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 Template  epSOS-eDispensation

Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.2 - epSOS-eD
Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.2
Classification CDA document level template
Relationship Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Context Pathname /
Version valid from 2012‑05‑03 status Under develeopment
Open/Closed Open (other than defined elements are allowed)
Description

epSOS eDispensation Template

The implementers must be familiar with the context of the project, as it shall not be repeated in this document. The implementers must also be familiar with the content of the following documents:

  • CDA Release 2.0 Normative Web Edition, May, 2005
  • HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), HL7, April 1, 2007.
  • Integrating the Healthcare Enterprise, Patient Care Coordination Technical Framework, Volume 1 and Volume 2- Revision 5, IHE International, August 10, 2009.
  • Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules- Trial Implementation Supplement, August 10, 2009.
  • HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, HL7, July 16, 2008.

It must also be noted that although the guidelines are based on the above documents, they contain specific developments particular to the project epSOS. This document can be used as a standalone to develop the syntax of the epSOS documents; however in order to achieve the full functionality of the epSOS Semantic Services, they are to be used within the context of the deliverable 3.9.1.

Item DT Card Conf Desc Label
hl7:ClinicalDocument
CDA header (epSOS-eD)
treetree hl7:realmCode
CS 1 .. 1 M (epSOS-eD)
treeblank treetree @code
1 .. 1 F UV
Example
<realmCode code="UV"/>
treetree hl7:typeId
II 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.
(epSOS-eD)
treeblank treetree @extension
1 .. 1 F POCD_HD000040
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.1.3
Example
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
treetree hl7:templateId
II 1 .. 1 M Template ID for epSOS eDispensation document (epSOS-eD)
treeblank treetree @root
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"/>
treetree hl7:id
II 1 .. 1 M 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"/>
treetree hl7:code
CV 1 .. 1 M Determines the document type "epSOS eDispensation" R1.11.6
treeblank treetree @code
1 .. 1 F 60593-1
treeblank treetree @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"/>
treetree 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>
treetree hl7:effectiveTime
TS.DATETIME.MIN 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"/>
treetree hl7:confidentialityCode
CE 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"/>
treetree 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 red 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 from epSOS CDA setId (DYNAMIC) 0 .. 1
treetree hl7:setId
II 0 .. 1

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.

(epSOS-eD)
treetree hl7:versionNumber
0 .. 1 (epSOS-eD)
Included from epSOS CDA recordTarget (DYNAMIC) 1 .. 1 Mandatory
treetree hl7:recordTarget
1 .. 1 M (epSOS-eD)
treeblank treetree @typeCode
0 .. 1 F RCT
treeblank treetree @contextControlCode
0 .. 1 F OP
treeblank treetree hl7:patientRole
1 .. 1 M (epSOS-eD)
treeblank treeblank treetree @classCode
0 .. 1 F PAT
treeblank treeblank treetree hl7:id
II 1 .. * Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) R1.4 / R1.4.1 / R1.4.2
treeblank treeblank treeblank treetree @extension
1 .. 1  
treeblank treeblank treeblank treetree @nullFlavor
0 .. 1 F UNC
  When the @root is impossible to know, e.g. for insurance numbers, @nullFlavor SHALL be 'UNC' while @extension contains the id
Example
<id nullFlavor="UNC" extension="EHIC"/>
treeblank treeblank treetree hl7:addr
AD 1 .. 1 R The patient address <addr> 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. Optionalities and Cardinalities of the address sub-parts shall be interpreted according to this rule. R1.5
treeblank treeblank treeblank treetree @nullFlavor
0 .. 1 F NI
Choice min 0 element(s) and max * element(s). Elements to choose from:
  • hl7:streetAddressLine
  • hl7:city
  • hl7:postalCode
  • hl7:state
  • hl7:country
treeblank treeblank treeblank treeblank treetree hl7:streetAddressLine
ADXP 1 .. * Patient's Number of Street/Patient's Number of Street R1.5.1/R1.5.2
treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treetree hl7:city
ADXP 1 .. * Patient's City R1.5.3
treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treetree hl7:postalCode
ADXP 1 .. * Patient's Postal Code R1.5.4
treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treetree hl7:state
ADXP 1 .. * Patient's State or Province R1.5.5
treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treetree hl7:country
ADXP 1 .. * Patient's Country R1.5.6
treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treetree hl7:telecom
TEL 1 .. * R Patient’s telephone number / Patient e-mail address. The patient 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 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
treeblank treeblank treeblank treetree @use
0 .. 1  
  CONF
The value of @use shall be drawn from value set epSOSTelecomAddress (DYNAMIC)
treeblank treeblank treeblank treetree @nullFlavor
0 .. 1 F NI
treeblank treeblank treetree hl7:patient
1 .. 1 M (epSOS-eD)
treeblank treeblank treeblank treetree @classCode
0 .. 1 F PSN
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:name
PN 1 .. * Patient Name R1.1
Choice min 1 element(s) and max * element(s). Elements to choose from:
  • hl7:family
  • hl7:prefix
  • hl7:given
treeblank treeblank treeblank treeblank treeblank treetree hl7:family
ENXP 1 .. * Patient's Family Name/Surname R1.1.1
treeblank treeblank treeblank treeblank treeblank treetree hl7:prefix
ENXP 0 .. * 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
treeblank treeblank treeblank treeblank treeblank treetree hl7:given
ENXP 1 .. * Patient's Given Name R1.1.3
treeblank treeblank treeblank treetree hl7:administrativeGenderCode
CE 1 .. 1 Patient's Gender R1.2
CONF
The value of @code shall be drawn from value set epSOSAdministrativeGender (DYNAMIC)
treeblank treeblank treeblank treetree hl7:birthTime
TS 1 .. 1 M Patient's Date of Birth R1.3
treeblank treeblank treeblank treetree hl7:guardian
1 .. * 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 classCode attribute shall be present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or other relations respectively.

