Request OrCD Hospital Discharge Report of country A Patient Data Information about the patient Identification Country ID, unique for the patient in that country. Example: ID for United Kingdom patient National Health Care patient ID (country of affiliation) Country ID from the country of origin, unique for the patient in that country. Example: ID for United Kingdom patient 999999512 943 476 5919 National Health Care patient ID (country of treatment) Country ID given in the country of treatment, unique for the patient in that country. Identifier that identifies that patient within the country B eHealth Infrastructure. Other Identifier Other identifiers than the national health care patient IDs from either the country of affiliation or the country of treatment Personal Information Personal information about the patient Full Name The full name of the patient Given name The Name of the patient (Example: John). This field can contain more than one element John Family Name/Surname This field can containe more than one element. Español Smith Prefix Suffix Date of Birth The date of birth of the patient. This field may contain only the year if day and month are not available 091/01/2009 Gender It must contained a recognized valid value for this field. M The gender of a person used for adminstrative purposes (as opposed to clinical gender) http://www.epSOS.eu Female Male Undifferentiated Contact Information Contact information of the patient, including information of the contacts of the patient. Address Address of the patient Street Name of street where the patient lives Oxford Number of Street House number where the patient lives 221 City City where the patient lives London Postal Code Postal code where the patient lives W1W 8LG State or Province State or province where the patient lives London Country Country where the patient lives UK Telecom Telecommunication addresses of the patient Telephone No Telephone number of the patient +45 20 7025 6161 Email Email address of the patient jens@hotmail.com Preferred HP to contact Preferred Health Professional to contact. A foreign HP may need a contact (HP/legal organization) who knows the patient Full Name 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) Given Name The Name of the HP (Example: John). This field can contain more than one element John Family Name/Surname This field can contain more than one element. Español Smith Prefix Suffix Telephone No Telephone number of the HP/name of the legal organization +45 20 7025 6161 Email Email address of the HP/name of the legal organization Legal Organization to contact Legal organization to contact about patient. A foreign HP may need a contact (HP/legal organization) who knows the patient Organization Name Name of the organization Telephone No Telephone number of the organization +45 20 7025 6161 Email Email address of the organization Contact Person/legal guardian Contact or guardian of the patient Role of that person The role of the person: contact person or legal guardian Contact Person Legal Guardian Full Name Full name of the contact person or guardian Given Name The Name of the person (Example: John). This field can contain more than one element John Family Name/Surname This field can contain more than one element. Español Smith Prefix Suffix Telephone No Telephone number of the person +45 20 7025 6161 Email Email address of the person Return date Estimated date of return to country A Insurance Information Information about the insurance of the patient Insurance Number European Health Insurance Code (EHIC) number of the patient QQ 12 34 56 A Document Data Information about the document itself Identification Identification of the document Type Type of the document Defines to which category the document belongs to : summary, prescription, or dispensation. http://www.epSOS.eu Summary of episode note Medication summary Document Privacy policy acknowledgment Document Prescription for medication Patient