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retired Template  epSOS-Health Care Encounter Report

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.4 Effective Date 2013‑12‑20
Other versions this id:
Status retired Retired Version Label
Name epSOS-HCER Display Name epSOS-Health Care Encounter Report
Description

epSOS Health Care Encounter Report Template

The implementers must be familiar with the context of the project, as it shall not be repeated in this document. The implementers must also be familiar with the content of the following documents:

  • CDA Release 2.0 Normative Web Edition, May, 2005
  • HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), HL7, April 1, 2007.
  • Integrating the Healthcare Enterprise, Patient Care Coordination Technical Framework, Volume 1 and Volume 2- Revision 5, IHE International, August 10, 2009.
  • Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules- Trial Implementation Supplement, August 10, 2009.
  • HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, HL7, July 16, 2008.

The Healthcare Encounter Report service not only supports the patient summary extension use case, but also supports the ePrescription extension use case and the 112 emergency use case. Therefore this service description not only covers the patient summary extension, but also the ePrescription extension and the part of the 112 emergency use case where information about the emergency encounter is sent back to country A.

The definition of a healthcare event can be broad. The HCER service is designed to offer a health professional in country B flexibility to record a wide range of medical information, enough to cover the most basic healthcare encounters. The service offers country A the basic contact information of the health professional in country B together with the medical information gathered during the healthcare encounter. Informing country A of a healthcare encounter in county B, of course, is done with consent of the patient.

Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 21 templates
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.110 Include active eHDSI Id DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.108 Include active eHDSI SetId DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.100 Include active eHDSI RecordTarget DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.102 Include active eHDSI Author DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.104 Include active eHDSI Custodian DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.109 Include active eHDSI LegalAuthenticator DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.101 Include active eHDSI Contact/Preferred HP/Legal Organization DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.112 Include active eHDSI Participant DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.106 Include active eHDSI DocumentationOf PCPR DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.107 Include active eHDSI RelatedDocument DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 Containment active eHDSI Medication Summary DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.13 Containment active eHDSI Allergies and Other Adverse Reactions DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.12 Containment active eHDSI List of Surgeries DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment active eHDSI Active Problems DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.4 Containment active eHDSI Medical Devices DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.23 Containment active eHDSI Immunizations DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.9.50 Containment active eHDSI Health Maintenance Care Plan DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.8 Containment active eHDSI History Of Past Illness DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.16.1 Containment active eHDSI Social History DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Containment active eHDSI Pregnancy History DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Containment active eHDSI Vital Signs DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
XML overview
XML overview
Scenario doublearrow Transaction Transaction
Item DT Card Conf Description Label
hl7:ClinicalDocument
R CDA header (epSdotsCER)
hl7:realmCode
CS 1 … 1 M (epSdotsCER)
hl7:typeId
II.EPSOS 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.
(epSdotsCER)
@root
uid 1 … 1 F 2.16.840.1.113883.1.3
@extension
st 1 … 1 F POCD_HD000040
  Example <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
hl7:templateId
II.EPSOS 1 … 1 M Template ID for epSOS Health Care Encounter Report (epSdotsCER)
@root
uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.1.4
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.110 eHDSI Id (DYNAMIC)
hl7:id
II 1 … 1 M

The ClinicalDocument/id element is an instance identifier data type. The root attribute is an OID. If there is a value in @extension, then the root uniquely identifies the scope of the extension. If there is no value in @extension then @root SHALL uniquely identify the document

UUIDs SHALL be represented in the form XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX, where each X is a character from the set [A-Fa-f0-9].

OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0, or starts with a nonzero digit. More formally, an OID SHALL be in the form ([0-2])(.([1-9][0-9]*|0))+.