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 480 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.

Healthcare Service Identification

The Healthcare Service Identification information is represented in structures under the /ClinicalDocument/author XML element

R1.7.A
treeblank treeblank treeblank treeblank treetree @classCode
1 .. 1 F GUARD
treeblank treeblank treeblank treeblank treetree @nullFlavor
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>
treeblank treeblank treeblank treeblank treetree hl7:templateId
II 1 .. 1 M Template id for Patient's Guardian R1.7.A
treeblank treeblank treeblank treeblank treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
treeblank treeblank treeblank treeblank treetree hl7:addr
AD 1 .. 1 The guardian’s address <addr> element is required. If there is no information, the nullFlavor attribute shall have a value of 'UNK' 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
treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1 F UNK
treeblank treeblank treeblank treeblank treeblank treetree hl7:streetAddressLine
ADXP 1 .. * Guardian's Number of Street/Guardian's Number of Street R1.7.A.3.1/R1.7.A.3.2
treeblank treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treeblank treetree hl7:city
ADXP 1 .. * Guardian's City R1.7.A.3.3
treeblank treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treeblank treetree hl7:postalCode
ADXP 1 .. * Guardian's Postal Code R1.7.A.3.4
treeblank treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treeblank treetree hl7:state
ADXP 1 .. * Guardian's State or Province R1.7.A.3.5
treeblank treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treeblank treetree hl7:country
ADXP 1 .. * Guardian's Country R1.7.A.3.6
treeblank treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1  
  Use nullFlavor if unknown or if no information is applicable
treeblank treeblank treeblank treeblank treetree hl7:telecom
TEL 1 .. * R Guardian’s telephone number / Patient e-mail address. The guardian 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 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.A.4.1/R1.7.A.4.2
treeblank treeblank treeblank treeblank treeblank treetree @use
0 .. 1  
  CONF
The value of @use shall be drawn from value set epSOSTelecomAddress (DYNAMIC)
treeblank treeblank treeblank treeblank treeblank treetree @nullFlavor
0 .. 1 F NI
treeblank treeblank treeblank treeblank treetree hl7:guardianPerson
1 .. 1 R R1.7.A
treeblank treeblank treeblank treeblank treeblank treetree hl7:name
PN 1 .. * Patient Guardian's Name R1.7.A
Choice min 1 element(s) and max * element(s). Elements to choose from:
  • hl7:family
  • hl7:given
treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree hl7:family
ENXP 1 .. * Patient Guardian's Family Name/Surname R1.7.A.1
treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree hl7:given
ENXP 1 .. * Patient Guardian's Given Name R1.7.A.2
treeblank treeblank treeblank treetree hl7:languageCommunication
0 .. * R (epSOS-eD)
treeblank treeblank treeblank treeblank treetree hl7:templateId
II 1 .. 1 M Template id for LanguageCommunication (epSOS-eD)
treeblank treeblank treeblank treeblank treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.1
treeblank treeblank treeblank treeblank treetree hl7:languageCode
CS 0 .. 1 R Patient’s preferred language R1.7
CONF
The value of @code shall be drawn from value set epSOSLanguage (DYNAMIC)
Included from epSOS CDA author (DYNAMIC) 1 .. * Required
treetree hl7:author
1 .. * R (epSOS-eD)
treeblank treetree @typeCode
0 .. 1 F AUT
treeblank treetree @contextControlCode
0 .. 1 F OP
treeblank treetree hl7:functionCode
CE 0 .. 1 R1.10.6
CONF
The value of @code shall be drawn from value set epSOSHealthcareProfessionalRoles (DYNAMIC)
treeblank treetree hl7:assignedAuthor
1 .. 1 (epSOS-eD)
treeblank treeblank treetree @classCode
0 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:id
II 1 .. * R HP ID number R1.10.5
treeblank treeblank treetree hl7:code
CE 0 .. 1 HP Specialty R1.10.7
treeblank treeblank treetree hl7:telecom
TEL 0 .. * Attribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLScheme R1.10.8 / R1.10.8.1 / R1.10.8.2
treeblank treeblank treeblank treetree @use
0 .. 1  
  CONF
The value of @use shall be drawn from value set epSOSTelecomAddress (DYNAMIC)
