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Effective Date |
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Templates with direct association to a transaction |
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eHDSI-ePrescription PDF embedded 1.3.6.1.4.1.12559.11.10.1.3.1.1.6
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2017‑03‑11 22:32:59 |
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< DESCRIPTION TO BE UPDATED >
...
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eHDSI-Patient Summary PDF embedded 1.3.6.1.4.1.12559.11.10.1.3.1.1.7
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2017‑03‑11 18:41:31 |
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< DESCRIPTION TO BE UPDATED >
...
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epSOS-eDispensation 1.3.6.1.4.1.12559.11.10.1.3.1.1.2
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2013‑12‑20 |
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Note for the readers
...
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Transaction |
Direction |
Underlying Model |
Schematron |
Send eD to country A |
 |
initial |
ClinicalDocument |
epsos-eDispensation.sch |
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epSOS-ePrescription 1.3.6.1.4.1.12559.11.10.1.3.1.1.1
|
2013‑12‑20 |
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Note for the readers
...
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Transaction |
Direction |
Underlying Model |
Schematron |
Return eP from country A |
 |
back |
ClinicalDocument |
epsos-ePrescription.sch |
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epSOS-Health Care Encounter Report 1.3.6.1.4.1.12559.11.10.1.3.1.1.4
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2013‑12‑20 |
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epSOS Health Care Encounter Report Template
The implementers must be familiar with the context of the project, as it shall n...
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Transaction |
Direction |
Underlying Model |
Schematron |
Return MRO |
 |
back |
ClinicalDocument |
epsos-MedicationRelatedOverview.sch |
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epSOS-Medication Related Overview 1.3.6.1.4.1.12559.11.10.1.3.1.1.5
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2013‑12‑20 |
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epSOS Medication Related Overview Template
The implementers must be familiar with the context of the project, as it shall no...
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Transaction |
Direction |
Underlying Model |
Schematron |
Send HCER to country A |
 |
initial |
ClinicalDocument |
epsos-HealthCareEncounterReport.sch |
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html |
epSOS-Patient Summary 1.3.6.1.4.1.12559.11.10.1.3.1.1.3
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2013‑12‑20 |
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Note for the readers
...
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Transaction |
Direction |
Underlying Model |
Schematron |
Return PS of country A |
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back |
ClinicalDocument |
epsos-PatientSummary.sch |
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CDA Document Level Template
|
html |
eHDSI-ePrescription PDF embedded 1.3.6.1.4.1.12559.11.10.1.3.1.1.6
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2017‑03‑11 22:32:59 |
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< DESCRIPTION TO BE UPDATED >
...
|
html |
eHDSI-Patient Summary PDF embedded 1.3.6.1.4.1.12559.11.10.1.3.1.1.7
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2017‑03‑11 18:41:31 |
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< DESCRIPTION TO BE UPDATED >
...
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html |
epSOS-eDispensation 1.3.6.1.4.1.12559.11.10.1.3.1.1.2
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2013‑12‑20 |
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Note for the readers
...
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html |
epSOS-ePrescription 1.3.6.1.4.1.12559.11.10.1.3.1.1.1
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2013‑12‑20 |
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Note for the readers
...
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html |
epSOS-Health Care Encounter Report 1.3.6.1.4.1.12559.11.10.1.3.1.1.4
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2013‑12‑20 |
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epSOS Health Care Encounter Report Template
The implementers must be familiar with the context of the project, as it shall n...
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html |
epSOS-Medication Related Overview 1.3.6.1.4.1.12559.11.10.1.3.1.1.5
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2013‑12‑20 |
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epSOS Medication Related Overview Template
The implementers must be familiar with the context of the project, as it shall no...
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html |
epSOS-Patient Summary 1.3.6.1.4.1.12559.11.10.1.3.1.1.3
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2013‑12‑20 |
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Note for the readers
...