summary Document Medication dispensed.extended Document Confidentiality Confidentiality of the document as a whole The Value Set is used for encoding the confidentiality level of the entire CDA. This Value Set encodes the level of access with regards to the content of the Value Set – for example N concerns all the medical team, R is restricted for specialist that take care of the patient in certain circumstances, and VIP would be for the persons that need the Privacy Officer present or other special consideration (for example a celebrity hospitalized who needs their records protected) http://www.epSOS.eu normal restricted very restricted Language The principal language of the document 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 en-GB nl-NL nl-BE de-DE de-AT Country A Name of country A United Kindom The Value Set is used to identify the nationality of all persons and organizations. http://www.epSOS.eu ANDORRA UNITED ARAB EMIRATES AFGHANISTAN ANTIGUA AND BARBUDA ANGUILLA ALBANIA ARMENIA ANGOLA ANTARCTICA ARGENTINA AMERICAN SAMOA AUSTRIA AUSTRALIA ARUBA ÅLAND ISLANDS AZERBAIJAN BOSNIA AND HERZEGOVINA BARBADOS BANGLADESH BELGIUM BURKINA FASO BULGARIA BAHRAIN BURUNDI BENIN SAINT BARTHÉLEMY BERMUDA BRUNEI DARUSSALAM BOLIVIA (PLURINATIONAL STATE OF) BONAIRE, SINT EUSTATIUS AND SABA BRAZIL BAHAMAS BHUTAN BOUVET ISLAND BOTSWANA BELARUS BELIZE CANADA COCOS (KEELING) ISLANDS CONGO, DEMOCRATIC REPUBLIC OF CENTRAL AFRICAN REPUBLIC CONGO SWITZERLAND COTE D'IVOIRE COOK ISLANDS CHILE CAMEROON CHINA COLOMBIA COSTA RICA CUBA CAPE VERDE CURAÇAO CHRISTMAS ISLAND CYPRUS CZECH REPUBLIC GERMANY DJIBOUTI DENMARK DOMINICA DOMINICAN REPUBLIC ALGERIA ECUADOR ESTONIA EGYPT WESTERN SAHARA ERITREA SPAIN ETHIOPIA FINLAND FIJI FALKLAND ISLANDS (MALVINAS) MICRONESIA (FEDERATED STATES OF) FAROE ISLANDS FRANCE GABON UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND GRENADA GEORGIA FRENCH GUIANA GUERNSEY GHANA GIBRALTAR GREENLAND GAMBIA GUINEA GUADELOUPE EQUATORIAL GUINEA GREECE SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS GUATEMALA GUAM GUINEA-BISSAU GUYANA HONG KONG HEARD ISLAND AND MCDONALD ISLANDS HONDURAS CROATIA HAITI HUNGARY INDONESIA IRELAND ISRAEL ISLE OF MAN INDIA BRITISH INDIAN OCEAN TERRITORY IRAQ IRAN (ISLAMIC REPUBLIC OF) ICELAND ITALY JERSEY JAMAICA JORDAN JAPAN KENYA KYRGYZSTAN CAMBODIA KIRIBATI COMOROS SAINT KITTS AND NEVIS KOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF) KOREA, REPUBLIC OF KUWAIT CAYMAN ISLANDS KAZAKHSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LEBANON SAINT LUCIA LIECHTENSTEIN SRI LANKA LIBERIA LESOTHO LITHUANIA LUXEMBOURG LATVIA LIBYA MOROCCO MONACO MOLDOVA, REPUBLIC OF MONTENEGRO SAINT MARTIN (FRENCH PART) MADAGASCAR MARSHALL ISLANDS MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MALI MYANMAR MONGOLIA MACAO NORTHERN MARIANA ISLANDS MARTINIQUE MAURITANIA MONTSERRAT MALTA MAURITIUS MALDIVES MALAWI MEXICO MALAYSIA MOZAMBIQUE NAMIBIA NEW CALEDONIA NIGER NORFOLK ISLAND NIGERIA NICARAGUA NETHERLANDS NORWAY NEPAL NAURU NIUE NEW ZEALAND OMAN PANAMA PERU FRENCH POLYNESIA PAPUA NEW GUINEA PHILIPPINES PAKISTAN POLAND SAINT PIERRE AND MIQUELON PITCAIRN PUERTO RICO PALESTINE, STATE OF PORTUGAL PALAU PARAGUAY QATAR REUNION ROMANIA SERBIA RUSSIAN FEDERATION RWANDA SAUDI ARABIA SOLOMON ISLANDS SEYCHELLES SUDAN SWEDEN SINGAPORE SAINT HELENA, ASCENSION AND TRISTAN DA CUNHA SLOVENIA SVALBARD AND JAN MAYEN SLOVAKIA SIERRA LEONE SAN MARINO SENEGAL SOMALIA SURINAME SOUTH SUDAN SAO TOME AND PRINCIPE EL SALVADOR SINT MAARTEN (DUTCH PART) SYRIAN ARAB REPUBLIC SWAZILAND TURKS AND CAICOS ISLANDS CHAD FRENCH SOUTHERN TERRITORIES TOGO THAILAND TAJIKISTAN TOKELAU TIMOR-LESTE TURKMENISTAN TUNISIA TONGA TURKEY TRINIDAD AND TOBAGO TUVALU TAIWAN, PROVINCE OF CHINA TANZANIA, UNITED REPUBLIC OF UKRAINE UGANDA UNITED STATES MINOR OUTLYING ISLANDS UNITED STATES OF AMERICA URUGUAY UZBEKISTAN HOLY SEE SAINT VINCENT AND THE GRENADINES VENEZUELA (BOLIVARIAN REPUBLIC