| Item |
DT |
Card |
Conf |
Desc |
Label |
|
|
|
|
|
CDA header |
(epSOS-PS) |
 |
hl7:realmCode
|
|
CS |
1 .. 1 |
M |
|
(epSOS-PS) |
 |
|
@code
|
|
|
1 .. 1 |
F |
UV |
|
Example |
|
|
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-PS) |
|
|
@extension
|
|
|
1 .. 1 |
F |
POCD_HD000040 |
|
|
@root
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.1.3 |
|
Example |
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
|
|
hl7:templateId
|
|
II |
1 .. 1 |
M |
Template ID for epSOS Patient Summary document |
(epSOS-PS) |
|
|
@root
|
|
|
1 .. 1 |
F |
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
|
|
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"/>
|
|
hl7:code
|
|
CV |
1 .. 1 |
M |
Determines the document type "epSOS Patient Summary Document" |
R1.11.6 |
|
|
@code
|
|
|
1 .. 1 |
F |
60591-5 |
|
|
@codeSystem
|
|
|
1 .. 1 |
F |
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 Document"/>
|
|
hl7:title
|
|
ST |
1 .. 1 |
M |
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 |
M |
Relevant times for the Patient Summary
By definition, a Patient Summary document describes the Patient Summary at the time
of creation of the document, represented by the /ClinicalDocument/effectiveTime XML Element.
The time when this instance of the document has been authored may be instead recorded
by the /ClinicalDocument/author/time element. (e.g. when a “spider” has collected
information for generating this instance of the document; or a practitioner updated
its local summary document).
Finally, the latest summary update, intended as the last date documented by this summary
(e.g. the last update occurred to the PHR from which the PS data has been extracted)
can be represented by the /ClinicalDocument/documentationOf/serviceEvent/effectiveTime/high XML Element (see section 2.1, CONF-2, CONF-3 and CONF-4 of the CCD specification).
|
R1.11.1 |
|
Example |
<effectiveTime value="20111113125600"/>
|
|
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 |
|
|
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 from epSOS CDA setId (DYNAMIC) 0 .. 1
|
|
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-PS) |
|
hl7:versionNumber
|
|
|
0 .. 1 |
|
|
(epSOS-PS) |
| Included from epSOS CDA recordTarget (DYNAMIC) 1 .. 1 Mandatory
|
|
hl7:recordTarget
|
|
|
1 .. 1 |
M |
|
(epSOS-PS) |
|
|
@typeCode
|
|
|
0 .. 1 |
F |
RCT |
|
|
@contextControlCode
|
|
|
0 .. 1 |
F |
OP |
|
|
hl7:patientRole
|
|
|
1 .. 1 |
M |
|
(epSOS-PS) |
|
|
|
0 .. 1 |
F |
PAT |
|
|
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 |
|
|
|
1 .. 1 |
|
|
|
|
|
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"/>
|
|
|
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 |
|
|
|
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
|
|
|
ADXP |
1 .. * |
|
Patient's Number of Street/Patient's Number of Street |
R1.5.1/R1.5.2 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Patient's City |
R1.5.3 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Patient's Postal Code |
R1.5.4 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Patient's State or Province |
R1.5.5 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Patient's Country |
R1.5.6 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
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 |
|
|
|
0 .. 1 |
|
|
| |
CONF |
|
|
|
|
0 .. 1 |
F |
NI |
|
|
|
1 .. 1 |
M |
|
(epSOS-PS) |
|
|
|
0 .. 1 |
F |
PSN |
|
|
|
0 .. 1 |
F |
INSTANCE |
|
|
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
|
|
|
ENXP |
1 .. * |
|
Patient's Family Name/Surname |
R1.1.1 |
|
|
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
|
|
|
ENXP |
1 .. * |
|
Patient's Given Name |
R1.1.3 |
|
|
|
|
hl7:administrativeGenderCode
|
|
CE |
1 .. 1 |
|
Patient's Gender |
R1.2 |
|
CONF |
|
|
|
TS |
1 .. 1 |
M |
Patient's Date of Birth |
R1.3 |
|
|
|
