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ref Template  epSOS-Patient Summary

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name epSOS-PS Display Name epSOS-Patient Summary
Description

Note for the readers
This template version represents the best representation of the original epSOS/EXPAND specifications in ART DECOR. However  the original epSOS/EXPAND  specifications in Microsoft Word took the original IHE Templates and added constraints in written language. This actually is not best practice in electronic Template Design because the additional constraints are not assigned to the original IHE template but rather than that are text only constraints. In order to make everything computable new Template OIDs need to be assigned to the epSOS Templates in order to cover both, the original IHE Template Design and the additional constraints from epSOS in the text and represent them electronically.
Caveat: for the above mentioned reasons this version cannot be used  for (automatic) testing/validation purposes. It shall be used however as basis for refinement (repository)

Note: there is a new version planned that covers all above and makes proper testing/validation possible

epSOS Patient Summary 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 10, IHE International, November 4, 2014.
  • Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules- Trial Implementation Supplement, December 3, 2014.
  • 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.

Prescribed and dispensed medications, including a specification of the Medication Summary section used in the Patient Summary document, have described in the previous chapter. The following sub-paragraphs specify how other sections that may be present in a Patient Summary are implemented.

According to requirements described in the Body Data Elements, the following sections - at least - shall be present in a Patient Summary document:

The Medication Summary Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.3

The Allergies and Other Adverse Reactions Section 1.3.6.1.4.1.19376.1.5.3.1.3.13

The Coded List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.12

The Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6

The Medical Devices Coded Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.4

Appropriated codes and/or nullFlavor values will be used in these sections to express for example that coded information is not available, either that an entry is not applicable or that information is not known, ….. See the related paragraph for further details.

Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 5 concepts
Id Name Data Set
epsos-dataelement-296 Type epSOS Data Set
epsos-dataelement-297 Confidentiality epSOS Data Set
epsos-dataelement-298 Language epSOS Data Set
epsos-dataelement-65 Date Created epSOS Data Set
epsos-dataelement-16 Clinical Data epSOS Data Set
Used by / Uses
Used by 1 transaction and 0 templates, Uses 22 templates
Used by as Name Version
epsos-transactions-12 Transaction draft Return PS of country A 2012‑05‑02
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.110 Include draft epSOS CDA Id DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.108 Include draft epSOS CDA setId DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.100 Include draft epSOS CDA recordTarget DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.102 Include draft epSOS CDA author DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.104 Include draft epSOS CDA custodian DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.109 Include draft epSOS CDA legalAuthenticator DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.101 Include draft epSOS CDA Contact/Preferred HP/Legal Organization DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.106 Include draft epSOS CDA documentationOf PCPR DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.107 Include draft epSOS CDA relatedDocument DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 Containment draft Section Medication Summary DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.13 Containment draft Section Allergies and Other Adverse Reactions DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.23 Containment draft Section Immunizations DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.8 Containment draft Section History of Past Illness DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.12 Containment draft Section Coded List of Surgeries DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment draft Section Active Problems DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.4 Containment draft Section Medical Devices Coded DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.9.50 Containment draft Section Health Maintenance Care Plan DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.17 Containment draft Section Functional Status DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.16.1 Containment draft Section Coded Social History DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Containment draft Section Pregnancy History DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Containment draft Section Coded Vital Signs DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Containment draft Section Coded Results DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
notice There are open issues with this item:
Item DT Card Conf Description Label
hl7:ClinicalDocument
 R CDA header (epS…-PS)
hl7:realmCode
 CS 0 … 1 R (epS…-PS)
hl7:typeId
 II.EPSOS 1 … 1 M 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. 		(epS…-PS)
@root
 uid 1 … 1 F 2.16.840.1.113883.1.3
@extension
 st 1 … 1 F POCD_HD000040
  Example <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
hl7:templateId
 II.EPSOS 1 … 1 M Template ID for epSOS Patient Summary document (epS…-PS)
@root
 uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.1.3
  Example <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.3"/>
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.110 epSOS CDA Id (DYNAMIC)
hl7:id
 1 … 1 M

