hl7:ClinicalDocument
|
|
|
R |
CDA header |
(epS-eD) |
hl7:realmCode
|
CS |
0 … 1 |
R |
|
(epS-eD) |
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-eD) |
@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 eDispensation document |
(epS-eD) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.12559.11.10.1.3.1.1.2 |
|
Example |
<templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.2"/> |
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 |
|
|
|
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 eDispensation" |
R1.11.6 |
@displayName
|
|
1 … 1 |
R |
|
@code
|
CONF |
1 … 1 |
F |
60593-1 |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
|
Example |
<code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed.extended Document"/> |
hl7:title
|
ST |
1 … 1 |
M |
ClinicalDocument/title is used for display purposes. |
R1.11.7 |
|
Example |
<title>epSOS eDispensation 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 |
|
|
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 |
|
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 |
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-eD) |
hl7:versionNumber
|
|
0 … 1 |
R |
|
(epS-eD) |
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-eD) |
|
|
@typeCode
|
cs |
0 … 1 |
F |
RCT |
@contextControlCode
|
cs |
0 … 1 |
F |
OP |
hl7:patientRole
|
|
1 … 1 |
M |
|
(epS-eD) |
|
|
@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 |
|
|
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 |
|
|
@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 |
|
|
hl7:city
|
|
0 … 1 |
R |
Patient's City |
R1.5.3 |
|
|
hl7:postalCode
|
|
0 … 1 |
R |
Patient's Postal Code |
R1.5.4 |
|
|
hl7:state
|
|
0 … 1 |
R |
Patient's State or Province |
R1.5.5 |
|
|
hl7:country
|
|
0 … 1 |
R |
Patient's Country. When used addr.country it is always bound to the epSOSCountry value
set
|
R1.5.6 |
|
|
|
CONF |
|
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 |
|
|
@use
|
set_cs |
0 … 1 |
|
|
|
CONF |
|
@nullFlavor
|
cs |
0 … 1 |
F |
NI |
hl7:patient
|
|
1 … 1 |
M |
|
(epS-eD) |
|
|
@classCode
|
cs |
0 … 1 |
F |
PSN |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … * |
R |
Patient Name |
R1.1 |
|
|
hl7:family
|
|
1 … * |
M |
Patient's Family Name/Surname |
R1.1.1 |
|
|
hl7:prefix
|
|
0 … * |
R |
Patient's Prefix |
R1.1.2 |
|
|
|
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 |
|
|
hl7:administrativeGenderCode
|
CE.EPSOS |
1 … 1 |
R |
Patient's Gender |
R1.2 |
|
|
@nullFlavor
|
cs |
0 … 1 |
F |
UNK |
|
CONF |
|
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 |
|
|
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
|
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 |
|
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 |
|
|
@use
|
set_cs |
0 … 1 |
|
|
|
CONF |
|
@nullFlavor
|
cs |
0 … 1 |
F |
NI |
hl7:guardianPerson
|
|
1 … 1 |
R |
|
R1.7.A |
|
|
hl7:name
|
PN |
1 … * |
R |
Patient Guardian's Name |
IHE PCC |
|
|
Choice |
2 … * |
|
Elements to choose from:
|
hl7:family
|
|
1 … * |
R |
Patient Guardian's Family Name/Surname |
R1.7.A.1 |
|
|
hl7:given
|
|
1 … * |
R |
Patient Guardian's Given Name |
R1.7.A.2 |
|
|
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-eD) |
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 |
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 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author (DYNAMIC)
|
hl7:author
|
|
1 … * |
M |
|
(epS-eD) |
|
|
@typeCode
|
cs |
0 … 1 |
F |
AUT |
@contextControlCode
|
cs |
0 … 1 |
F |
OP |
hl7:functionCode
|
CE.EPSOS |
0 … 1 |
R |
|
R1.10.6 |
|
|
|
CONF |
|
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-eD) |
hl7:assignedAuthor
|
|
1 … 1 |
R |
|
(epS-eD) |
@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 |
|
Choice |
0 … 1 |
|
Elements to choose from:
|
hl7:assignedPerson
|
|
|
R |
|
(epS-eD) |
@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:assignedAuthoringDevice
|
|
|
R |
Contains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC)
|
(epS-eD) |
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-eD) |
@typeCode
|
|
0 … 1 |
F |
CST |
hl7:assignedCustodian
|
|
1 … 1 |
R |
|
(epS-eD) |
@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 … * |
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.
|
R1.10.9.4 / R1.10.9.4.1 / R1.10.9.4.2 |
@use
|
set_cs |
0 … 1 |
|
|
|
CONF |
|
@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 |
|
|
Included |
1 … 1 |
M |
from 2.16.840.1.113883.3.1937.777.11.10.115 CDA inFulfillmentOf (DYNAMIC)
|
hl7:inFulfillmentOf
|
|
1 … 1 |
M |
|
(epS-eD) |
@typeCode
|
|
0 … 1 |
F |
FLFS |
hl7:order
|
|
1 … 1 |
|
|
(epS-eD) |
@classCode
|
|
0 … 1 |
F |
ACT |
@moodCode
|
|
1 … 1 |
F |
RQO |
hl7:id
|
II |
1 … * |
R |
|
(epS-eD) |
hl7:code
|
CE |
0 … 1 |
|
|
(epS-eD) |
@codeSystem
|
CONF |
0 … 1 |
F |
2.16.840.1.113883.5.4 (ActCode) |
hl7:priorityCode
|
CE |
0 … 1 |
|
|
(epS-eD) |
|
CONF |
|
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-eD) |
@typeCode
|
cs |
1 … 1 |
R |
|
|
CONF |
|
hl7:parentDocument
|
|
1 … 1 |
R |
|
(epS-eD) |
@classCode
|
|
0 … 1 |
F |
DOCCLIN |
@moodCode
|
|
0 … 1 |
F |
EVN |
hl7:id
|
II.EPSOS |
1 … * |
R |
|
(epS-eD) |
hl7:code
|
CD.EPSOS |
0 … 1 |
R |
|
(epS-eD) |
@codeSystem
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CONF |
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F |
2.16.840.1.113883.6.1 (LOINC) |
hl7:text
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ED |
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(epS-eD) |
hl7:setId
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II.EPSOS |
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hl7:versionNumber
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INT |
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hl7:component
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M |
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hl7:structuredBody
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1 … 1 |
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@classCode
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cs |
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DOCBODY |
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Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.2 Section Dispensation (DYNAMIC)
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where [hl7:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.1.8'] and hl7:templateId
[@root = '1.3.6.1.4.1.12559.11.10.1.3.1.2.2']]] |
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@typeCode
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cs |
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COMP |