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ref Template  epSOS CDA author prescriber

Id 2.16.840.1.113883.3.1937.777.11.10.103 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name epSOSCDAauthorPrescriber Display Name epSOS CDA author prescriber

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/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.


Classification CDA Header Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 9 templates, Uses 1 template
Used by as Name Version Include draft epSOS-ePrescription 2013‑12‑20 Include draft eHDSI-ePrescription PDF embedded 2017‑03‑11 22:32:59 Include draft epSOS CDA substanceAdministration 2013‑12‑20 link draft Section Prescription 2013‑12‑20 Include draft Medication Item 2013‑12‑20 link draft Section Medication Summary 2013‑12‑20 link draft epSOS-Patient Summary 2013‑12‑20 link draft epSOS-Health Care Encounter Report 2013‑12‑20 link draft epSOS-Medication Related Overview 2013‑12‑20
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.111 Containment draft epSOS CDA Organization DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.102 (2005‑09‑07)
  <time value="20121229"/>  <assignedAuthor>
    <id root="2.16.840.1.113883." 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>
        <given>Paolo</given>        <family>Rossi</family>      </name>
Item DT Card Conf Description Label
1 … * R (epSdotsber)
cs 0 … 1 F AUT
cs 0 … 1 F OP
CE.EPSOS 1 … 1 M R1.10.6
The value of @code shall be drawn from value set epSOSHealthcareProfessionalRoles (DYNAMIC)
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. (epSdotsber)
1 … 1 R (epSdotsber)
cs 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.  
II.EPSOS 1 … * R HP ID number R1.10.5
cs 0 … 1 F NA
CE.EPSOS 0 … 1 R HP Specialty R1.10.7
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
set_cs 0 … 1  
The value of @use shall be drawn from value set epSOSTelecomAddress (DYNAMIC)
1 … 1 M (epSdotsber)
cs 0 … 1 F PSN
cs 0 … 1 F INSTANCE
PN 1 … 1 R HP Name IHE PCC
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
1 … * R HP Family Name/Surname R1.10.1
1 … * R HP Given Name R1.10.2
0 … * R HP Prefix R1.10.3
0 … * R HP Suffix R1.10.4
1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9