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
  target
epsos-dataelement-176 Identification epSOS Data Set
  Example <id extension="a621" root="2.16.840.1.113883.3.1937.777.11.9999"/>
hl7:code
 CV.EPSOS 1 … 1 M Determines the document type "epSOS Patient Summary Document" R1.11.6
  target
epsos-dataelement-296 Type epSOS Data Set
@displayName
 1 … 1 R
@code
 CONF 1 … 1 F 60591-5
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient summary Document"/>
hl7:title
 ST 1 … 1 M ClinicalDocument/title is used for display purposes. R1.11.7
  Example <title>epSOS Patient Summary Maria Bakker November 13, 2011</title>
hl7:effectiveTime
 TS.EPSOS.TZ 1 … 1 M

Relevant times for the Patient Summary

By definition, a Patient Summary document describes the Patient Summary at the time of creation of the document, represented by the /ClinicalDocument/effectiveTime XML Element.

The time when this instance of the document has been authored may be instead recorded by the /ClinicalDocument/author/time element. (e.g. when a “spider” has collected information for generating this instance of the document; or a practitioner updated its local summary document).

Finally, the latest summary update, intended as the last date documented by this summary (e.g. the last update occurred to the PHR from which the PS data has been extracted) can be represented by the /ClinicalDocument/documentationOf/serviceEvent/effectiveTime/high XML Element (see section 2.1, CONF-2, CONF-3 and CONF-4 of the CCD specification).

R1.11.1
  target
epsos-dataelement-65 Date Created epSOS Data Set
  Example <effectiveTime value="20111113125600+0200"/>
hl7:confidentialityCode
 CE.EPSOS 1 … 1 R ClinicalDocument/confidentialityCode shall be present in accordance with the HL7 CDA R2 standard. R1.11.8
  target
epsos-dataelement-297 Confidentiality epSOS Data Set
  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
 CS 1 … 1 M 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
  target
epsos-dataelement-298 Language epSOS Data Set
  Example <languageCode code="en-GB"/>
  Schematron assert role red 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 0 … 1 from 2.16.840.1.113883.3.1937.777.11.10.108 epSOS CDA setId (DYNAMIC)
hl7:setId
 0 … 1 R

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.

 (epS…-PS)
hl7:versionNumber
 0 … 1 R (epS…-PS)
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.100 epSOS CDA recordTarget (DYNAMIC)
hl7:recordTarget
 1 … 1 M (epS…-PS)
  target
epsos-dataelement-5 Patient Data epSOS Data Set
@typeCode
 0 … 1 F RCT
@contextControlCode
 0 … 1 F OP
hl7:patientRole
 1 … 1 M (epS…-PS)
  target
epsos-dataelement-26 Contact Information epSOS Data Set
@classCode
 0 … 1 F PAT
hl7:id
 II.EPSOS 1 … * R Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) R1.4 / R1.4.1 / R1.4.2
  target
epsos-dataelement-7 National Health Care patient ID (country of affiliation) epSOS Data Set
epsos-dataelement-234 National Health Care patient ID (country of treatment) epSOS Data Set
epsos-dataelement-235 Other Identifier epSOS Data Set
epsos-dataelement-6 Identification epSOS Data Set
hl7:addr
 AD.EPSOS 1 … 1 R 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
  target
epsos-dataelement-27 Address epSOS Data Set
@nullFlavor
 0 … 1 F NI
hl7:streetAddressLine
 0 … * R Patient's Number of Street/Patient's Number of Street R1.5.1 / R1.5.2
  target
epsos-dataelement-51 Street epSOS Data Set
epsos-dataelement-52 Number of Street epSOS Data Set
hl7:city
 0 … 1 R Patient's City R1.5.3
  target
epsos-dataelement-55 City epSOS Data Set
hl7:postalCode
 0 … 1 R Patient's Postal Code R1.5.4
  target
epsos-dataelement-53 Postal Code epSOS Data Set
hl7:state
 0 … 1 R Patient's State or Province R1.5.5
  target
epsos-dataelement-56 State or Province epSOS Data Set
hl7:country
 0 … 1 R Patient's Country. When used addr.country it is always bound to the epSOSCountry value set R1.5.6
  target
epsos-dataelement-54 Country epSOS Data Set
hl7:telecom
 TEL 1 … * R 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
  target
epsos-dataelement-300 Telecom epSOS Data Set
epsos-dataelement-28 Telephone No epSOS Data Set
epsos-dataelement-29 Email epSOS Data Set
@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 F NI
hl7:patient
 1 … 1 M (epS…-PS)
  target
epsos-dataelement-8 Personal Information epSOS Data Set
@classCode
 0 … 1 F PSN
@determinerCode
 0 … 1 F INSTANCE
hl7:name
 PN 1 … * R Patient Name R1.1
  target
epsos-dataelement-9 Full Name epSOS Data Set
hl7:family
 1 … * M Patient's Family Name/Surname R1.1.1
  target
epsos-dataelement-13 Family Name/Surname epSOS Data Set
hl7:prefix
 0 … * R Patient's Prefix R1.1.2
  target
epsos-dataelement-263 Prefix epSOS Data Set
  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 … * M Patient's Given Name R1.1.3
  target
epsos-dataelement-12 Given name epSOS Data Set
hl7:administrativeGenderCode
 CE.EPSOS 1 … 1 R Patient's Gender R1.2
  target
epsos-dataelement-11 Gender epSOS Data Set
@nullFlavor
 0 … 1 F 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
 TS 1 … 1 M Patient's Date of Birth. The patient date of birth may be a partial date such as only the year. R1.3
  target
epsos-dataelement-10 Date of Birth epSOS Data Set
hl7:guardian
 0 … * R

