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.
The Healthcare Encounter Report service not only supports the patient summary extension
use case, but also supports the ePrescription extension use case and the 112 emergency
use case. Therefore this service description not only covers the patient summary extension,
but also the ePrescription extension and the part of the 112 emergency use case where
information about the emergency encounter is sent back to country A.
The definition of a healthcare event can be broad. The HCER service is designed to
offer a health professional in country B flexibility to record a wide range of medical
information, enough to cover the most basic healthcare encounters. The service offers
country A the basic contact information of the health professional in country B together
with the medical information gathered during the healthcare encounter. Informing country
A of a healthcare encounter in county B, of course, is done with consent of the patient.
Context
Pathname /
Classification
CDA Document Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 21 templates
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.
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))+.
The patient address
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.
Patient’s telephone number / Patient e-mail address. The patient telephone or e-mail
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.
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
cs
1 … 1
F
GUARD
@nullFlavor
cs
0 … 1
Use nullFlavor if unknown or if no information is applicable
Example
<guardianclassCode="GUARD"> <templateIdroot="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><telecomvalue="tel:+452070256161"/><telecomvalue="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
uid
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
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
cs
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
Guardian’s telephone number / Patient e-mail address. The guardian telephone or e-mail
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.
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".
(epSCER)
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
<languageCodecode="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
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.
(epSCER)
hl7:assignedAuthor
1 … 1
R
(epSCER)
@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.
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
1 … 1
M
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
1 … *
R
Legal Authenticator's Telecom
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.
The participant element identifies other supporting participants, including parents,
relatives, caregivers, insurance policy holders, guarantors, and other participants
related in some way to the patient. A supporting person or organization is an individual
or an organization with a relationship to the patient. A supporting person who is
playing multiple roles would be recorded in multiple particpants (e.g., emergency
contact and next-of-kin)
Elements to choose from:
hl7:participant[hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4'] included from
template 2.16.840.1.113883.3.1937.777.11.10.101epSOS CDA Contact/Preferred HP/Legal Organization (DYNAMIC)
The
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”.
The relationship between the patient and the guardian or other contact should be recorded
in the 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
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
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
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
(epSCER)
@typeCode
cs
1 … 1
R
CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601x_ServiceEventPerformer (DYNAMIC)
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.
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument
1 … 1
R
(epSCER)
@classCode
0 … 1
F
DOCCLIN
@moodCode
0 … 1
F
EVN
hl7:id
II.EPSOS
1 … *
R
(epSCER)
hl7:code
CD.EPSOS
0 … 1
R
(epSCER)
@codeSystem
CONF
0 … 1
F
2.16.840.1.113883.6.1 (LOINC)
hl7:text
ED
0 … 1
R
(epSCER)
hl7:setId
II.EPSOS
0 … 1
R
(epSCER)
hl7:versionNumber
INT
0 … 1
R
(epSCER)
hl7:component
1 … 1
M
(epSCER)
hl7:structuredBody
1 … 1
M
the component/structuredBody SHALL contain at least one [1..*] component/section. the component/structuredBody SHALL conform to the section constraints below
MAY contain zero or one [0..1] Medication Summary Section (templateId: 1.3.6.1.4.1.12559.11.10.1.3.1.2.3).
MAY contain zero or one [0..1] Allergies and Other Adverse Reactions Section (templateId:
1.3.6.1.4.1.19376.1.5.3.1.3.13).
MAY contain zero or one [0..1] Coded List of Surgeries Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.12).
MAY contain zero or one [0..1] Active Problems Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.6).
MAY contain zero or one [0..1] Medical Devices Coded Section (templateId: 1.3.6.1.4.1.12559.11.10.1.3.1.2.4).
MAY contain zero or one [0..1] Immunizations Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.23).
MAY contain zero or one [0..1] Health Maintenance Care Plan Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.9.50).
MAY contain zero or one [0..1] History of Past Illness Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.8).
MAY contain zero or one [0..1] Coded Social History Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.16.1).
MAY contain zero or one [0..1] Pregnancy History Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4).
MAY contain zero or one [0..1] Coded Vital Signs Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2).
MAY contain zero or one [0..1] Coded Results Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.28)
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']]]
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']]]
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']]]
Template epSOS-Health Care Encounter Report
Draft
CER)
error