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 |
|
|
|
1 .. 1 |
F |
GUARD |
|
|
|
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> |
|
|
II |
1 .. 1 |
M |
Template id for Patient's Guardian |
R1.7.A |
|
|
|
1 .. 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.2.4 |
|
|
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 |
|
|
|
0 .. 1 |
F |
UNK |
|
|
ADXP |
1 .. * |
|
Guardian's Number of Street/Guardian's Number of Street |
R1.7.A.3.1/R1.7.A.3.2 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Guardian's City |
R1.7.A.3.3 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Guardian's Postal Code |
R1.7.A.3.4 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Guardian's State or Province |
R1.7.A.3.5 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
ADXP |
1 .. * |
|
Guardian's Country |
R1.7.A.3.6 |
|
|
|
0 .. 1 |
|
|
| |
Use nullFlavor if unknown or if no information is applicable |
|
|
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 |
|
|
|
0 .. 1 |
|
|
| |
CONF |
|
|
|
|
0 .. 1 |
F |
NI |
|
|
|
1 .. 1 |
R |
|
R1.7.A |
|
|
PN |
1 .. * |
|
Patient Guardian's Name |
R1.7.A |
| Choice min 1 element(s) and max * element(s). Elements to choose from:
|
|
|
ENXP |
1 .. * |
|
Patient Guardian's Family Name/Surname |
R1.7.A.1 |
|
|
ENXP |
1 .. * |
|
Patient Guardian's Given Name |
R1.7.A.2 |
|
|
|
|
hl7:languageCommunication
|
|
|
0 .. * |
R |
|
(epSOS-PS) |
|
|
II |
1 .. 1 |
M |
Template id for LanguageCommunication |
(epSOS-PS) |
|
|
|
1 .. 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.2.1 |
|
|
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
|
|
hl7:author
|
|
|
1 .. * |
R |
|
(epSOS-PS) |
|
|
@typeCode
|
|
|
0 .. 1 |
F |
AUT |
|
|
@contextControlCode
|
|
|
0 .. 1 |
F |
OP |
|
|
hl7:functionCode
|
|
CE |
0 .. 1 |
|
|
R1.10.6 |
|
CONF |
|
|
|
hl7:assignedAuthor
|
|
|
1 .. 1 |
|
|
(epSOS-PS) |
|
|
|
0 .. 1 |
F |
ASSIGNED |
|
|
II |
1 .. * |
R |
HP ID number |
R1.10.5 |
|
|
CE |
0 .. 1 |
|
HP Specialty |
R1.10.7 |
|
|
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 |
|
|
|
0 .. 1 |
|
|
| |
CONF |
|
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)
|
|
|
|
|
|
|
(epSOS-PS) |
|
|
|
0 .. 1 |
F |
PSN |
|
|
|
0 .. 1 |
F |
INSTANCE |
|
|
PN |
0 .. 1 |
|
HP Name |
(epSOS-PS) |
|
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
|
|
|
ENXP |
1 .. * |
|
HP Family Name/Surname |
R1.10.1 |
|
|
ENXP |
1 .. * |
|
HP Given Name |
R1.10.2 |
|
|
ENXP |
1 .. * |
|
HP Prefix |
R1.10.3 |
|
|
ENXP |
1 .. * |
|
HP Suffix |
R1.10.4 |
|
|
|
|
|
|
(epSOS-PS) |
|
Contains |
inherited template rules CDA Device (DYNAMIC) with overridden cardinality
|
|
|
|
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
|
|
hl7:custodian
|
|
|
1 .. 1 |
M |
|
(epSOS-PS) |
|
|
@typeCode
|
|
|
0 .. 1 |
F |
CST |
|
|
hl7:assignedCustodian
|
|
|
1 .. 1 |
|
|
(epSOS-PS) |
|
|
|
0 .. 1 |
F |
ASSIGNED |
|
|
|
hl7:representedCustodianOrganization
|
|
|
1 .. 1 |
|
|
R1.10.9 |
|
|
|
0 .. 1 |
F |
ORG |
|
|
|
0 .. 1 |
F |
INSTANCE |
|
Contains |
inherited template rules epSOS CDA Organization (DYNAMIC) with overridden cardinality 1 .. 1
|
|
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> |
|
|
hl7:time
|
|
TS |
1 .. 1 |
M |
Time of signing the document |
R1.11.9 |
|
|
hl7:signatureCode
|
|
CS |
0 .. 1 |
|
Signature code |
R1.11.9 |
|
CONF |
The value of @code shall be drawn from value set ParticipationSignature (DYNAMIC)
 |
Error: Cannot find value set "ParticipationSignature" |
|
|
|
|
hl7:assignedEntity
|
|
|
0 .. 1 |
|
The regional authority that is responsible for the legal authentication of the CDA
document
|
R1.11.9 |
|
|
|
1 .. 1 |
M |
Unique identification of ligal authenticator |
R1.11.9 |
|
|
|
hl7:representedOrganization
|
|
|
1 .. 1 |
M |
The healthcare facility where the health professional works |
R1.11.9 |
|
|
ON |
1 .. * |