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 F 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 M Template id for IHE PCC Patient Contacts R1.7.A
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:addr
 AD.EPSOS 1 … 1 R 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 F NI
hl7:streetAddressLine
 0 … * R Guardian's Number of Street/Guardian's Number of Street R1.7….3.2
hl7:city
 0 … 1 R Guardian's City R1.7….3.3
hl7:postalCode
 0 … 1 R Guardian's Postal Code R1.7….3.4
hl7:state
 0 … 1 R Guardian's State or Province R1.7….3.5
hl7:country
 0 … 1 R Guardian's Country. When used addr.country it is always bound to the epSOSCountry value set R1.7….3.6
hl7:telecom
 TEL 1 … * R 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….4.2
  target
epsos-dataelement-39 Telephone No epSOS Data Set
@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 F NI
hl7:guardianPerson
 1 … 1 R R1.7.A
  target
epsos-dataelement-34 Contact Person/legal guardian epSOS Data Set
hl7:name
 PN 1 … * R Patient Guardian's Name IHE PCC
  target
epsos-dataelement-36 Full Name epSOS Data Set
Choice 2 … * Elements to choose from:
  • hl7:family
  • hl7:given
hl7:family
 1 … * R Patient Guardian's Family Name/Surname R1.7.A.1
  target
epsos-dataelement-38 Family Name/Surname epSOS Data Set
hl7:given
 1 … * R Patient Guardian's Given Name R1.7.A.2
  target
epsos-dataelement-37 Given Name epSOS Data Set
hl7:languageCommunication
 1 … * R 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". (epS…-PS)
hl7:languageCode
 CS 1 … 1 R 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 red 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 1 … * R from 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author (DYNAMIC)
hl7:author
 1 … * R (epS…-PS)
  target
epsos-dataelement-67 Author epSOS Data Set
@typeCode
 cs 0 … 1 F AUT
@contextControlCode
 cs 0 … 1 F OP
hl7:functionCode
 CE.EPSOS 0 … 1 R R1.10.6
  target
epsos-dataelement-180 Author Role epSOS Data Set
  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 R 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. (epS…-PS)
hl7:assignedAuthor
 1 … 1 R (epS…-PS)
@classCode
 cs 0 … 1 F ASSIGNED
  Schematron assert role red 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 … * R HP ID number R1.10.5
  target
epsos-dataelement-22 Author Identification epSOS Data Set
@nullFlavor
 cs 0 … 1 F NA
hl7:code
 CE.EPSOS 0 … 1 R HP Specialty R1.10.7
hl7:addr
 AD.EPSOS 1 … * R IHE PCC
hl7:telecom
 TEL.EPSOS 1 … * R 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
 set_cs 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)
Choice 0 … 1 Elements to choose from:
hl7:assignedPerson
 R (epS…-PS)
@classCode
 cs 0 … 1 F PSN
@determinerCode
 cs 0 … 1 F INSTANCE
hl7:name
 PN 1 … 1 R HP Name IHE PCC
  target
epsos-dataelement-19 Author Full Name epSOS Data Set
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
 1 … * R HP Family Name/Surname R1.10.1
  target
epsos-dataelement-21 Family Name/Surname epSOS Data Set
hl7:given
 1 … * R HP Given Name R1.10.2
  target
epsos-dataelement-20 Given Name epSOS Data Set
hl7:prefix
 0 … * R HP Prefix R1.10.3
  target
epsos-dataelement-273 Prefix epSOS Data Set
hl7:suffix
 0 … * R HP Suffix R1.10.4
  target
epsos-dataelement-274 Suffix epSOS Data Set
hl7:assignedAuthoringDevice
 R Contains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC) (epS…-PS)
hl7:representedOrganization
 1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9
  target
epsos-dataelement-23 Author Healthcare Facility epSOS Data Set
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.104 epSOS CDA custodian (DYNAMIC)