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CDA Header Level Template
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html |
CDA inFulfillmentOf 2.16.840.1.113883.3.1937.777.11.10.115
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2013‑12‑20 |
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Template CDA inFulfillmentOf (prototype, directly derived from POCD_RM000040 MIF) |
html |
CDA participant 2.16.840.1.113883.3.1937.777.11.10.112
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2013‑12‑20 |
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Template CDA participant (prototype, directly derived from POCD_RM000040 MIF) |
html |
CDA Participant (Body) 2.16.840.1.113883.3.1937.777.11.10.134
|
2013‑12‑20 |
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Template CDA Participant (Body) (prototype, directly derived from POCD_RM000040 MIF) |
html |
CDA Person 2.16.840.1.113883.3.1937.777.11.10.113
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2013‑12‑20 |
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Template CDA Person (prototype, directly derived from POCD_RM000040 MIF) |
html |
epSOS CDA AssignedEntity 2.16.840.1.113883.3.1937.777.11.10.114
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2013‑12‑20 |
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Template CDA AssignedEntity (prototype, directly derived from POCD_RM000040 MIF) |
html |
epSOS CDA author 2.16.840.1.113883.3.1937.777.11.10.102
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2013‑12‑20 |
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A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson)
either devices (ClinicalDocument/author/assignedA...
|
html |
epSOS CDA author prescriber 2.16.840.1.113883.3.1937.777.11.10.103
|
2013‑12‑20 |
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A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson)
either devices (ClinicalDocument/author/assignedA...
|
html |
epSOS CDA Contact/Preferred HP/Legal Organization 2.16.840.1.113883.3.1937.777.11.10.101
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2013‑12‑20 |
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The guardians of a patient shall be recorded in the <guardian> element beneath the
/ClinicalDocument/recordTarget/patientRole/patient
...
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epSOS CDA custodian 2.16.840.1.113883.3.1937.777.11.10.104
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2013‑12‑20 |
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This elements represents the organization that is in charge of maintaining the document.
This information is required by the CDA R2 standard and shall be recorded i...
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html |
epSOS CDA documentationOf 2.16.840.1.113883.3.1937.777.11.10.105
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2013‑12‑20 |
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/ClinicalDocument/author/assignedAuthor /ClinicalDocument/documentationOf/serviceEvent/performer
(this applies to the prescriber and the dispenser). The template ID referenced here
refers to HP infor...
|
html |
epSOS CDA documentationOf PCPR 2.16.840.1.113883.3.1937.777.11.10.106
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2013‑12‑20 |
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/ClinicalDocument/author/assignedAuthor /ClinicalDocument/documentationOf/serviceEvent/performer
(this applies to the prescriber and the dispenser). The template ID referenced here
refers to HP infor...
|
html |
epSOS CDA legalAuthenticator 2.16.840.1.113883.3.1937.777.11.10.109
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2013‑12‑20 |
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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 N...
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html |
epSOS CDA recordTarget 2.16.840.1.113883.3.1937.777.11.10.100
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2013‑12‑20 |
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html |
epSOS CDA relatedDocument 2.16.840.1.113883.3.1937.777.11.10.107
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2013‑12‑20 |
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Links among documents
Depending on the document type, any instance of epSOS pivot CDA shall have a related
CDA embedding the...
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CDA Section Level Template
|
html |
Section Active Problems 1.3.6.1.4.1.19376.1.5.3.1.3.6
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2013‑12‑20 |
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The active problem section shall contain a narrative description of the conditions
currently being monitored for the patient. It shall include entries for patient conditions
as described in the Entry ...
|
html |
Section Allergies and Other Adverse Reactions 1.3.6.1.4.1.19376.1.5.3.1.3.13
|
2013‑12‑20 |
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The adverse and other adverse reactions section shall contain a narrative description
of the substance intolerances and the associated adverse reactions suffered by the
patient. It s...