OF) VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. VIET NAM VANUATU WALLIS AND FUTUNA SAMOA YEMEN MAYOTTE SOUTH AFRICA ZAMBIA ZIMBABWE Country B Name of country B The Value Set is used to identify the nationality of all persons and organizations. http://www.epSOS.eu ANDORRA UNITED ARAB EMIRATES AFGHANISTAN ANTIGUA AND BARBUDA ANGUILLA ALBANIA ARMENIA ANGOLA ANTARCTICA ARGENTINA AMERICAN SAMOA AUSTRIA AUSTRALIA ARUBA ÅLAND ISLANDS AZERBAIJAN BOSNIA AND HERZEGOVINA BARBADOS BANGLADESH BELGIUM BURKINA FASO BULGARIA BAHRAIN BURUNDI BENIN SAINT BARTHÉLEMY BERMUDA BRUNEI DARUSSALAM BOLIVIA (PLURINATIONAL STATE OF) BONAIRE, SINT EUSTATIUS AND SABA BRAZIL BAHAMAS BHUTAN BOUVET ISLAND BOTSWANA BELARUS BELIZE CANADA COCOS (KEELING) ISLANDS CONGO, DEMOCRATIC REPUBLIC OF CENTRAL AFRICAN REPUBLIC CONGO SWITZERLAND COTE D'IVOIRE COOK ISLANDS CHILE CAMEROON CHINA COLOMBIA COSTA RICA CUBA CAPE VERDE CURAÇAO CHRISTMAS ISLAND CYPRUS CZECH REPUBLIC GERMANY DJIBOUTI DENMARK DOMINICA DOMINICAN REPUBLIC ALGERIA ECUADOR ESTONIA EGYPT WESTERN SAHARA ERITREA SPAIN ETHIOPIA FINLAND FIJI FALKLAND ISLANDS (MALVINAS) MICRONESIA (FEDERATED STATES OF) FAROE ISLANDS FRANCE GABON UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND GRENADA GEORGIA FRENCH GUIANA GUERNSEY GHANA GIBRALTAR GREENLAND GAMBIA GUINEA GUADELOUPE EQUATORIAL GUINEA GREECE SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS GUATEMALA GUAM GUINEA-BISSAU GUYANA HONG KONG HEARD ISLAND AND MCDONALD ISLANDS HONDURAS CROATIA HAITI HUNGARY INDONESIA IRELAND ISRAEL ISLE OF MAN INDIA BRITISH INDIAN OCEAN TERRITORY IRAQ IRAN (ISLAMIC REPUBLIC OF) ICELAND ITALY JERSEY JAMAICA JORDAN JAPAN KENYA KYRGYZSTAN CAMBODIA KIRIBATI COMOROS SAINT KITTS AND NEVIS KOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF) KOREA, REPUBLIC OF KUWAIT CAYMAN ISLANDS KAZAKHSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LEBANON SAINT LUCIA LIECHTENSTEIN SRI LANKA LIBERIA LESOTHO LITHUANIA LUXEMBOURG LATVIA LIBYA MOROCCO MONACO MOLDOVA, REPUBLIC OF MONTENEGRO SAINT MARTIN (FRENCH PART) MADAGASCAR MARSHALL ISLANDS MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MALI MYANMAR MONGOLIA MACAO NORTHERN MARIANA ISLANDS MARTINIQUE MAURITANIA MONTSERRAT MALTA MAURITIUS MALDIVES MALAWI MEXICO MALAYSIA MOZAMBIQUE NAMIBIA NEW CALEDONIA NIGER NORFOLK ISLAND NIGERIA NICARAGUA NETHERLANDS NORWAY NEPAL NAURU NIUE NEW ZEALAND OMAN PANAMA PERU FRENCH POLYNESIA PAPUA NEW GUINEA PHILIPPINES PAKISTAN POLAND SAINT PIERRE AND MIQUELON PITCAIRN PUERTO RICO PALESTINE, STATE OF PORTUGAL PALAU PARAGUAY QATAR REUNION ROMANIA SERBIA RUSSIAN FEDERATION RWANDA SAUDI ARABIA SOLOMON ISLANDS SEYCHELLES SUDAN SWEDEN SINGAPORE SAINT HELENA, ASCENSION AND TRISTAN DA CUNHA SLOVENIA SVALBARD AND JAN MAYEN SLOVAKIA SIERRA LEONE SAN MARINO SENEGAL SOMALIA SURINAME SOUTH SUDAN SAO TOME AND PRINCIPE EL SALVADOR SINT MAARTEN (DUTCH PART) SYRIAN ARAB REPUBLIC SWAZILAND TURKS AND CAICOS ISLANDS CHAD FRENCH SOUTHERN TERRITORIES TOGO THAILAND TAJIKISTAN TOKELAU TIMOR-LESTE TURKMENISTAN TUNISIA TONGA TURKEY TRINIDAD AND TOBAGO TUVALU TAIWAN, PROVINCE OF CHINA TANZANIA, UNITED REPUBLIC OF UKRAINE UGANDA UNITED STATES MINOR OUTLYING ISLANDS UNITED STATES OF AMERICA URUGUAY UZBEKISTAN HOLY SEE SAINT VINCENT AND THE GRENADINES VENEZUELA (BOLIVARIAN REPUBLIC OF) VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. VIET NAM VANUATU WALLIS AND FUTUNA SAMOA YEMEN MAYOTTE SOUTH AFRICA ZAMBIA ZIMBABWE Nature Define the context in which it was generated. Distinguish among three methodological approaches to build the document: direct human intervention of a HP, automatically generated and mixed approach Topicality Date Created Date on which the document was generated 01/01/2009 Date of Last Update Date on which the document was updated (date of last version) 01/01/2012 Author 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. Author Identification Unique identification of the Health Professional. Author Full Name The full name of the