hl7:custodian
 1 … 1 M (epS…-PS)
@typeCode
 0 … 1 F CST
hl7:assignedCustodian
 1 … 1 R (epS…-PS)
@classCode
 0 … 1 F ASSIGNED
hl7:representedCustodianOrganization
 1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9
@classCode
 0 … 1 F ORG
@determinerCode
 0 … 1 F INSTANCE
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.109 epSOS CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
 1 … 1 M 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
hl7:time
 TS.EPSOS.TZ 1 … 1 M Time of signing the document R1.11.9
hl7:signatureCode
 CS 1 … 1 R Signature code R1.11.9
@code
 CONF 0 … 1 F S
hl7:assignedEntity
 0 … 1 R The regional authority that is responsible for the legal authentication of the CDA document R1.11.9
hl7:id
 1 … 1 M Unique identification of legal authenticator R1.11.9
hl7:addr
 AD.EPSOS 1 … * R IHE PCC
hl7:telecom
 TEL.EPSOS 1 … * R IHE PCC
hl7:assignedPerson
 1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.113 CDA Person (DYNAMIC) IHE PCC
@classCode
 cs 0 … 1 F PSN
@determinerCode
 cs 0 … 1 F INSTANCE
hl7:name
 PN 1 … 1 R HP Name IHE PCC
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
 1 … * R HP Family Name/Surname R1.10.1
hl7:given
 1 … * R HP Given Name R1.10.2
hl7:prefix
 0 … * R HP Prefix R1.10.3
hl7:suffix
 0 … * R HP Suffix R1.10.4
hl7:representedOrganization
 1 … 1 M Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.11.9
treeblank treeblank treeblank where [not(@nullFlavor)]
Included 1 … * R from 2.16.840.1.113883.3.1937.777.11.10.101 epSOS CDA Contact/Preferred HP/Legal Organization (DYNAMIC)
hl7:participant
 1 … * R Contact person / Preferred Health Professional to contact about patient. (epS…-PS)
treeblank where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4']
  target
epsos-dataelement-30 Preferred HP to contact epSOS Data Set
epsos-dataelement-31 Legal Organization to contact epSOS Data Set
epsos-dataelement-34 Contact Person/legal guardian epSOS Data Set
@typeCode
 cs 1 … 1 F IND R1.8.5
  Participant typeCode
hl7:templateId
 1 … 1 M (epS…-PS)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:functionCode
 0 … 1 C (epS…-PS)
  Constraint The <functionCode> element is mandatory when this participant is the preferred HP
@code
 CONF 0 … 1 F PCP
@codeSystem
 0 … 1 F 2.16.840.1.113883.5.88 (HL7 ParticipationFunction)
hl7:time
 IVL_TS.EPSOS.TZ.OPT 0 … 1 R The <time> element may be present and indicates the time of the participation. (epS…-PS)
hl7:associatedEntity
 R The <associatedEntity> element identifies the type of contact. The classCode attribute shall be present, and contains a value from the epSOSRoleClass value set when used for the patient contacts; ‘PRS’ when used for “Preferred HP / Legal Organization”. (epS…-PS)
@classCode
 cs 1 … 1 R R1.8.6
  CONF
The value of @classCode shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.39 epSOSRoleClass (DYNAMIC)
or
@classCode shall be "PRS"
hl7:code
 CV.EPSOS 0 … 1 R 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 with codeSystem (2.16.840.1.113883.5.111). The codeSystem attribute is required. The relationship between the patient and his preferred HP comes from the the full RoleCode (2.16.840.1.113883.5.111) codeSystem R1.8.6
  target
epsos-dataelement-35 Role of that person epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.38 epSOSPersonalRelationship (DYNAMIC)
hl7:addr
 AD.EPSOS 1 … 1 R Patient Contact's / Preferred HP's Address R1.8.3 / R1.9.2
@nullFlavor
 cs 0 … 1 F NI
  Schematron assert role red error  
  test @nullFlavor or hl7:*  