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html |
Section Coded List of Surgeries 1.3.6.1.4.1.19376.1.5.3.1.3.12
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2013‑12‑20 |
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The list of surgeries section shall include entries for procedures and references
to procedure reports when known as described in the Entry Content Modules. In epSOS
this section should be used to des...
|
html |
Section Coded Results 1.3.6.1.4.1.12559.11.10.1.3.1.2.5
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2013‑12‑20 |
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In epSOS this section is used only for the purpose of providing the results for the
blood group. This is determined in the simple observation entry; hence only this entry
will be described. If this se...
|
html |
Section Coded Social History 1.3.6.1.4.1.19376.1.5.3.1.3.16.1
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2013‑12‑20 |
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The social history section shall contain a narrative description of the person’s beliefs,
home life, community life, work life, hobbies, and risky habits. It shall include
Social History Observations....
|
html |
Section Coded Vital Signs 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
|
2013‑12‑20 |
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The vital signs section contains coded measurement results of a patient’s vital signs.
Warning: Some of these elements were not included in the functional specification
of WP3.2, however they have be...
|
html |
Section Dispensation 1.3.6.1.4.1.12559.11.10.1.3.1.2.2
|
2013‑12‑20 |
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The dispensation section shall contain a description of the medication dispensed
for the patient at a given pharmacy. It shall include only one entry for each dispensed
medication as described in th...
|
html |
Section Functional Status 1.3.6.1.4.1.19376.1.5.3.1.3.17
|
2013‑12‑20 |
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The functional status section shall contain a narrative description of capability
of the patient to perform acts of daily living.
|
html |
Section Health Maintenance Care Plan 1.3.6.1.4.1.19376.1.5.3.1.1.9.50
|
2013‑12‑20 |
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The health maintenance care plan section shall contain a description of the expectations
for wellness care including proposals, goals, and order requests for monitoring, tracking,
or improving the lif...
|
html |
Section History of Past Illness 1.3.6.1.4.1.19376.1.5.3.1.3.8
|
2013‑12‑20 |
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The History of Past Illness section shall contain a narrative description of the conditions
the patient suffered in the past. It shall include entries for problems as described
in the Entry Content Mo...
|
html |
Section Immunizations 1.3.6.1.4.1.19376.1.5.3.1.3.23
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2013‑12‑20 |
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The immunizations section shall contain a narrative description of the immunizations
administered to the patient in the past. It shall include entries for medication administration
as described in the...
|
html |
Section Medical Devices Coded 1.3.6.1.4.1.12559.11.10.1.3.1.2.4
|
2013‑12‑20 |
|
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The medical devices section contains narrative text describing the patient history
of medical device use. For the epSOS Patient Summary this is a mandatory section
and shall be used to record the Med...
|
html |
Section Medication Summary 1.3.6.1.4.1.12559.11.10.1.3.1.2.3
|
2013‑12‑20 |
|
|
The medication summary section shall contain a description of the patient's medications
as part of the patient summary
|
html |
Section Pregnancy History 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
|
2013‑12‑20 |
|
|
The pregnancy history section contains coded entries describing the patient history
of pregnancies. This section is used in epSOS only for the purpose of providing the
Expected Date of Delivery, when ...
|
html |
Section Prescription 1.3.6.1.4.1.12559.11.10.1.3.1.2.1
|
2013‑12‑20 |
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The prescription section shall contain a description of the medications in a given
prescription for the patient. It shall include entries for each prescription item
as described in the Prescription I...
|
|
CDA Entry Level Template
|
html |
Allergies And Intolerances 1.3.6.1.4.1.19376.1.5.3.1.4.6
|
2013‑12‑20 |
|
|
Allergies and intolerances are special kinds of problems, and so are also recorded
in the CDA <observation> element, with classCode='OBS'. They follow the same pattern
as the problem...
|
html |
Allergy and Intolerance Concern 1.3.6.1.4.1.19376.1.5.3.1.4.5.3
|
2013‑12‑20 |
|
|
This entry is a specialization of the Concern Entry, wherein the subject of the concern
is focused on an allergy or intolerance.
