode

0 .. 1

AUT

@contextControlCode

0 .. 1

Example <author> <time value="20121229"/> <assignedAuthor> <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/> <addr> <streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country> </addr> <telecom use="WP" value="tel:(+39)051-34343434"/> <assignedPerson> <name> <given>Paolo</given> <family>Rossi</family> </name> </assignedPerson> </assignedAuthor></author>

hl7:functionCode

CE.EPSOS

1 .. 1

R1.10.6

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.1 epSOSHealthcareProfessionalRoles (DYNAMIC)

hl7:time

TS.EPSOS.TZ

1 .. 1

The author/time element represents the start time of the author’s participation in the creation of the clinical document. The author/time element SHALL be present.

(epSOS-eP)

hl7:assignedAuthor

1 .. 1

(epSOS-eP)

@classCode

0 .. 1

ASSIGNED

Schematron assert role error

test @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice

Message If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for "ClinicalDocument/author/assignedAuthor/id/@NullFlavor" SHALL be "NA" "Not applicable" 2.16.840.1.113883.5.1008 NullFlavor STATIC.

hl7:id

II.EPSOS

1 .. *

HP ID number

R1.10.5

@nullFlavor

0 .. 1

hl7:code

CE.EPSOS

0 .. 1

HP Specialty

R1.10.7

hl7:addr

AD.EPSOS

1 .. *

IHE PCC

hl7:telecom

TEL.EPSOS

1 .. *

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

IHE PCC / 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 1.3.6.1.4.1.12559.11.10.1.3.1.42.40 epSOSTelecomAddress (DYNAMIC)

hl7:assignedPerson

1 .. 1

(epSOS-eP)

@classCode

0 .. 1

PSN

@determinerCode

0 .. 1

INSTANCE

hl7:name

1 .. 1

HP Name

IHE PCC

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

hl7:family

1 .. *

HP Family Name/Surname

R1.10.1

hl7:given

1 .. *

HP Given Name

R1.10.2

hl7:prefix

1 .. *

HP Prefix

R1.10.3

hl7:suffix

1 .. *

HP Suffix

R1.10.4

hl7:representedOrganization

1 .. 1

R1.10.9

Contains 2.16.840.1.113883.3.1937.777.10.10.111 epSOS CDA Organization (DYNAMIC)

Included from 2.16.840.1.113883.3.1937.777.10.10.104 epSOS CDA custodian (DYNAMIC) 1..1 Mandatory

hl7:custodian

1 .. 1

(epSOS-eP)

@typeCode

0 .. 1

CST

hl7:assignedCustodian

1 .. 1

(epSOS-eP)

@classCode

0 .. 1

ASSIGNED

hl7:representedCustodianOrganization

1 .. 1

R1.10.9

@classCode

0 .. 1

ORG

@determinerCode

0 .. 1

INSTANCE

Contains 2.16.840.1.113883.3.1937.777.10.10.111 epSOS CDA Organization (DYNAMIC)

Included from 2.16.840.1.113883.3.1937.777.10.10.109 epSOS CDA legalAuthenticator (DYNAMIC) 1..* Mandatory

hl7:legalAuthenticator

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

TS.EPSOS.TZ

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 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)

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 legal authenticator

R1.11.9

hl7:addr

AD.EPSOS

1 .. *

IHE PCC

hl7:telecom

TEL.EPSOS

1 .. *

IHE PCC

hl7:assignedPerson

1 .. 1

IHE PCC

@classCode

0 .. 1

PSN

@determinerCode

0 .. 1

INSTANCE

Contains 2.16.840.1.113883.3.1937.777.10.10.113 CDA Person (DYNAMIC)

hl7:name

1 .. 1

HP Name

IHE PCC

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

hl7:family

1 .. *

HP Family Name/Surname

R1.10.1

hl7:given

1 .. *

HP Given Name

R1.10.2

hl7:prefix

1 .. *

HP Prefix

R1.10.3

hl7:suffix

1 .. *

HP Suffix

R1.10.4

hl7:representedOrganization

1 .. 1

R1.11.9

Contains 2.16.840.1.113883.3.1937.777.10.10.111 epSOS CDA Organization (DYNAMIC)

Included from 2.16.840.1.113883.3.1937.777.10.10.107 epSOS CDA relatedDocument (DYNAMIC) 1..1 Mandatory

hl7:relatedDocument

1 .. 1

(epSOS-eP)

@typeCode

1 .. 1

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)

hl7:parentDocument

1 .. 1

(epSOS-eP)

@classCode

0 .. 1

DOCCLIN

@moodCode

0 .. 1

EVN

hl7:id

II.EPSOS

1 .. *

(epSOS-eP)

hl7:code

CD.EPSOS

0 .. 1

(epSOS-eP)

@codeSystem

1 .. 1

2.16.840.1.113883.6.1 (LOINC)

hl7:text

0 .. 1

(epSOS-eP)

hl7:setId

II.EPSOS

0 .. 1

(epSOS-eP)

hl7:versionNumber

INT

0 .. 1

(epSOS-eP)

hl7:component

1 .. 1

(epSOS-eP)

hl7:structuredBody

1 .. 1

(epSOS-eP)

@classCode

0 .. 1

DOCBODY

hl7:component
where
[hl7:section [hl7:templateId/@root='1.3.6.1.4.1.12559.11.10.1.3.1.2.1']]

1 .. *

(epSOS-eP)

Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.1 Section Prescription (DYNAMIC)

Template epSOS-ePrescription