  Message If addr is not nullflavored at least one sub element has to be provided  
hl7:streetAddressLine
 0 … * R Patient Contact's Street/Number of Street / Preferred HP's Street/Number of Street R1.8.3.1 / R1.8.3.2 / R1.9.2.1 / R1.9.2.2
hl7:city
 0 … 1 R Patient Contact's City / Preferred HP's City R1.8.2.3 / R1.9.2.3
hl7:postalCode
 0 … 1 R Patient Contact's Postal Code / Preferred HP's Postal Code R1.8.2.4 / R1.9.2.4
hl7:state
 0 … 1 R Patient Contact's State or Province / Preferred HP's State or Province R1.8.2.5 / R1.9.2.5
hl7:country
 0 … 1 R Patient Contact's Country / Preferred HP's Country. When used addr.country it is always bound to the epSOSCountry value set R1.8.2.6 / R1.9.2.6
hl7:telecom
 TEL 1 … * R Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required. If there is no information, the nullFlavor attribute shall have a value of 'UNK' 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 R1.8.4.1 / R1.8.4.2 / R1.9.3.1 / R1.9.3.2
  target
epsos-dataelement-41 Telephone No epSOS Data Set
epsos-dataelement-43 Email epSOS Data Set
epsos-dataelement-49 Telephone No epSOS Data Set
epsos-dataelement-50 Email epSOS Data Set
epsos-dataelement-39 Telephone No epSOS Data Set
epsos-dataelement-40 Email epSOS Data Set
@use
 set_cs 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
 cs 0 … 1 F UNK
  Example <art:placeholder>
  <telecom use="WP" value="tel:+45 20 7025 6161"/>  <telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/></art:placeholder>
Choice 1 … 1 Elements to choose from:
  • hl7:associatedPerson
  • hl7:scopingOrganization
hl7:associatedPerson
 R (epS…-PS)
hl7:name
 PN 1 … 1 R Patient Contact's Name / Preferred HP's Name IHE PCC / R1.9.1
  target
epsos-dataelement-46 Full Name epSOS Data Set
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
Choice 2 … * Elements to choose from:
  • hl7:family
  • hl7:given
hl7:family
 1 … * R Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname R1.8.1 / R1.9.1.1
  target
epsos-dataelement-48 Family Name/Surname epSOS Data Set
epsos-dataelement-38 Family Name/Surname epSOS Data Set
hl7:given
 1 … * R Patient Contact's Given Name / Preferred HP's Given Name R1.8.2 / R1.9.1.2
  target
epsos-dataelement-47 Given Name epSOS Data Set
epsos-dataelement-37 Given Name epSOS Data Set
hl7:scopingOrganization
 R (epS…-PS)
hl7:name
 ON 1 … 1 R Organization's Name R1.9.1
  target
epsos-dataelement-33 Organization Name epSOS Data Set
Included 1 … 1 R from 2.16.840.1.113883.3.1937.777.11.10.106 epSOS CDA documentationOf PCPR (DYNAMIC)
hl7:documentationOf
 1 … 1 R (epS…-PS)
@typeCode
 cs 1 … 1 F DOC
hl7:serviceEvent
 1 … 1 R (epS…-PS)
@classCode
 cs 1 … 1 F PCPR
@moodCode
 cs 1 … 1 F EVN
hl7:id
 II.EPSOS 0 … * R (epS…-PS)
hl7:code
 CE.EPSOS 0 … 1 R (epS…-PS)
Choice 1 … 1 Elements to choose from:
  • hl7:effectiveTime[hl7:high]
  • hl7:effectiveTime[@nullFlavor or @value]
hl7:effectiveTime
 IVL_TS  … 1 R (epS…-PS)
treeblank treeblank treeblank treeblank where [hl7:high]
hl7:low
 TS 0 … 1 R (epS…-PS)
hl7:high
 TS 1 … 1 R (epS…-PS)
hl7:effectiveTime
 TS  … 1 R (epS…-PS)
treeblank treeblank treeblank treeblank where [@nullFlavor or @value]
hl7:performer
 0 … * R represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors (epS…-PS)
@typeCode
 cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)
hl7:functionCode
 CE.EPSOS 1 … 1 R (epS…-PS)
  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
 IVL_TS 0 … 1 R (epS…-PS)
hl7:assignedEntity
 1 … 1 M (epS…-PS)
hl7:id
 II.EPSOS 1 … * R HP ID number (epS…-PS)
hl7:code
 CE.EPSOS 0 … 1 R HP Specialty (epS…-PS)
hl7:addr
 AD.EPSOS 1 … * R IHE PCC
