Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.1

Template epSOS-ePrescription

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.1 Effective Date 2013‑12‑20

Status Draft Version Label

Name epSOS-eP Display Name epSOS-ePrescription

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 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 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.

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 8 templates

Used by	as	Name	Version
epsos-transactions-19	Transaction	Return eP from country A	2013‑11‑02
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
2.16.840.1.113883.3.1937.777.11.10.103	Include	epSOS CDA author prescriber	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
2.16.840.1.113883.3.1937.777.11.10.107	Include	epSOS CDA relatedDocument	DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.1	Containment	Section Prescription	DYNAMIC

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

There is an open issue with this item:

epsos-issue-165: realmCode (Open)

Item DT Card Conf Description Label

hl7:ClinicalDocument R CDA header (epS-eP)

hl7:realmCode CS 0 … 1 R (epS-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.

(epS

-eP)

@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 ePrescription document (epS-eP)

@root uid 1 … 1 F 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 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 ePrescription" R1.11.6

@displayName 1 … 1 R

@code CONF 1 … 1 F 57833-6

@codeSystem 1 … 1 F 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 ST 1 … 1 M 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 M 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 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.

(epS

-eP)

hl7:versionNumber 0 … 1 R (epS-eP)

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-eP)


	epsos-dataelement-5	Patient Data	epSOS Data Set

@typeCode cs 0 … 1 F RCT

@contextControlCode cs 0 … 1 F OP

hl7:patientRole 1 … 1 M (epS-eP)


	epsos-dataelement-26	Contact Information	epSOS Data Set

@classCode cs 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-235	Other Identifier	epSOS Data Set
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-6	Identification	epSOS Data Set

hl7:addr AD.EPSOS 1 … 1 R 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. R1.5


	epsos-dataelement-27	Address	epSOS Data Set

@nullFlavor cs 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

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.4 epSOSCountry (DYNAMIC)

hl7:telecom TEL 1 … * R 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. R1.6.1 / R1.6.2


epsos-dataelement-28	Telephone No	epSOS Data Set
epsos-dataelement-300	Telecom	epSOS Data Set
epsos-dataelement-29	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 NI

hl7:patient 1 … 1 M (epS-eP)


	epsos-dataelement-8	Personal Information	epSOS Data Set

@classCode cs 0 … 1 F PSN

@determinerCode cs 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 cs 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 cs 1 … 1 F GUARD

@nullFlavor cs 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 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 R1.7.3.6

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.4 epSOSCountry (DYNAMIC)

hl7:telecom TEL 1 … * R 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. R1.7.4.2


	epsos-dataelement-39	Telephone No	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 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 0 … * 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-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 1 … * M from 2.16.840.1.113883.3.1937.777.11.10.103 epSOS CDA author prescriber (DYNAMIC)

hl7:author 1 … * M (epS-eP)

@typeCode cs 0 … 1 F AUT

@contextControlCode cs 0 … 1 F OP

hl7:functionCode CE.EPSOS 1 … 1 M 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 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-eP)

hl7:assignedAuthor 1 … 1 R (epS-eP)

@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

@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)

hl7:assignedPerson 1 … 1 M (epS-eP)

@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 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9

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-eP)

@typeCode 0 … 1 F CST

hl7:assignedCustodian 1 … 1 R (epS-eP)

@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 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 … *

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.

R1.10.9.4 / R1.10.9.4.1 / R1.10.9.4.2

@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)

@nullFlavor cs 0 … 1 F NI

Example <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>

hl7:assignedPerson 1 … 1 R 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 … * M HP Family Name/Surname R1.10.1

hl7:given 1 … * M 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 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.107 epSOS CDA relatedDocument (DYNAMIC)

hl7:relatedDocument 1 … 1 M (epS-eP)

@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-eP)

@classCode 0 … 1 F DOCCLIN

@moodCode 0 … 1 F EVN

hl7:id II.EPSOS 1 … * R (epS-eP)

hl7:code CD.EPSOS 0 … 1 R (epS-eP)

@codeSystem CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)

hl7:text ED 0 … 1 R (epS-eP)

hl7:setId II.EPSOS 0 … 1 R (epS-eP)

hl7:versionNumber INT 0 … 1 R (epS-eP)

hl7:component 1 … 1 M (epS-eP)

hl7:structuredBody 1 … 1 M (epS-eP)

@classCode cs 0 … 1 F DOCBODY

hl7:component 1 … * R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.1 Section Prescription (DYNAMIC) (epS-eP)

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

Template epSOS-ePrescription