Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.7

Template eHDSI-Patient Summary (PDF embedded)

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.7 Effective Date valid from 2017‑03‑11 18:41:31

Status Draft Version Label

Name eHDSI-OriginalPS Display Name eHDSI-Patient Summary (PDF embedded)

Description

< DESCRIPTION TO BE UPDATED >

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 Template type not specified

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

Used by / Uses

Used by 0 transactions and 0 templates, Uses 9 templates

Uses	as	Name	Version
2.16.840.1.113883.3.1937.777.11.10.110	Include	epSOS CDA Id	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.108	Include	epSOS CDA setId	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.100	Include	epSOS CDA recordTarget	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.102	Include	epSOS CDA author	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.104	Include	epSOS CDA custodian	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.109	Include	epSOS CDA legalAuthenticator	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.101	Include	epSOS CDA Contact/Preferred HP/Legal Organization	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.106	Include	epSOS CDA documentationOf PCPR	DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.107	Include	epSOS CDA relatedDocument	DYNAMIC

There is an open issue with this item:

epsos-issue-229: custodian org, see epsos-issue-219 (Open)

Item DT Card Conf Description Label

hl7:ClinicalDocument R CDA header (eHD…lPS)

hl7:realmCode CS 1 … 1 M (eHD…lPS)

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.

(eHD…lPS)

@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 1 … 1 M Template ID for eHDSI original Patient Summary document. (eHD…lPS)

@root uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.1.7

Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.110 epSOS CDA Id (DYNAMIC)

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

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

@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

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

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

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 0 … 1 from 2.16.840.1.113883.3.1937.777.11.10.108 epSOS CDA setId (DYNAMIC)

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.

(eHD…lPS)

hl7:versionNumber 0 … 1 R (eHD…lPS)

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 (eHD…lPS)

epsos-dataelement-5

Patient Data

epSOS Data Set

@typeCode 0 … 1 F RCT

@contextControlCode 0 … 1 F OP

hl7:patientRole 1 … 1 M (eHD…lPS)

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

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

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

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

epsos-dataelement-55

City

epSOS Data Set

hl7:postalCode 0 … 1 R Patient's Postal Code R1.5.4

epsos-dataelement-53

Postal Code

epSOS Data Set

hl7:state 0 … 1 R Patient's State or Province R1.5.5

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

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

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 (eHD…lPS)

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

epsos-dataelement-9

Full Name

epSOS Data Set

hl7:family 1 … * M Patient's Family Name/Surname R1.1.1

epsos-dataelement-13

Family Name/Surname

epSOS Data Set

hl7:prefix 0 … * R Patient's Prefix R1.1.2

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

epsos-dataelement-12

Given name

epSOS Data Set

hl7:administrativeGenderCode CE.EPSOS 1 … 1 R Patient's Gender R1.2

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

epsos-dataelement-10

Date of Birth

epSOS Data Set

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 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

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

epsos-dataelement-34

Contact Person/legal guardian

epSOS Data Set

hl7:name PN 1 … * R Patient Guardian's Name IHE PCC

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

epsos-dataelement-38

Family Name/Surname

epSOS Data Set

hl7:given 1 … * R Patient Guardian's Given Name R1.7.A.2

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". (eHD…lPS)

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 1 … * R from 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author (DYNAMIC)

hl7:author 1 … * R (eHD…lPS)

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

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. (eHD…lPS)

hl7:assignedAuthor 1 … 1 R (eHD…lPS)

@classCode cs 0 … 1 F 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 … * R HP ID number R1.10.5

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
hl7:assignedAuthoringDevice containing template 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC)

hl7:assignedPerson R (eHD…lPS)

@classCode cs 0 … 1 F PSN

@determinerCode cs 0 … 1 F INSTANCE

hl7:name PN 1 … 1 R HP Name IHE PCC

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

epsos-dataelement-21

Family Name/Surname

epSOS Data Set

hl7:given 1 … * R HP Given Name R1.10.2

epsos-dataelement-20

Given Name

epSOS Data Set

hl7:prefix 0 … * R HP Prefix R1.10.3

epsos-dataelement-273

Prefix

epSOS Data Set

hl7:suffix 0 … * R HP Suffix R1.10.4

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) (eHD…lPS)

hl7:representedOrganization 1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9