This entry has a template identifi...
|
html |
Blood Group 1.3.6.1.4.1.19376.1.5.3.1.4.13.6
|
2017‑07‑12 16:25:39 |
|
|
Note that this template was specified by IHE PCC. Find the referenced specification
here: https://art-decor.ihe-europe.net/art-decor/decor-templates--IHE-PCC-?section=templates&id=1.3.6.1.4.1.19376.1....
|
html |
CDA Device 2.16.840.1.113883.3.1937.777.11.10.129
|
2013‑12‑20 |
|
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Template CDA Device (prototype, directly derived from POCD_RM000040 MIF) |
html |
CDA Number of Packages 1.3.6.1.4.1.12559.11.10.1.3.1.3.6
|
2017‑12‑21 15:44:42 |
|
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This template is used to represent the number of packages in an ePrescription document. |
html |
CDA Performer (Body) 2.16.840.1.113883.3.1937.777.11.10.136
|
2013‑12‑20 |
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Template CDA Performer (Body) (prototype, directly derived from POCD_RM000040 MIF) |
html |
CDA PlayingEntity 2.16.840.1.113883.3.1937.777.11.10.128
|
2013‑12‑20 |
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Template CDA PlayingEntity (prototype, directly derived from POCD_RM000040 MIF) |
html |
Comment 1.3.6.1.4.1.19376.1.5.3.1.4.2
|
2013‑12‑20 |
|
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This entry allows for a comment to be supplied with each entry. For CDA this structure
is usually included in the target act using the <entryRelationship> element defined
in the CDA Schema, but can al...
|
html |
Entry Health Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.2
|
2013‑12‑20 |
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A problem observation may reference a health status observation. This structure is
included in the target observation using the <entryRelationship> element defined in
the CDA Schema. The health status...
|
html |
Entry Medication FulFillment Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3.1
|
2013‑12‑20 |
|
|
Any medication may be the subject of further instructions to the pharmacist, for example
to indicate that it should be labeled in Spanish, et cetera. This structure is included
in the target substance...
|
html |
Entry Problem Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
|
2013‑12‑20 |
|
|
(CCD) Any problem or allergy observation may reference a problem status observation.
This structure is included in the target observation using the <entryRelationship>
element define...
|
html |
epSOS CDA ManufacturedProduct 1.3.6.1.4.1.12559.11.10.1.3.1.3.1
|
2013‑12‑20 |
|
|
Template CDA ManufacturedProduct (prototype, directly derived from POCD_RM000040 MIF)
The medicine entry content module describes a medication used in a <substanceAdministration>
or <supply> act. This...
|
html |
epSOS CDA Material 2.16.840.1.113883.3.1937.777.11.10.143
|
2013‑12‑20 |
|
html |
epSOS CDA substanceAdministration 1.3.6.1.4.1.12559.11.10.1.3.1.3.2
|
2013‑12‑20 |
|
|
The general model is to record each prescribed medication in a <substanceAdministration>
intent (moodCode='INT'). The <substanceAdministration> element may contain subordinate
<sub-stanceAdministrati...
|
html |
epSOS CDA Supply 1.3.6.1.4.1.12559.11.10.1.3.1.3.3
|
2013‑12‑20 |
|
|
Dispensed Medicine Entry Content Module |
html |
epSOS Patient Medication Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3
|
2013‑12‑20 |
|
|
Any medication may be the subject of further instructions to the patient, for example
to indicate that it should be taken with food, etc.
This structure is include...
|
html |
epSOS Related Prescription Item 2.16.840.1.113883.3.1937.777.11.10.144
|
2013‑12‑20 |
|
html |
External Reference 1.3.6.1.4.1.19376.1.5.3.1.4.4
|
2013‑12‑20 |
|
|
CDA Documents may reference information contained in other documents. While CDA Release
2.0 supports references in content via the <linkHtml> element, this is insufficient
for many E...
|
html |
Immunization Material 2.16.840.1.113883.3.1937.777.11.10.145
|
2013‑12‑20 |
|
html |
Immunization Product 1.3.6.1.4.1.19376.1.5.3.1.4.7.2
|
2013‑12‑20 |
|
|
The product entry describes an immunization used in a <substanceAdministration> act.
It adopts the constraints of the ASTM/HL7 Continuity of Care Document.