M |
Healthcare Facility's name |
R1.11.9 |
|
|
AD |
1 .. 1 |
M |
Healthcare Facility's Country |
R1.11.9 |
|
hl7:participant
where
[@typeCode='IND'] |
|
|
1 .. * |
|
Contact person of the patient. |
(epSOS-PS) |
|
|
@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 .. *
|
|
hl7:participant
where
[hl7:functionCode [@code='PCP'] [@codeSystem='2.16.840.1.113883.5.88']] |
|
|
1 .. * |
|
Preferred Health Professional to contact about patient. |
(epSOS-PS) |
|
|
@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 .. *
|
|
|
hl7:functionCode
|
|
|
1 .. 1 |
M |
|
(epSOS-PS) |
|
|
|
1 .. 1 |
F |
PCP |
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.5.88 |
|
hl7:component
|
|
|
1 .. 1 |
M |
|
(epSOS-PS) |
|
|
hl7:structuredBody
|
|
|
1 .. 1 |
M |
|
(epSOS-PS) |
|
|
|
0 .. 1 |
F |
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 .. * |
R |
|
(epSOS-PS) |
|
|
|
0 .. 1 |
F |
COMP |
|
Contains |
inherited template rules Section Alerts (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 .. * |
R |
|
(epSOS-PS) |
|
Contains |
inherited template rules Section History Of Past Illnesses (DYNAMIC) with overridden cardinality 0 .. * Required
|
|
|
|
1 .. 1 |
M |
History of Past Illnesses |
R7 |
|
|
|
0 .. 1 |
F |
DOCSECT |
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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> |
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II |
1 .. 1 |
M |
Template id History of Past Illnesses |
R7 |
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1 .. 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.3.8 |
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CV |
1 .. 1 |
M |
Section code for History of Past Illnesses |
R7 |
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1 .. 1 |
F |
11348-0 |
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1 .. 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
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ST |
1 .. 1 |
M |
Section title |
R7 |
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SD.TEXT |
1 .. 1 |
M |
Section text |
R7 |
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0 .. * |
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R7.1 |
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0 .. 1 |
F |
COMP |
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Contains |
an element from template Section Problems Resolved Closed Inactive (DYNAMIC) with overridden cardinality 0 .. *
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0 .. * |
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R8 |
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0 .. 1 |
F |
COMP |
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Contains |
an element from template Section Vaccinations (DYNAMIC) with overridden cardinality 0 .. *
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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']]] |
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0 .. * |
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R9 |
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0 .. 1 |
F |
COMP |
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Contains |
inherited template rules Section Procedures (DYNAMIC) with overridden cardinality 0 .. *
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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']]] |
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0 .. * |
R |
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(epSOS-PS) |
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0 .. 1 |
F |
COMP |
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Contains |
inherited template rules Section Procedures (DYNAMIC) with overridden cardinality 0 .. * Required
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Template epSOS-Patient Summary