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 (eHD…lPS)

@typeCode 0 … 1 F CST

hl7:assignedCustodian 1 … 1 R (eHD…lPS)

@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

where [not(@nullFlavor)]

Included 0 … * from 2.16.840.1.113883.3.1937.777.11.10.101 epSOS CDA Contact/Preferred HP/Legal Organization (DYNAMIC)
The IHE PCC template Patient Contacts shall be used for describing the patient contacts or the preferred HP.

hl7:participant 0 … * R Contact person / Preferred Health Professional to contact about patient. (eHD…lPS)

where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4']

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 (eHD…lPS)

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4

hl7:functionCode 0 … 1 C (eHD…lPS)

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. (eHD…lPS)

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”. (eHD…lPS)

@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)

@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

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 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

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 (eHD…lPS)

hl7:name PN 1 … 1 R Patient Contact's Name / Preferred HP's Name IHE PCC / R1.9.1

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

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

epsos-dataelement-47	Given Name	epSOS Data Set
epsos-dataelement-37	Given Name	epSOS Data Set

hl7:scopingOrganization R (eHD…lPS)

hl7:name ON 1 … 1 R Organization's Name R1.9.1

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 (eHD…lPS)

@typeCode cs 1 … 1 F DOC

hl7:serviceEvent 1 … 1 R (eHD…lPS)

@classCode cs 1 … 1 F PCPR

@moodCode cs 1 … 1 F EVN

hl7:id II.EPSOS 0 … * R (eHD…lPS)

hl7:code CE.EPSOS 0 … 1 R (eHD…lPS)

Choice

1 … 1

Elements to choose from:

hl7:effectiveTime[hl7:high]
hl7:effectiveTime[@nullFlavor or @value]

hl7:effectiveTime IVL_TS … 1 R (eHD…lPS)

where [hl7:high]

hl7:low TS 0 … 1 R (eHD…lPS)

hl7:high TS 1 … 1 R (eHD…lPS)

hl7:effectiveTime TS … 1 R (eHD…lPS)

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 (eHD…lPS)

@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 (eHD…lPS)

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 (eHD…lPS)

hl7:assignedEntity 1 … 1 M (eHD…lPS)

hl7:id II.EPSOS 1 … * R HP ID number (eHD…lPS)

hl7:code CE.EPSOS 0 … 1 R HP Specialty (eHD…lPS)

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) (eHD…lPS)

hl7:representedOrganization 0 … 1 Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) (eHD…lPS)

Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.107 epSOS CDA relatedDocument (DYNAMIC)

hl7:relatedDocument 1 … 1 M (eHD…lPS)

@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 (eHD…lPS)

@classCode 0 … 1 F DOCCLIN

@moodCode 0 … 1 F EVN

hl7:id II.EPSOS 1 … * R (eHD…lPS)

hl7:code CD.EPSOS 0 … 1 R (eHD…lPS)

@codeSystem CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)

hl7:text ED 0 … 1 R (eHD…lPS)

hl7:setId II.EPSOS 0 … 1 R (eHD…lPS)

hl7:versionNumber INT 0 … 1 R (eHD…lPS)

hl7:component 1 … 1 M (eHD…lPS)

hl7:nonXMLBody 1 … 1 M (eHD…lPS)

@classCode cs 1 … 1 F DOCBODY

@moodCode cs 1 … 1 F EVN

hl7:text 1 … 1 M This element is used in this template to embed the PDF representation of the original document produced in the Country of Affiliation (Country A). The reference element shall never be used for this template. (eHD…lPS)

@mediaType cs 1 … 1 F application/pdf

@representation cs 1 … 1 F B64

Constraint The encoding rules of the pdf, including the allowed pdf formats, SHALL be the same defined by the IHE XDS-SD profile

hl7:reference NP (eHD…lPS)

Template eHDSI-Patient Summary (PDF embedded)