Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3

Template epSOS-PS

Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 - epSOS-PS

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.3

Context Pathname /

Version valid from 2012‑05‑03 status Under develeopment

Open/Closed Open (other than defined elements are allowed)

Associated with

Associated with 13 concepts

Id	Name	as of
epsos-dataelement-62	Patient Summary Data	2013‑06‑03
epsos-dataelement-64	Patient Summary	2013‑06‑03
epsos-dataelement-65	Date Created	2013‑06‑03
epsos-dataelement-16	Clinical Data	2013‑05‑30
epsos-dataelement-67	Author HCP	2013‑06‑03
epsos-dataelement-22	Identification	2013‑06‑03
epsos-dataelement-19	Full Name	2013‑06‑03
epsos-dataelement-20	Given Name	2013‑06‑03
epsos-dataelement-21	Family Name/Surname	2013‑06‑03
epsos-dataelement-23	Healthcare Facility	2013‑06‑03
epsos-dataelement-25	Identifier	2013‑06‑03
epsos-dataelement-24	Name	2013‑06‑03
epsos-dataelement-63	Country	2013‑06‑03

Item DT Card Conf Desc Label

hl7:ClinicalDocument

CDA header

(epSOS-PS)

Target of concept id(s)

epsos-dataelement-62	Patient Summary Data
epsos-dataelement-64	Patient Summary

hl7:realmCode

1 .. 1

(epSOS-PS)

@code

1 .. 1

Example

<realmCode code="UV"/>

hl7:typeId

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.

(epSOS-PS)

@extension

1 .. 1

POCD_HD000040

@root

1 .. 1

2.16.840.1.113883.1.3

Example

<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>

hl7:templateId

1 .. 1

Template ID for Patient Summary epSOS document

(epSOS-PS)

@root

1 .. 1

1.3.6.1.4.1.12559.11.10.1.3.1.1.3

Example

<templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.3"/>

hl7:id

1 .. 1

The ClinicalDocument/id element is an instance identifier data type. The root attribute is an OID. The root uniquely identifies the scope of the extension. The root and extension attributes uniquely identify the document.

R1.11.3

Example

<id extension="a621" root="2.16.840.1.113883.2.4.3.11.60.22.9999"/>

hl7:code

1 .. 1

Determines the document type "Patient Summary Document"

R1.11.6

@code

1 .. 1

60591-5

@codeSystem

1 .. 1

2.16.840.1.113883.6.1 (LOINC)

Example

<code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/>

hl7:title

1 .. 1

ClinicalDocument/title is used for display purposes.

R1.11.7

Example

<title>epSOS Patient Summary Maria Bakker November 13, 2011</title>

hl7:effectiveTime

TS.DATETIME.MIN

1 .. 1

The element contains the date and time at which this patient summary was created as an electronic document.

R1.11.1

Target of concept id(s)

epsos-dataelement-65

Date Created

Example

<effectiveTime value="20111113125600"/>

hl7:confidentialityCode

1 .. 1

ClinicalDocument/confidentialityCode shall be present 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 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

hl7:setId

0 .. 1

This element shall be present to enable further updates to this ClinicalDocument. This identifier is to remain the same across all revisions of a patient summary.

(epSOS-PS)

hl7:versionNumber

0 .. 1

(epSOS-PS)

hl7:recordTarget

1 .. 1

This element contains patient data.

(epSOS-PS)

@typeCode

0 .. 1

RCT

@contextControlCode

0 .. 1

Contains inherited template rules PatientRole (DYNAMIC) with overridden cardinality 1 .. 1 mandatory

hl7:author

1 .. *

The Health Care Professional that is the author of the patient summary

(epSOS-PS)

Example

<author> <time value="20111113125600"/> <assignedAuthor> <id nullFlavor="NAV"/> <assignedPerson> <name> <given>John</given> <family>Español Smith</family> </name> </assignedPerson>  <representedOrganization> <name>Hospital Duinrust</name> <name>Unit geriatric</name> <addr> <streetName>Duinweg</streetName> <houseNumber>23</houseNumber> <postalCode>7364 RX</postalCode> <city>Amsterdam</city> </addr> </representedOrganization> </assignedAuthor> </author>

hl7:time

TS.DATE.MIN

1 .. 1

The time when the document came out.

