| Concept |
Card/Conf |
Id |
 |
Patient Data |
|
1 … 1 Required |
|
|
Information about the patient |
 |
|
Identification |
|
1 … 1 Mandatory |
|
|
Country ID, unique for the patient in that country. Example: ID for United Kingdom
patient
|
 |
|
|
National Health Care patient ID (country of affiliation) |
|
1 … 1 Mandatory |
|
|
Country ID from the country of origin, unique for the patient in that country. Example:
ID for United Kingdom patient
|
|
|
0 … * |
epsos-dataelement-235 link
|
|
Other identifiers than the national health care patient IDs from either the country
of affiliation or the country of treatment
|
|
|
Personal Information |
|
1 … 1 Mandatory |
|
|
Personal information about the patient |
|
|
1 … 1 Mandatory |
|
|
The full name of the patient |
|
|
1 … 1 Mandatory |
|
|
The Name of the patient (Example: John). This field can contain more than one element |
|
|
1 … 1 Mandatory |
|
|
This field can containe more than one element. |
|
|
0 … 1 |
epsos-dataelement-263 link
|
|
|
0 … 1 |
epsos-dataelement-264 link
|
|
|
1 … 1 Mandatory |
|
|
The date of birth of the patient. This field may contain only the year if day and
month are not available
|
|
|
1 … 1 Mandatory |
|
|
It must contained a recognized valid value for this field. |
|
|
Contact Information |
|
0 … 1 |
|
|
Contact information of the patient, including information of the contacts of the patient. |
|
|
0 … * |
|
|
Address of the patient |
|
|
0 … 1 |
|
|
Name of street where the patient lives |
|
|
0 … 1 |
|
|
House number where the patient lives |
|
|
0 … 1 |
|
|
City where the patient lives |
|
|
0 … 1 |
|
|
Postal code where the patient lives |
|
|
0 … 1 |
|
|
State or province where the patient lives |
|
|
0 … 1 |
|
|
Country where the patient lives |
|
|
1 … * Required |
epsos-dataelement-300 link
|
|
Telecommunication addresses of the patient |
|
|
0 … 1 |
|
|
Telephone number of the patient |
|
|
0 … 1 |
|
|
Email address of the patient |
|
|
0 … 1 Required |
|
|
Preferred Health Professional to contact. A foreign HP may need a contact (HP/legal
organization) who knows the patient
|
|
|
1 … 1 Required |
|
|
Name of the HP/name of the legal organization. If it is an HP, the structure of the
name will be the same as described in ‘Full name’ (Given name, family name/surname)
|
|
|
1 … 1 Required |
|
|
The Name of the HP (Example: John). This field can contain more than one element |
|
|
0 … 1 Required |
|
|
This field can contain more than one element. |
|
|
0 … 1 |
epsos-dataelement-265 link
|
|
|
0 … 1 |
epsos-dataelement-266 link
|
|
|
0 … 1 |
|
|
Telephone number of the HP/name of the legal organization |
|
|
0 … 1 |
|
|
Email address of the HP/name of the legal organization |
|
|
|
Contact Person/legal guardian |
|
0 … 1 |
|
|
Contact or guardian of the patient |
|
|
0 … 1 Required |
|
|
The role of the person: contact person or legal guardian |
|
|
0 … 1 |
|
|
Full name of the contact person or guardian |
|
|
0 … 1 |
|
|
The Name of the person (Example: John). This field can contain more than one element |
|
|
0 … 1 |
|
|
This field can contain more than one element. |
|
|
0 … 1 |
epsos-dataelement-267 link
|
|
|
0 … 1 |
epsos-dataelement-268 link
|
|
|
0 … 1 |
|
|
Telephone number of the person |
|
|
0 … 1 |
|
|
Email address of the person |
|
|
Insurance Information |
|
0 … 1 |
|
|
Information about the insurance of the patient |
|
|
0 … 1 |
|
|
European Health Insurance Code (EHIC) number of the patient |
|
Clinical Data |
|
0 … 1 |
|
|
Clinical information of the patient |
|
|
Medical Problems |
|
0 … 1 |
|
|
|
0 … * Conditional |
epsos-dataelement-228 link
|
|
| Card/Conf |
Condition |
| 0 … * |
New problem/diagnosis |
| 0 … 0 Not present |
otherwise |
|
|
|
|
|
|
Problem/diagnosis Description |
|
0 … 1 |
epsos-dataelement-229 link
|
|
Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’.
Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that
solved the problem and therefore it ́s a closed problem)
|
|
|
|
|
Problem/diagnosis Id (Code) |
|
0 … 1 |
epsos-dataelement-230 link
|
|
Normalized identifier |
|
|
0 … 1 |
epsos-dataelement-307 link
|
|
|
0 … 1 |
epsos-dataelement-303 link
|
|
|
0 … 1 |
epsos-dataelement-231 link
|
|
Date of problem onset |
|
|
0 … * Conditional |
epsos-dataelement-188 link
|
|
| Card/Conf |
Condition |
| 0 … * |
Executed surgical procedures |
| 0 … 0 Not present |
otherwise |
|
|
|
|
0 … 1 |
epsos-dataelement-189 link
|
|
Describes the type of procedure that has been executed as part of the healthcare event. |
|
|
0 … 1 |
epsos-dataelement-190 link
|
|
Normalized identifier |
|
|
0 … 1 |
epsos-dataelement-191 link
|
|
Date when procedure was performed |
|
|
|
Medical Devices and Implants |
|
0 … * Conditional |
|
|
| Card/Conf |
Condition |
| 0 … * Required |
New medical devices/implants |
| 0 … 0 Not present |
otherwise |
|
|
|
|
|
|
Medical Devices and Implants Description |
|
0 … 1 |
|
|
Describes the patient's implanted and external medical devices and equipment that
their health status depends on. Includes devices as cardiac pacemakers, implantable
defribillator, prothesis, feromagnetic bone implants etc that are important to be
known by HP.
|
|
|
0 … 1 |
|
|
Normalized identifier |
|
|
0 … 1 |
|
|
|
0 … * |
epsos-dataelement-128 link
|
|
|
0 … 1 |
epsos-dataelement-129 link
|
|
Therapeutic treatment that does not include drugs (diet, physical excersize constraints
etc)
|
|
|
0 … 1 |
epsos-dataelement-130 link
|
|
normalized identifier, concept code |
|
|
0 … 1 |
epsos-dataelement-131 link
|
|
Date of treatment onset |
|
|
0 … * |
|
|
|
|
|
Recommendations Description |
|
0 … 1 |
|
|
Therapeutic recommendations that do not include drugs (diet, physical exercise constraints,
etc.)
|
|
|
|
|
Recommendations Id (code) |
|
0 … 1 |
|
|
Normalized identifier |
|
|
0 … * |
|
|
|
0 … 1 |
|
|
Need of the patient to be continuously assisted by third parties. Invalidity status
may influence decisions about how to administer treatments
|
|
|
0 … 1 |
epsos-dataelement-132 link
|
|
Date of invalidity onset |
|
|
Medication |
|
0 … 1 |
epsos-dataelement-101 link
|
|
|
0 … * Conditional |
epsos-dataelement-102 link
|
|
| Card/Conf |
Condition |
| 0 … * Required |
All prescribed medicine whose period of time indicated for the treatment has not yet
expired
|
| 0 … 0 Not present |
otherwise |
|
|
|
|
|
|
Prescription identification |
|
1 … 1 Mandatory |
epsos-dataelement-134 link
|
|
Unique identification of the prescription |
|
|
0 … 1 Required |
epsos-dataelement-135 link
|
|
Code that identifies the medicinal product description |
|
|
|
|
Date of issue of prescription |
|
1 … 1 Mandatory |
epsos-dataelement-136 link
|
|
Date when medicine has been prescribed |
|
|
1 … 1 Required |
epsos-dataelement-137 link
|
|
Original brand name of the medicine (in the language of the country in which the prescription
was made)
|
|
|
1 … * Required |
epsos-dataelement-103 link
|
|
Substance that alone or in combination with one or more other ingredients produces
the intended activity of a medicinal product.
