| Item | DT | Card | Conf | Description | Label |
|---|
hl7:ClinicalDocument
| | | R | CDA header | eHDS tion |
| | Schematron assert | role |  error | |
| | test | not(@xsi:schemaLocation) | |
| | Message | While the XML Schema Language allows a schema location to be associated with an XML document by including a schemaLocation attribute associated with the http://www.w3.org/2001/XMLSchema-instance namespace, this is explicitly PROHIBITED by [ITS§1.4], and thus by the CDA standard. | |
hl7:realmCode
| CS | 0 … 1 | R | | eHDStion |
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. | eHDStion |
@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 | eHDSI ePrescription | eHDStion |
@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 eHDSI Id (DYNAMIC) |
hl7:id
| II | 1 … 1 | M | Unique identifier of this instance of the clinical document. Following attributes can be used to uniquely identify the instance:
- @root: A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier. Required if @nullFlavor is not present.
- @extension: An optional character string as a unique identifier within the scope of the identifier root.
The @root attribute must be a UID. The allowable formats and values and procedures of this data type are strictly controlled by HL7. At this time, user-assigned identifiers may be certain character representations of ISO Object Identifiers (OID) and DCE Universally Unique Identifiers (UUID).
- UUIDs SHALL be represented in the form XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX, where each X is a character from the set [0-9a-zA-Z].
- 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](\.(0|[1-9][0-9]*))*.
| 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 "eHDSI 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 |
| | 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>eHDSI ePrescription Maria Bakker June 17, 2020</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.
- The CC portion SHALL be an ISO-3166 country code in upper case.
| R.11.10 |
| | CONF | |
| | 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 language code and CC is ISO-3166 country code) | |
| Included | 0 … 1 | | from 2.16.840.1.113883.3.1937.777.11.10.108 eHDSI SetId (DYNAMIC) |
hl7:setId
| | 0 … 1 | R | This identifier is used to link together different versions of the same document: the CDA L3 document, the CDA PDF embedded document and the version in the national infrastructure.
| eHDSetId |
hl7:versionNumber
| | 0 … 1 | R | | eHDStion |
| Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.777.11.10.100 eHDSI RecordTarget (DYNAMIC) |
hl7:recordTarget
| | 1 … 1 | M | | eHDSrget |
@typeCode
| cs | 0 … 1 | F | RCT |
@contextControlCode
| cs | 0 … 1 | F | OP |
hl7:patientRole
| | 1 … 1 | M | | eHDSrget |
@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 eHDSICountry value set | R1.5.6 |
| | |
| | Constraint | The content of this element SHALL be selected from ValueSet eHDSICountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4
|
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 | | eHDSrget |
@classCode
| cs | 0 … 1 | F | PSN |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:name
| PN | 1 … * | M | 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 (eHDSIPersonalRelationship 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"/> <code code="AUNT" displayName="aunt" codeSystem="2.16.840.1.113883.5.111"/> <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:code
| CE.EPSOS | 0 … 1 | R | The relationship between the patient and the guardian or other contact may be recorded in the code element
| R1.7.A |
| | CONF | |
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 eHDSICountry value set | R1.7.3.6 |
| | Constraint | The content of this element SHALL be selected from ValueSet eHDSICountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4
|
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". | eHDSrget |
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 eHDSILanguage.
- The CC portion SHALL be an ISO-3166 country code in upper case derived by the value Set eHDSICountry.
| R1.7 |
| | CONF | |
| | 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 eHDSILanguage and CC is ISO-3166 eHDSICountry | |
| Included | 1 … * | M | from 2.16.840.1.113883.3.1937.777.11.10.103 eHDSI Author Prescriber (DYNAMIC) |
hl7:author
| | 1 … * | M | | eHDSiber |
@typeCode
| cs | 0 … 1 | F | AUT |
@contextControlCode
| cs | 0 … 1 | F | OP |
hl7:functionCode
| CE.EPSOS | 1 … 1 | M | | 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. | eHDSiber |
hl7:assignedAuthor
| | 1 … 1 | R | | eHDSiber |
@classCode
| cs | 0 … 1 | F | ASSIGNED |
| | Schematron assert | role | error | |
| | test | @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice | |
| | Message | At least an assignedPerson or an assignedAuthoringDevice has to be provided, otherwise a nullFlavor shall be present. | |
hl7:id
| II.EPSOS | 1 … * | R | Identification of the Healthcare Practitioner that is the author of this document.
| 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 | This 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.