hl7:telecom
 TEL.EPSOS 1 … * R IHE PCC
hl7:assignedPerson
 0 … 1 Contains 2.16.840.1.113883.3.1937.777.11.10.113 CDA Person (DYNAMIC) (epS…-PS)
hl7:representedOrganization
 0 … 1 Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) (epS…-PS)
Included 1 … * M from 2.16.840.1.113883.3.1937.777.11.10.107 epSOS CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
 1 … * M (epS…-PS)
@typeCode
 cs 1 … 1 R
  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 R (epS…-PS)
@classCode
 0 … 1 F DOCCLIN
@moodCode
 0 … 1 F EVN
hl7:id
 II.EPSOS 1 … * R (epS…-PS)
hl7:code
 CD.EPSOS 0 … 1 R (epS…-PS)
@codeSystem
 CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:text
 ED 0 … 1 R (epS…-PS)
hl7:setId
 II.EPSOS 0 … 1 R (epS…-PS)
hl7:versionNumber
 INT 0 … 1 R (epS…-PS)
hl7:component
 1 … 1 M (epS…-PS)
hl7:structuredBody
 1 … 1 M (epS…-PS)
  target
epsos-dataelement-16 Clinical Data epSOS Data Set
@classCode
 cs 0 … 1 F DOCBODY
hl7:component
 1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 Section Medication Summary (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.12559.11.10.1.3.1.2.3'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.8']]]
hl7:component
 1 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.13 Section Allergies and Other Adverse Reactions (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.840.1.113883.10.20.1.2'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.13']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.23 Section Immunizations (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.23'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.6']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.8 Section History of Past Illness (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.8']]]
hl7:component
 1 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.12 Section Coded List of Surgeries (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.12'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.11']]]
hl7:component
 1 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 Section Active Problems (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.6'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.11']]]
hl7:component
 1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 Section Medical Devices Coded (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.12559.11.10.1.3.1.2.4'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.7'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 Section Health Maintenance Care Plan (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.840.1.113883.10.20.1.10'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.31'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.1.9.50']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.17 Section Functional Status (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.17'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.5']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 Section Coded Social History (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.16.1'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.16'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.15']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Section Pregnancy History (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Section Coded Vital Signs (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.25']]]
hl7:component
 0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Section Coded Results (DYNAMIC) (epS…-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.12559.11.10.1.3.1.2.5']]]