|
|
|
1 … * Mandatory |
epsos-dataelement-104 link
|
|
Code that identifies the Active ingredient |
|
|
1 … * Mandatory |
epsos-dataelement-105 link
|
|
The content of the active ingredient expressed quantitatively per dosage unit, per
unit of volume or per unit of weight, according to the pharmaceutical dose form. Example:
500 mg per tablet
|
|
|
|
|
Medicinal product package size |
|
1 … 1 Required |
epsos-dataelement-138 link
|
|
The size of the package prescribed |
|
|
1 … 1 Mandatory |
epsos-dataelement-106 link
|
|
It is the form in which a pharmaceutical product is presented in the medicinal product
package (e.g. tablets, syrup)
|
|
|
1 … 1 Required |
epsos-dataelement-139 link
|
|
Number of boxes that have been prescribed |
|
|
|
|
Number of units per intake |
|
1 … 1 Required |
epsos-dataelement-107 link
|
|
The number of units per intake that the patient is taking (e.g. 1 tablet) |
|
|
1 … * Required |
epsos-dataelement-108 link
|
|
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours |
|
|
1 … 1 Required |
epsos-dataelement-109 link
|
|
|
|
|
Date of onset of treatment |
|
1 … 1 Required |
epsos-dataelement-110 link
|
|
Date when patient needs to start taking the medicine prescribed |
|
|
0 … 1 Required |
epsos-dataelement-140 link
|
|
Indicates the part of the body through or into which, or the way in which, the medicinal
product is intended to be introduced. In some cases a medicinal product can be intended
for more than one route and/or method of administration.
NOTE FOR GUIDANCE ON DATA ELEMENTS AND STANDARDS FOR DRUG DICTIONARIES
(EMEA/CHMP/ICH/168535/2005)
|
|
|
0 … 1 Required |
epsos-dataelement-141 link
|
|
The prescriber might give to the patient instructions; They must be presented in the
original language.
|
|
|
0 … 1 |
epsos-dataelement-142 link
|
|
The prescriber might give instructions to the dispenser. The information will be in
the original language as automatic translation is not secure enough. To avoid legal
and ethical issues to the dispenser, it should be wise to implement an option that
allows the dispenser to decide, knowing that this data is available, whether he wants
to consult it or not.
|
|
|
0 … 1 |
epsos-dataelement-236 link
|
|
|
0 … 1 |
epsos-dataelement-237 link
|
|
|
0 … 1 |
epsos-dataelement-238 link
|
|
Some countries need the specialty of the prescriber for the epSOS ePrescription to
be seen as valid. In the epSOS phase 1 ePrescription data set, this element is not
basic (minimum), therefore not always filled in. The proposal is to define the specialty
of the prescriber as a basic element, so it should be filled in, if available. As
it could be that this information is not available in every country, null values should
be allowed.