In a CD...
|
html |
Immunizations 1.3.6.1.4.1.19376.1.5.3.1.4.12
|
2013‑12‑20 |
|
|
An immunizations entry is used to record the patient's immunization history.
|
html |
Internal Reference 1.3.6.1.4.1.19376.1.5.3.1.4.4.1
|
2013‑12‑20 |
|
|
CDA and HL7 Version 3 Entries may reference (point to) information contained in other
entries within the same document or message as shown below.
|
html |
Medical Devices 1.3.6.1.4.1.12559.11.10.1.3.1.3.5
|
2013‑12‑20 |
|
|
The medical devices entry content module describes the kind of device that is, or
has been used by the patient
|
html |
Medication Item 1.3.6.1.4.1.12559.11.10.1.3.1.3.4
|
2013‑12‑20 |
|
|
This entry content module makes use of the medicine and instruction entry content
modules. Medi- cations and their prescriptions are perhaps the most difficult data
elements to model...
|
html |
OpenMed ManufacturedProduct 2.16.840.1.113883.3.1937.777.11.10.146
|
2016‑05‑10 22:32:31 |
|
|
< this template is currently used for demonstration purposes for the OpenMedicine
preoject>
...
|
html |
OpenMed Material 2.16.840.1.113883.3.1937.777.11.10.147
|
2016‑05‑10 22:43:03 |
|
|
This Template maps the IDMP (
PhP, MP and PC )
and other identifiers and attributes proposed by the Open Medicine project into a
CDA compliant structure. This is ...
|
html |
Position Of Vaccination 2.16.840.1.113883.10.20.1.46
|
2013‑12‑20 |
|
html |
Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5
|
2013‑12‑20 |
|
|
A pregnancy observation is a Simple Observation that uses a specific vocabulary to
record observations about a patient's pregnancy history.
The parent of this templ...
|
html |
Problem 1.3.6.1.4.1.19376.1.5.3.1.4.5
|
2013‑12‑20 |
|
|
This section makes use of the linking, severity, clinical status and comment content
specifications defined elsewhere in the technical framework. In HL7 RIM parlance,
observations ab...
|
html |
Problem Concern 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
|
2013‑12‑20 |
|
|
This entry is a specialization of the Concern Entry, wherein the subject of the concern
is focused on a problem. Elements shown in the example below in gray are explained
in the Conc...
|
html |
Procedure 1.3.6.1.4.1.19376.1.5.3.1.4.19
|
2013‑12‑20 |
|
|
The procedure entry is used to record procedures that have occured, or which are planned
for in the future.
In case no procedures are expected to be recorded, a single “NA” n...
|
html |
Severity 1.3.6.1.4.1.19376.1.5.3.1.4.1
|
2013‑12‑20 |
|
|
The <templateId> elements identifies this <observation> as a severity observation,
allowing for validation of the content. As a side effect, readers of the CDA can quickly
locate and...
|
html |
Simple Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13
|
2013‑12‑20 |
|
|
The simple observation entry is meant to be an abstract representation of many of
the observations used in this specification. It can be made concrete by the specification
of a few a...
|
html |
Social History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.4
|
2013‑12‑20 |
|
|
A social history observation is a simple observation that uses a specific vocabulary,
and inherits constraints from CCD.
epSOS functional experts limited the socia...
|
html |
Vital Signs Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.2
|
2013‑12‑20 |
|
|
A vital signs observation is a simple observation that uses a specific vocabulary,
and inherits constraints from CCD.
Note: Although
...
|
html |
Vital Signs Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.1
|
2013‑12‑20 |
|
|
A vital signs organizer collects vital signs observations.
|
|
Template type not specified
|
html |
epSOS CDA Id 2.16.840.1.113883.3.1937.777.11.10.110
|
2013‑12‑20 |
|
html |
epSOS CDA Organization 2.16.840.1.113883.3.1937.777.11.10.111
|
2013‑12‑20 |
|
html |
epSOS CDA setId 2.16.840.1.113883.3.1937.777.11.10.108
|
2013‑12‑20 |
|