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active Template  eHDSI Author Prescriber

Id 2.16.840.1.113883.3.1937.777.11.10.103 Effective Date 2020‑04‑16 10:53:17
Other versions this id:
Status active Active Version Label
Name eHDSIAuthorPrescriber Display Name eHDSI Author Prescriber
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

Classification CDA Header Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 5 transactions and 30 templates, Uses 1 template
Used by as Name Version
epsos-transactions-32 Transaction draft Return eP (PDF embedded) from country A 2017‑11‑21 10:26:49
epsos-transactions-19 Transaction draft Return eP from country A 2013‑11‑02
epsos-transactions-23 Transaction draft Return MRO 2013‑11‑02
epsos-transactions-21 Transaction draft Send HCER to country A 2013‑11‑02
epsos-transactions-12 Transaction draft Return PS of country A 2012‑05‑02
1.3.6.1.4.1.12559.11.10.1.3.1.1.1 Include active eHDSI ePrescription 2020‑06‑17 09:25:30
1.3.6.1.4.1.12559.11.10.1.3.1.1.1 Include retired eHDSI ePrescription 2020‑04‑16 10:42:14
1.3.6.1.4.1.12559.11.10.1.3.1.1.1 Include retired epSOS-ePrescription 2018‑11‑14 10:49:44
1.3.6.1.4.1.12559.11.10.1.3.1.1.1 Include retired epSOS-ePrescription 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.6 Include active eHDSI ePrescription PDF embedded 2020‑06‑17 09:27:29
1.3.6.1.4.1.12559.11.10.1.3.1.1.6 Include retired eHDSI ePrescription PDF embedded 2020‑04‑16 10:39:54
1.3.6.1.4.1.12559.11.10.1.3.1.1.6 Include retired eHDSI-ePrescription PDF embedded 2018‑11‑14 09:01:05
1.3.6.1.4.1.12559.11.10.1.3.1.1.6 Include retired eHDSI-ePrescription PDF embedded 2017‑03‑11 22:32:59
1.3.6.1.4.1.12559.11.10.1.3.1.3.2 Include active eHDSI Substance Administration 2020‑04‑14 14:55:37
1.3.6.1.4.1.12559.11.10.1.3.1.2.1 link active eHDSI Prescription 2020‑04‑16 12:20:48
1.3.6.1.4.1.12559.11.10.1.3.1.2.1 link retired Section Prescription 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.3.2 Include retired epSOS CDA substanceAdministration 2020‑03‑30 13:06:06
1.3.6.1.4.1.12559.11.10.1.3.1.3.2 Include retired epSOS CDA substanceAdministration 2019‑11‑07 16:15:52
1.3.6.1.4.1.12559.11.10.1.3.1.3.2 Include retired epSOS CDA substanceAdministration 2019‑03‑21 13:51:15
1.3.6.1.4.1.12559.11.10.1.3.1.3.2 Include retired epSOS CDA substanceAdministration 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.3.4 Include active eHDSI Medication Item 2020‑04‑15 15:15:45
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 link active eHDSI Medication Summary 2020‑04‑16 12:19:40
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link active eHDSI Patient Summary 2020‑04‑14 13:03:47
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired epSOS-Patient Summary 2018‑11‑14 10:53:50
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link retired epSOS-Health Care Encounter Report 2018‑11‑14 09:02:41
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link retired epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link retired epSOS-Medication Related Overview 2018‑11‑14 09:03:13
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link retired epSOS-Medication Related Overview 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 link retired Section Medication Summary 2019‑04‑08 12:31:22
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 link retired Section Medication Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.3.4 Include retired Medication Item 2020‑03‑24 15:58:29
1.3.6.1.4.1.12559.11.10.1.3.1.3.4 Include retired Medication Item 2019‑12‑03 08:26:05
1.3.6.1.4.1.12559.11.10.1.3.1.3.4 Include retired Medication Item 2019‑04‑08 12:46:30
1.3.6.1.4.1.12559.11.10.1.3.1.3.4 Include retired Medication Item 2013‑12‑20
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.111 Containment active eHDSI Organization DYNAMIC
Relationship Version: template 2.16.840.1.113883.3.1937.777.11.10.103 epSOS CDA author prescriber (2013‑12‑20)
Specialization: template 2.16.840.1.113883.10.12.102 CDA author (2005‑09‑07)
ref
ad1bbr-
Example
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>
Item DT Card Conf Description Label
hl7:author
1 … * R (eHDdotsber)
@typeCode
cs 0 … 1 F AUT
@contextControlCode
cs 0 … 1 F OP
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 eHDSIHealthcareProfessionalRole (DYNAMIC)
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. (eHDdotsber)
hl7:assignedAuthor
1 … 1 R (eHDdotsber)
@classCode
cs 0 … 1 F ASSIGNED
  Schematron assert role red error  
  test @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice  
  Message At least an assignedPerson or an assignedAuthoringDevice has to be provided, otherwise a nullFlavor shall be present.  
hl7:id
II.EPSOS 1 … * R Identification of the Healthcare Practitioner that is the author of this document.
R1.10.5
@nullFlavor
cs 0 … 1 F NA
hl7:code
CE.EPSOS 0 … 1 R HP Specialty R1.10.7
hl7:addr
AD.EPSOS 1 … * R IHE PCC
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
@use
set_cs 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 eHDSITelecomAddress (DYNAMIC)
hl7:assignedPerson
1 … 1 M (eHDdotsber)
@classCode
cs 0 … 1 F PSN
@determinerCode
cs 0 … 1 F INSTANCE
hl7:name
PN 1 … 1 R HP Name IHE PCC
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … * R HP Family Name/Surname R1.10.1
hl7:given
1 … * R HP Given Name R1.10.2
hl7:prefix
0 … * R HP Prefix R1.10.3
hl7:suffix
0 … * R HP Suffix R1.10.4
hl7:representedOrganization
1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) R1.10.9