|
|
|
0 … 1 |
epsos-dataelement-239 link
|
|
Date/time the medication was prescribed |
|
|
|
|
|
Prescriber Identification |
|
0 … 1 |
epsos-dataelement-240 link
|
|
Unique identification of the prescriber |
|
|
0 … 1 |
epsos-dataelement-241 link
|
|
The full name of the Health Professional |
|
|
0 … 1 |
epsos-dataelement-242 link
|
|
The Name of the Prescriber (Example: John). This field can contain more than one element |
|
|
0 … 1 |
epsos-dataelement-243 link
|
|
This field can contain more than one element. |
|
|
0 … 1 |
epsos-dataelement-269 link
|
|
|
0 … 1 |
epsos-dataelement-270 link
|
|
|
0 … * |
epsos-dataelement-282 link
|
|
|
0 … 1 |
epsos-dataelement-280 link
|
|
|
0 … 1 |
epsos-dataelement-281 link
|
|
|
|
|
|
Prescriber Healthcare Facility |
|
0 … 1 |
epsos-dataelement-244 link
|
|
Information about the healthcare facility where the health professional works |
|
|
0 … 1 |
epsos-dataelement-245 link
|
|
Unique identification of the healthcare facility |
|
|
0 … 1 |
epsos-dataelement-246 link
|
|
Name of the healthcare facility |
|
|
|
|
|
|
Healthcare Facility Telecom |
|
0 … * |
epsos-dataelement-283 link
|
|
|
0 … 1 |
epsos-dataelement-278 link
|
|
|
0 … 1 |
epsos-dataelement-279 link
|
|
|
|
|
|
Prescriber Credentialing Organization |
|
0 … 1 |
epsos-dataelement-290 link
|
|
The organization which provided the credentialing for the prescriber |
|
|
0 … 1 |
epsos-dataelement-291 link
|
|
Unique identification of the organization which provided the credentialing for the
prescriber
|
|
|
0 … 1 |
epsos-dataelement-292 link
|
|
The name of the organization which provided the credentialing for the prescriber |
|
|
0 … * |
epsos-dataelement-143 link
|
|
Information about dispensed medication |
|
|
1 … 1 Mandatory |
epsos-dataelement-165 link
|
|
Unique identification of the dispensed medication |
|
|
|
|
Date of issue of dispense |
|
1 … 1 Required |
epsos-dataelement-173 link
|
|
Date when the medicine has been dispensed |
|
|
0 … 1 Required |
epsos-dataelement-162 link
|
|
The ID of the prescription serving as the basis for the dispensation |
|
|
0 … 1 Required |
epsos-dataelement-172 link
|
|
Original brand name of the medicine (in the language of the country in which the prescription
was made)
|
|
|
1 … * Mandatory |
epsos-dataelement-160 link
|
|
Substance that alone or in combination with one or more other ingredients produces
the intended activity of a medicinal product.
|
|
|
1 … * Required |
epsos-dataelement-159 link
|
|
Code that identifies the Active ingredient |
|
|
1 … * Mandatory |
epsos-dataelement-156 link
|
|
The content of the active ingredient expressed quantitatively per dosage unit, per
unit of volume or per unit of weight, according to the pharmaceutical dose form. Example:
500 mg per tablet
|
|
|
|
|
Medicinal product package size |
|
1 … 1 Mandatory |
epsos-dataelement-158 link
|
|
The size of the package prescribed |
|
|
1 … 1 Mandatory |
epsos-dataelement-154 link
|
|
It is the form in which a pharmaceutical product is presented in the medicinal product
package (e.g. tablets, syrup)
|
|
|
0 … 1 Required |
epsos-dataelement-153 link
|
|
Indicates the part of the body through or into which, or the way in which, the medicinal
product is intended to be introduced. In some cases a medicinal product can be intended
for more than one route and/or method of administration.