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 | |
hl7:assignedPerson
| | 1 … 1 | M | | eHDSiber |
@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 eHDSI Organization (DYNAMIC) | R1.10.9 |
| | |
| Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.777.11.10.104 eHDSI Custodian (DYNAMIC) |
hl7:custodian
| | 1 … 1 | M | This elements represents the organization that is in charge of maintaining the document.
| eHDSdian |
@typeCode
| cs | 0 … 1 | F | CST |
hl7:assignedCustodian
| | 1 … 1 | R | | eHDSdian |
@classCode
| cs | 0 … 1 | F | ASSIGNED |
hl7:representedCustodianOrganization
| | 1 … 1 | R | | eHDSdian |
@classCode
| cs | 0 … 1 | F | ORG |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:id
| II.EPSOS | 1 … 1 | R | Custodian organization Id | eHDSdian |
@nullFlavor
| cs | 0 … 1 | | |
hl7:name
| ON | 1 … 1 | R | Custodian organization Name
| eHDSdian |
@nullFlavor
| cs | 0 … 1 | | |
hl7:telecom
| TEL | 1 … 1 | R | Custodian organization 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. | eHDSdian |
@use
| set_cs | 0 … 1 | | |
| | CONF | |
@nullFlavor
| cs | 0 … 1 | F | NI |
| | Example | <telecom use="WP" value="tel:+45 20 7025 6161"/> |
hl7:addr
| AD.EPSOS | 1 … 1 | R | Custodian Organization Address | eHDSdian |
| | 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 | Street/Number of Street
| eHDSdian |
hl7:city
| | 0 … 1 | R | City
| eHDSdian |
hl7:postalCode
| | 0 … 1 | R | Postal Code
| eHDSdian |
hl7:state
| | 0 … 1 | R | State or Province
| eHDSdian |
hl7:country
| | 1 … 1 | R | Country. When used addr.country it is always bound to the eHDSICountry value set.
| eHDSdian |
| | Constraint | The content of this element SHALL be selected from ValueSet eHDSICountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4
|
| Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.777.11.10.109 eHDSI 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 eHDSI Organization (DYNAMIC) | R1.11.9 |
| Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.777.11.10.107 eHDSI RelatedDocument (DYNAMIC) |
hl7:relatedDocument
| | 1 … 1 | M | | eHDSment |
| | |
@typeCode
| cs | 1 … 1 | F | XFRM |
hl7:parentDocument
| | 1 … 1 | R | | eHDSment |
@classCode
| cs | 0 … 1 | F | DOCCLIN |
@moodCode
| cs | 0 … 1 | F | EVN |
hl7:id
| II.EPSOS | 1 … * | R | Identifier of the national version of the document.
| eHDSment |
hl7:code
| CD.EPSOS | 0 … 1 | R | | eHDSment |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.6.1 |
hl7:text
| ED | 0 … 1 | R | | eHDSment |
hl7:setId
| II.EPSOS | 0 … 1 | R | | eHDSment |
hl7:versionNumber
| INT | 0 … 1 | R | | eHDSment |
hl7:component
| | 1 … 1 | M | | eHDStion |
hl7:structuredBody
| | 1 … 1 | M | | eHDStion |
@classCode
| cs | 0 … 1 | F | DOCBODY |
hl7:component
| | 1 … 1 | R | Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.1 eHDSI Prescription (DYNAMIC) | eHDStion |
Retired
Street 
eHDSI Prescription