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draft Template  epSOS CDA author prescriber

Template (internal) 2.16.840.1.113883.3.1937.777.10.10.103 - epSOSCDAauthorPrescriber
Id 2.16.840.1.113883.3.1937.777.10.10.103
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Header Level Template
Open/Closed Open (other than defined elements are allowed)
Description

A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).

For definition “The author element represents the creator of the clinical document. If the role of the actor is the entry of information from his or her own knowledge or application of skills, that actor is the author. If one actor provides information to another actor who filters, reasons, or algorithmically creates new information, then that second actor is also an author, having created information from his or her own knowledge or skills. [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March 2009].

According to this definition, not any device that generates the electronic document has to be considered as an author:

  • a spider collecting and filtering information from different repositories, according to defined rules and policies, for the scope of creating a Patient Summary is definitely a document author (and maybe the only one for this document);
  • an application that transforms a prescription record into a epSOS eP CDA may not be an author instead;
  • The NCP that modifies the concepts conveyed, should appear as one of the authors.
  • The author of the parent document is often also an author of the document generated through a transformation process (in that case also the author time should be the same).

Further to this, is therefore possible to determine the Nature of Patient Summary as follows [Excluding the NCPs as authors]:

  • if there is a person author only, there the Patient Summary is the result of a practitioner clinical act;
  • if there is a device author only, the summary was automatically generated according to well defined rules defined by the responsible organization;
  • if there are both a person and a device as authors, the summary was created via a mixed approach.

The CDA provides a mechanism to better specify who authored what within the document, allowing the specification of authorship at the whole document level, at the section level and finally at the entry level. In any case is not required to repeat this information for each level, taking advantage of the context conduction propriety. Infact “context that is specified on an outer tag holds true for all nested tags, unless overridden on a nested tag. Context specified on a tag within the CDA body always overrides context propagated from an outer tag. For instance, the specification of authorship at a document section level overrides all authorship propagated from outer tags.” (HL7 CDA R2 Standard).


/ClinicalDocument/author/assignedAuthor
/ClinicalDocument/documentationOf/serviceEvent/performer (this applies to the prescriber and the dispenser).

The template ID referenced here refers to HP information in the /ClinicalDocument/documentationOf/serviceEvent/performer structure. In this document, the same requriements apply to the person author of the document (if there is one), and to the prescrober and dispenser (see body).

When there is no HP but we have the method of assembly of data by a device, such as the “spider” method, we have the following expression; ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice.

When the data is collected from different sources & pre-existing documents that are part of a bigger system. In that case the organization responsible of that collection “signed” the PS as responsible.

ClinicalDocument/author/assignedAuthor/representedOrganization

Used by / Uses
Used by / Uses 10 templates
Used by Template id as Name Version
1.3.6.1.4.1.12559.11.10.1.3.1.1.1 epSOS-eP epSOS-ePrescription 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.3.2 epSOSCDASubstanceAdministration epSOS CDA substanceAdministration 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.2.1 link SectionPrescription Section Prescription 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.3.4 EntryMedicationSummary Entry Medication Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 link SectionMedicationSummary Section Medication Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link epSOS-PS epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link epSOS-HCER epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link epSOS-MRO epSOS-Medication Related Overview 2013‑12‑20
Uses Template id as Name Version
2.16.840.1.113883.3.1937.777.10.10.111 Containment epSOSCDAOrganization DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.102 (2005‑09‑07)
Item DT Card Conf Description Label
hl7:author
1 .. * R (epSOSCDAauthorPrescriber)
treetree @typeCode
0 .. 1 F AUT
treetree @contextControlCode
0 .. 1 F OP
  Example <author>
  <time value="20121229"/>
  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>
    <addr>
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:(+39)051-34343434"/>
    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
  </assignedAuthor>
</author>
treetree hl7:functionCode
CE.EPSOS 1 .. 1 M R1.10.6
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.1 epSOSHealthcareProfessionalRoles (DYNAMIC)
treetree 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. (epSOSCDAauthorPrescriber)
treetree hl7:assignedAuthor
1 .. 1 R (epSOSCDAauthorPrescriber)
treeblank treetree @classCode
0 .. 1 F ASSIGNED
  Schematron assert role red error
  test @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice
  Message If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for "ClinicalDocument/author/assignedAuthor/id/@NullFlavor" SHALL be "NA" "Not applicable" 2.16.840.1.113883.5.1008 NullFlavor STATIC.
treeblank treetree hl7:id
II.EPSOS 1 .. * R HP ID number R1.10.5
treeblank treeblank treetree @nullFlavor
0 .. 1 F NA
treeblank treetree hl7:code
CE.EPSOS 0 .. 1 R HP Specialty R1.10.7
treeblank treetree hl7:addr
AD.EPSOS 1 .. * R IHE PCC
treeblank treetree hl7:telecom
TEL.EPSOS 1 .. * R 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
treeblank treeblank treetree @use
0 .. 1  
  CONF
The value of @use shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.40 epSOSTelecomAddress (DYNAMIC)
treeblank treetree hl7:assignedPerson
1 .. 1 M (epSOSCDAauthorPrescriber)
treeblank treeblank treetree @classCode
0 .. 1 F PSN
treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treetree hl7:name
PN 1 .. 1 R HP Name IHE PCC
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
treeblank treeblank treeblank treetree hl7:family
1 .. * R HP Family Name/Surname R1.10.1
treeblank treeblank treeblank treetree hl7:given
1 .. * R HP Given Name R1.10.2
treeblank treeblank treeblank treetree hl7:prefix
1 .. * R HP Prefix R1.10.3
treeblank treeblank treeblank treetree hl7:suffix
1 .. * R HP Suffix R1.10.4
treeblank treetree hl7:representedOrganization
1 .. 1 R R1.10.9
  Contains 2.16.840.1.113883.3.1937.777.10.10.111 epSOS CDA Organization (DYNAMIC)