NOTE FOR GUIDANCE ON DATA ELEMENTS AND STANDARDS FOR DRUG DICTIONARIES
(EMEA/CHMP/ICH/168535/2005)
|
|
|
0 … 1 Required |
epsos-dataelement-152 link
|
|
Number of boxes that have been prescribed |
|
|
|
|
Number of units per intake |
|
1 … 1 Required |
epsos-dataelement-151 link
|
|
The number of units per intake that the patient is taking (e.g. 1 tablet) |
|
|
1 … * Required |
epsos-dataelement-150 link
|
|
Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours |
|
|
0 … 1 Required |
epsos-dataelement-149 link
|
|
|
0 … 1 |
epsos-dataelement-148 link
|
|
|
|
|
Date of onset of treatment according to prescription |
|
0 … 1 |
epsos-dataelement-147 link
|
|
Date when the patient needs to start taking the medicine prescribed |
|
|
1 … 1 Required |
epsos-dataelement-146 link
|
|
Date of the end of the treatment or prescriptions where the end of treatment has expired |
|
|
|
|
Date of onset of dispense |
|
0 … 1 |
epsos-dataelement-145 link
|
|
Date when the patient starts taking the medicine dispensed |
|
|
|
|
Expected date of end of treatment |
|
0 … 1 |
epsos-dataelement-144 link
|
|
Expectation when the patient stops taking the medicine dispensed |
|
|
0 … 1 |
epsos-dataelement-247 link
|
|
|
0 … 1 |
epsos-dataelement-248 link
|
|
Date/time the medication was dispensed |
|
|
0 … 1 |
epsos-dataelement-249 link
|
|
Unique identification of the dispenser |
|
|
0 … 1 |
epsos-dataelement-250 link
|
|
|
0 … 1 |
epsos-dataelement-251 link
|
|
|
0 … 1 |
epsos-dataelement-252 link
|
|
|
0 … 1 |
epsos-dataelement-271 link
|
|
|
0 … 1 |
epsos-dataelement-272 link
|
|
|
0 … * |
epsos-dataelement-287 link
|
|
|
0 … 1 |
epsos-dataelement-288 link
|
|
|
0 … 1 |
epsos-dataelement-289 link
|
|
|
|
|
|
Dispenser Healthcare Facility |
|
0 … 1 |
epsos-dataelement-253 link
|
|
|
0 … 1 |
epsos-dataelement-254 link
|
|
Unique identification of the healthcare facility |
|
|
0 … 1 |
epsos-dataelement-255 link
|
|
|
0 … 1 |
epsos-dataelement-256 link
|
|
|
0 … 1 |
epsos-dataelement-257 link
|
|
|
0 … 1 |
epsos-dataelement-258 link
|
|
|
0 … 1 |
epsos-dataelement-259 link
|
|
|
0 … 1 |
epsos-dataelement-260 link
|
|
|
0 … 1 |
epsos-dataelement-261 link
|
|
|
0 … 1 |
epsos-dataelement-262 link
|
|
|
|
|
|
|
Healthcare Facility Telecom |
|
0 … * |
epsos-dataelement-284 link
|
|
|
0 … 1 |
epsos-dataelement-285 link
|
|
|
0 … 1 |
epsos-dataelement-286 link
|
|
|
|
|
|
Dispenser Credentialing Organization |
|
0 … 1 |
epsos-dataelement-293 link
|
|
The organization which provided the credentialing for the dispenser |
|
|
0 … 1 |
epsos-dataelement-294 link
|
|
Unique identification of the organization which provided the credentialing for the
dispenser
|
|
|
0 … 1 |
epsos-dataelement-295 link
|
|
The name of the organization which provided the credentialing for the dispenser |
|
|
Physical Findings |
|
0 … * Required |
epsos-dataelement-117 link
|
|
|
0 … 1 |
epsos-dataelement-118 link
|
|
|
0 … 1 Required |
epsos-dataelement-119 link
|
|
One value of blood pressure which includes: systolic Blood Pressure and Diastolic
Blood pressure
|
|
|
0 … 1 Required |
epsos-dataelement-120 link
|
|
|
0 … 1 Required |
epsos-dataelement-121 link
|
|
|
|
|
Date when blood pressure was measured |
|
0 … 1 Required |
epsos-dataelement-122 link
|
|
Date when blood pressure was measured |
|
|
Diagnostic Tests |
|
0 … * Required |
epsos-dataelement-123 link
|
|
|
0 … 1 Required |
epsos-dataelement-124 link
|
|
|
0 … 1 Required |
epsos-dataelement-125 link
|
|
Result from the blood group test made to the patient |
|
|
0 … 1 Required |
epsos-dataelement-126 link
|
|
Date in which the blood group test was done. This field may contain only the year
if day and month are not available. Eg: 01/01/2009
|
|
|
Vaccination |
|
0 … * Required |
epsos-dataelement-167 link
|
|
|
0 … 1 Required |
epsos-dataelement-168 link
|
|
Brand name of the vaccination |
|
|
0 … 1 Required |
epsos-dataelement-171 link
|
|
Description of the vaccine |
|
|
0 … 1 Required |
epsos-dataelement-170 link
|
|
The code of the vaccine |
|
|
0 … 1 Required |
epsos-dataelement-169 link
|
|
The date the vaccination was done |
|
|
Allergy |
|
0 … * Required |
|