Health Professional Given Name The Name of the HP (Example: John). This field can contain more than one element John Family Name/Surname This field can contain more than one element. Español Smith Prefix Suffix Author Role Role or specialism the author was in when sending the document. http://www.epSOS.eu Health professionals Medical doctors Generalist medical practitioners Specialist medical practitioners Nursing and midwifery professionals Nursing professionals Midwifery professionals Traditional and complementary medicine professionals Paramedical practitioners Veterinarians Other health professionals Dentists Pharmacists Environmental and occupational health and hygiene professionals Physiotherapists Dieticians and nutritionists Audiologists and speech therapists Optometrists and ophthalmic opticians Health professionals not elsewhere classified Health associate professionals Medical and pharmaceutical technicians Medical imaging and therapeutic equipment technicians Medical and pathology laboratory technicians Pharmaceutical technicians and assistants Medical and dental prosthetic technicians Nursing and midwifery associate professionals Nursing associate professionals Midwifery associate professionals Traditional and complementary medicine associate professionals Other health associate professionals Dental assistants and therapists Medical records and health information technicians Community health workers Dispensing opticians Physiotherapy technicians and assistants Medical assistants Environmental and occupational health inspectors and associates Ambulance workers Health associate professionals not elsewhere classified Author Healthcare Facility Information about the healthcare facility where the health professional works Identifier Unique identification of the healthcare facility Name Name of the healthcare facility St. Johns Hospital Legal Entity Responsible for the data in the document Health Professional ID Health professional ID responsible for the data in the document Healthcare Provider ID Legal organization ID responsible for the data in het document Health Professional Full Name Given Name Given name of the Health professional responsible for the data in the document Family Name/Surname Family name/Surname of the health professional responsible for the data in the document Prefix Prefix of the health professional responsible for the data in the document Suffix Suffix of the health professional responsible for the data in the document Health Professional Role Role the health professional is in while being responsible for the document data http://www.epSOS.eu Health professionals Medical doctors Generalist medical practitioners Specialist medical practitioners Nursing and midwifery professionals Nursing professionals Midwifery professionals Traditional and complementary medicine professionals Paramedical practitioners Veterinarians Other health professionals Dentists Pharmacists Environmental and occupational health and hygiene professionals Physiotherapists Dieticians and nutritionists Audiologists and speech therapists Optometrists and ophthalmic opticians Health professionals not elsewhere classified Health associate professionals Medical and pharmaceutical technicians Medical imaging and therapeutic equipment technicians Medical and pathology laboratory technicians Pharmaceutical technicians and assistants Medical and dental prosthetic technicians Nursing and midwifery associate professionals Nursing associate professionals Midwifery associate professionals Traditional and complementary medicine associate professionals Other health associate professionals Dental assistants and therapists Medical records and health information technicians Community health workers Dispensing opticians Physiotherapy technicians and assistants Medical assistants Environmental and occupational health inspectors and associates Ambulance workers Health associate professionals not elsewhere classified