(epSOS-PS)

hl7:assignedAuthor

1 .. 1

(epSOS-PS)

Target of concept id(s)

epsos-dataelement-67

Author HCP

hl7:id

0 .. 1

The identification of the Health Care Professional that is the author of the patient summary.

(epSOS-PS)

@nullFlavor

1 .. 1

NAV

Target of concept id(s)

epsos-dataelement-22

Identification

hl7:assignedPerson

0 .. 1

(epSOS-PS)

hl7:name

0 .. 1

Author's name.

(epSOS-PS)

Target of concept id(s)

epsos-dataelement-19

Full Name

Choice min 1 element(s) and max * element(s). Elements to choose from:

hl7:given
hl7:family

hl7:given

0 .. 1

Author's given name

(epSOS-PS)

Target of concept id(s)

epsos-dataelement-20

Given Name

hl7:family

0 .. 1

Author's family name

(epSOS-PS)

Target of concept id(s)

epsos-dataelement-21

Family Name/Surname

hl7:representedOrganization

1 .. 1

The healthcare facility where the health care professional works

R1.10.9.2

Target of concept id(s)

epsos-dataelement-23

Healthcare Facility

hl7:id

1 .. *

Healthcare Facility's ID

R1.10.9.2

Target of concept id(s)

epsos-dataelement-25

Identifier

hl7:name

1 .. *

Healthcare Facility's name

R1.10.9.2

Target of concept id(s)

epsos-dataelement-24

Name

hl7:addr

1 .. 1

Healthcare Facility's country

R1.10.9.3

Target of concept id(s)

epsos-dataelement-67

Author HCP

Choice min 0 element(s) and max * element(s). Elements to choose from:

hl7:streetAddressLine
hl7:city
hl7:postalCode
hl7:state
hl7:country

hl7:streetAddressLine

ADXP

0 .. *

Healthcare Facility's Number of Street/Healthcare Facility's Number of Street

R1.10.9.3.1/R1.10.9.3.2

hl7:city

ADXP

0 .. *

Healthcare Facility's City

R1.10.9.3.3

hl7:postalCode

ADXP

0 .. *

Healthcare Facility's Postal Code

R1.10.9.3.4

hl7:state

ADXP

0 .. *

Healthcare Facility's State or Province

R1.10.9.3.5

hl7:country

ADXP

0 .. *

Healthcare Facility's Country

R1.10.9.3.6

Target of concept id(s)

epsos-dataelement-63

Country

hl7:custodian

1 .. 1

Custodian

(epSOS-PS)

@typeCode

1 .. 1

CST

Example

<custodian typeCode="CST"> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.528.1.1007.3.3" extension="4687892"/> <name>Hospital Duinrust, Geriatric Unit</name> </representedCustodianOrganization> </assignedCustodian> </custodian>

hl7:assignedCustodian

1 .. 1

(epSOS-PS)

hl7:representedCustodianOrganization

1 .. 1

Custodian institution

(epSOS-PS)

hl7:id

1 .. 1

The custodian institution's identifier

(epSOS-PS)

@root

1 .. 1

2.16.528.1.1007.3.3

hl7:name

1 .. *

Custodian Institution's name

(epSOS-PS)

hl7:legalAuthenticator

1 .. 1

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

Example

<legalAuthenticator> <time value="20111013150937"/> <signatureCode code="S"/> <assignedEntity> <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/> <representedOrganization> <name>Healthcare Facility's name</name> <addr> <country>NL</country> <streetName>Duinweg</streetName> <houseNumber>23</houseNumber> <postalCode>7364 RX</postalCode> <city>Amsterdam</city> </addr> </representedOrganization> </assignedEntity> </legalAuthenticator>

hl7:time

1 .. 1

Time of signing the document

R1.11.9

hl7:signatureCode

0 .. 1

Signature code

R1.11.9

CONF

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

hl7:assignedEntity

0 .. 1

The regional authority that is responsible for the legal authentication of the CDA document

R1.11.9

hl7:id

1 .. 1

Unique identification of ligal authenticator

R1.11.9

hl7:representedOrganization

1 .. 1

The healthcare facility where the health care professional works

R1.11.9

hl7:name

1 .. *

Healthcare Facility's name

R1.11.9

hl7:addr

1 .. 1

Healthcare Facility's Country

R1.11.9

hl7:participant
where
[not(hl7:functionCode [@code='PCP'] [@codeSystem='2.16.840.1.113883.5.88'])]

1 .. *

Contact person of the patient.