|
Allergies and intolerances |
|
|
1 … 1 Required |
|
|
Description of the clinical manifestation of the allergy reaction. Example: Anaphylactic
shock, angioedema (the clinical manifestation also gives information about the severity
of the observed reaction)
|
|
|
1 … 1 Required |
|
|
The code of the allergy |
|
|
0 … 1 |
epsos-dataelement-304 link
|
|
|
0 … 1 |
|
|
Date when the allergy started |
|
|
1 … 1 Required |
|
|
Describes the agent (drug, food, chemical agent, etc) that is responsible for the
adverse reaction
|
|
|
1 … 1 Required |
|
|
The code of the allergen agent |
|
|
Pregnancy History |
|
0 … * Required |
epsos-dataelement-115 link
|
|
|
|
Expected date of delivery |
|
0 … 1 Required |
epsos-dataelement-116 link
|
|
Date in which the woman is due to give birth. Year, day and month are required. |
|
|
Social History |
|
0 … 1 Required |
epsos-dataelement-111 link
|
|
|
|
Social History Observations |
|
0 … * Required |
epsos-dataelement-112 link
|
|
|
|
|
Social History Observations related to: smoke, alcohol and diet |
|
0 … 1 Required |
epsos-dataelement-113 link
|
|
|
|
|
Date range of observation |
|
0 … 1 Required |
epsos-dataelement-114 link
|
|
Document Data |
|
1 … 1 Required |
|
|
Information about the document itself |
|
|
Identification |
|
1 … 1 Mandatory |
epsos-dataelement-176 link
|
|
Identification of the document |
|
|
Type |
|
1 … 1 Mandatory |
epsos-dataelement-296 link
|
|
Type of the document |
|
|
Confidentiality |
|
1 … 1 Required |
epsos-dataelement-297 link
|
|
Confidentiality of the document as a whole |
|
|
Language |
|
1 … 1 Mandatory |
epsos-dataelement-298 link
|
|
The principal language of the documentThe 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
|
|
|
Country B |
|
1 … 1 Mandatory |
epsos-dataelement-179 link
|
|
Name of country B |
|
|
Topicality |
|
1 … 1 Required |
|
|
|
1 … 1 Mandatory |
|
|
Date on which the document was generated |
|
|
1 … 1 Mandatory |
|
|
Date on which the document was updated (date of last version) |
|
|
Author |
|
1 … 1 Mandatory |
|
|
To highlight if the data is collected manually by an HP or is collected automatically
from different sources (eg: hospital doctor repository, GPs...etc) through predetermined
clinical rules.
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1 … 1 Mandatory |
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Unique identification of the Health Professional. |
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1 … 1 Required |
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The full name of the Health Professional |
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0 … * Required |
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The Name of the HP (Example: John). This field can contain more than one element |
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1 … 1 Required |
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This field can contain more than one element. |
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1 … 1 |
epsos-dataelement-180 link
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Role or specialism the author was in when sending the document. |
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Legal Entity |
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1 … 1 Required |
epsos-dataelement-177 link
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Responsible for the data in the document |
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0 … 1 Required |
epsos-dataelement-185 link
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Health professional ID responsible for the data in the document |
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0 … 1 Required |
epsos-dataelement-181 link
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Legal organization ID responsible for the data in het document |
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0 … 1 |
epsos-dataelement-182 link
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Role the health professional is in while being responsible for the document data |
Send HCER/Receive ACK
Send HCER to country A
Respond ACK