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • hl7:assignedPerson
  • assignedAuthoringDevice containing hl7:code from template CDA Device (DYNAMIC)
treeblank treeblank treeblank treetree hl7:assignedPerson
(epSOS-eD)
treeblank treeblank treeblank treeblank treetree @classCode
0 .. 1 F PSN
treeblank treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treeblank treetree hl7:name
PN 0 .. 1 HP Name (epSOS-eD)
Example
<name>
  <given>John</given>
  <family>Español Smith</family>
</name>
Choice min 1 element(s) and max * element(s). Elements to choose from:
  • hl7:family
  • hl7:given
  • hl7:prefix
  • hl7:suffix
treeblank treeblank treeblank treeblank treeblank treeblank treetree hl7:family
ENXP 1 .. * HP Family Name/Surname R1.10.1
treeblank treeblank treeblank treeblank treeblank treeblank treetree hl7:given
ENXP 1 .. * HP Given Name R1.10.2
treeblank treeblank treeblank treeblank treeblank treeblank treetree hl7:prefix
ENXP 1 .. * HP Prefix R1.10.3
treeblank treeblank treeblank treeblank treeblank treeblank treetree hl7:suffix
ENXP 1 .. * HP Suffix R1.10.4
treeblank treeblank treeblank treetree assignedAuthoringDevice
(epSOS-eD)
Contains inherited template rules CDA Device (DYNAMIC) with overridden cardinality
treeblank treeblank treetree hl7:representedOrganization
1 .. 1 R1.10.9
Contains inherited template rules epSOS CDA Organization (DYNAMIC) with overridden cardinality 1 .. 1
Included from epSOS CDA custodian (DYNAMIC) 1 .. 1 Required Mandatory
treetree hl7:custodian
1 .. 1 M (epSOS-eD)
treeblank treetree @typeCode
0 .. 1 F CST
treeblank treetree hl7:assignedCustodian
1 .. 1 (epSOS-eD)
treeblank treeblank treetree @classCode
0 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:representedCustodianOrganization
1 .. 1 R1.10.9
treeblank treeblank treeblank treetree @classCode
0 .. 1 F ORG
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
Contains inherited template rules epSOS CDA Organization (DYNAMIC) with overridden cardinality 1 .. 1
treetree 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
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>
treeblank treetree hl7:time
TS 1 .. 1 M Time of signing the document R1.11.9
treeblank treetree hl7:signatureCode
CS 0 .. 1 Signature code R1.11.9
CONF
The value of @code shall be drawn from value set ParticipationSignature (DYNAMIC)
alert Error: Cannot find value set "ParticipationSignature"
treeblank treetree hl7:assignedEntity
0 .. 1 The regional authority that is responsible for the legal authentication of the CDA document R1.11.9
treeblank treeblank treetree hl7:id
1 .. 1 M Unique identification of ligal authenticator R1.11.9
treeblank treeblank treetree hl7:representedOrganization
1 .. 1 M The healthcare facility where the health professional works R1.11.9
treeblank treeblank treeblank treetree hl7:name
ON 1 .. * M Healthcare Facility's name R1.11.9
treeblank treeblank treeblank treetree hl7:addr
AD 1 .. 1 M Healthcare Facility's Country R1.11.9
treetree hl7:participant
where
[@typeCode='IND']
1 .. * Contact person of the patient. (epSOS-eD)
treeblank treetree @typeCode
1 .. 1 F IND
  Participant typeCode
Example
<participant typeCode="IND">
  <associatedEntity classCode="CON">
    <!-- ... -->
  </associatedEntity>
</participant>
Contains inherited template rules epSOS CDA Contact Person (DYNAMIC) with overridden cardinality 1 .. *
treetree hl7:participant
where
[hl7:functionCode [@code='PCP'] [@codeSystem='2.16.840.1.113883.5.88']]
1 .. * Preferred Health Professional to contact about patient. (epSOS-eD)
treeblank treetree @typeCode
1 .. 1 F 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 epSOS CDA Preferred HP or Legal Organization (DYNAMIC) with overridden cardinality 1 .. *
treeblank treetree hl7:functionCode
1 .. 1 M (epSOS-eD)
treeblank treeblank treetree @code
1 .. 1 F PCP
treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.88
treetree hl7:component
1 .. 1 M (epSOS-eD)
treeblank treetree hl7:structuredBody
1 .. 1 M (epSOS-eD)
treeblank treeblank treetree @classCode
0 .. 1 F DOCBODY
treeblank treeblank treetree hl7:component
1 .. * R (epSOS-eD)
treeblank treeblank treeblank treetree @typeCode
0 .. 1 F COMP
Contains inherited template rules Section Dispensation (DYNAMIC) with overridden cardinality 1 .. * Required