(epSOS-PS)

@typeCode

1 .. 1

IND

Participant typeCode

Example

<participant typeCode="IND"> <associatedEntity classCode="CON">  </associatedEntity> </participant>

Contains inherited template rules ContactPerson (DYNAMIC) with overridden cardinality 1 .. *

hl7:participant
where
[hl7:functionCode [@code='PCP'] [@codeSystem='2.16.840.1.113883.5.88']]

1 .. *

Preferred Health Care Professional to contact about patient.

(epSOS-PS)

@typeCode

1 .. 1

CON

Example

<participant typeCode="IND"> <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/> <associatedEntity classCode="CON">  </associatedEntity> </participant>

Contains inherited template rules PreferredHCP (DYNAMIC) with overridden cardinality 1 .. *

hl7:functionCode

1 .. 1

(epSOS-PS)

@code

1 .. 1

PCP

@codeSystem

1 .. 1

2.16.840.1.113883.5.88

hl7:component

1 .. 1

(epSOS-PS)

hl7:structuredBody

1 .. 1

(epSOS-PS)

@classCode

0 .. 1

DOCBODY

hl7:component
where
[hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.13' or @root='2.16.840.1.113883.10.20.1.2']]]

0 .. *

(epSOS-PS)

@typeCode

0 .. 1

COMP

Contains inherited template rules SectionAlerts (DYNAMIC) with overridden cardinality 0 .. * required

hl7:component
where
[hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.8']]]

0 .. *

(epSOS-PS)

Contains inherited template rules SectionHistoryOfPastIllnesses (DYNAMIC) with overridden cardinality 0 .. * required

hl7:section

1 .. 1

History of Past Illnesses

@classCode

0 .. 1

DOCSECT

Target of concept id(s)

epsos-dataelement-16

Clinical Data

Example

<section> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.8"/> <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past Illnesses"/> <title>History of Past Illnesses</title> <text>  </text> <entry typeCode="DRIV">  </entry> </section>

hl7:templateId

1 .. 1

Template id History of Past Illnesses

@root

1 .. 1

1.3.6.1.4.1.19376.1.5.3.1.3.8

hl7:code

1 .. 1

Section code for History of Past Illnesses

@code

1 .. 1

11348-0

@codeSystem

1 .. 1

2.16.840.1.113883.6.1 (LOINC)

hl7:title

1 .. 1

Section title

hl7:text

SD.TEXT

1 .. 1

Section text

hl7:component

0 .. *

R7.1

@typeCode

0 .. 1

COMP

Contains an element from template SectionProblemsResolvedClosedInactive (DYNAMIC) with overridden cardinality 0 .. *

hl7:component

0 .. *

@typeCode

0 .. 1

COMP

Contains an element from template SectionVaccinations (DYNAMIC) with overridden cardinality 0 .. *

hl7:component
where
[hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.12' or @root='1.3.6.1.4.1.19376.1.5.3.1.3.11' or @root='2.16.840.1.113883.10.20.1.12']]]

0 .. *

@typeCode

0 .. 1

COMP

Contains inherited template rules SectionProcedures (DYNAMIC) with overridden cardinality 0 .. *

hl7:component
where
[hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.12' or @root='1.3.6.1.4.1.19376.1.5.3.1.3.11' or @root='2.16.840.1.113883.10.20.1.12']]]

0 .. *

(epSOS-PS)

@typeCode

0 .. 1

COMP

Contains inherited template rules SectionProcedures (DYNAMIC) with overridden cardinality 0 .. * required

Template epSOS-PS