R1.11.3
 
target
epsos-dataelement-176 draft Identification draft epSOS Data Set
  Example <id extension="a621" root="2.16.840.1.113883.3.1937.777.11.9999"/>
hl7:code
CV.EPSOS 1 … 1 M Determines the document type "epSOS Health Care Encounter Report" R1.11.6
@displayName
1 … 1 R
@code
CONF 1 … 1 F 34133-9
@codeSystem
1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of episode note"/>
hl7:title
ST 1 … 1 M ClinicalDocument/title is used for display purposes. R1.11.7
  Example <title>epSOS Health Care Encounter Report Maria Bakker November 13, 2011</title>
hl7:effectiveTime
TS.EPSOS.TZ 1 … 1 M The element contains the date and time at which this document was created as an electronic document. R1.11.1
  Example <effectiveTime value="20111113125600+0200"/>
hl7:confidentialityCode
CE.EPSOS 1 … 1 R ClinicalDocument/confidentialityCode shall be present in accordance with the HL7 CDA R2 standard. R1.11.8
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.31 eHDSIConfidentiality (DYNAMIC)
  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 red 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 0 … 1 from 2.16.840.1.113883.3.1937.777.11.10.108 eHDSI SetId (DYNAMIC)
hl7:setId
0 … 1 R

This identifier is used to link together different versions of the same document: the CDA L3 document, the CDA PDF embedded document and the version in the national infrastructure.

(epSdotsCER)
hl7:versionNumber
0 … 1 R (epSdotsCER)
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.100 eHDSI RecordTarget (DYNAMIC)
hl7:recordTarget
1 … 1 M (epSdotsCER)
 
target
epsos-dataelement-5 draft Patient Data draft epSOS Data Set
@typeCode
cs 0 … 1 F RCT
@contextControlCode
cs 0 … 1 F OP
hl7:patientRole
1 … 1 M (epSdotsCER)
 
target
epsos-dataelement-26 draft Contact Information draft epSOS Data Set
@classCode
cs 0 … 1 F PAT
hl7:id
II.EPSOS 1 … * R Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) R1.4 / R1.4.1 / R1.4.2
 
target
epsos-dataelement-235 draft Other Identifier draft epSOS Data Set
epsos-dataelement-7 draft National Health Care patient ID (country of affiliation) draft epSOS Data Set
epsos-dataelement-234 draft National Health Care patient ID (country of treatment) draft epSOS Data Set
epsos-dataelement-6 draft Identification draft epSOS Data Set
hl7:addr
AD.EPSOS 1 … 1 R The patient address 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. R1.5
 
target
epsos-dataelement-27 draft Address draft epSOS Data Set
@nullFlavor
cs 0 … 1 F NI
hl7:streetAddressLine
0 … * R Patient's Number of Street/Patient's Number of Street R1.5.1 / R1.5.2
 
target
epsos-dataelement-51 draft Street draft epSOS Data Set
epsos-dataelement-52 draft Number of Street draft epSOS Data Set
hl7:city
0 … 1 R Patient's City R1.5.3
 
target
epsos-dataelement-55 draft City draft epSOS Data Set
hl7:postalCode
0 … 1 R Patient's Postal Code R1.5.4
 
target
epsos-dataelement-53 draft Postal Code draft epSOS Data Set
hl7:state
0 … 1 R Patient's State or Province R1.5.5
 
target
epsos-dataelement-56 draft State or Province draft epSOS Data Set
hl7:country
0 … 1 R Patient's Country. When used addr.country it is always bound to the epSOSCountry value set R1.5.6
 
target
epsos-dataelement-54 draft Country draft epSOS Data Set
  Constraint The content of this element SHALL be selected from ValueSet epSOSCountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4
hl7:telecom
TEL 1 … * R Patient’s telephone number / Patient e-mail address. The patient telephone or e-mail 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
 
target
epsos-dataelement-28 draft Telephone No draft epSOS Data Set
epsos-dataelement-300 draft Telecom draft epSOS Data Set
epsos-dataelement-29 draft Email draft epSOS Data Set
@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)
@nullFlavor
cs 0 … 1 F NI
hl7:patient
1 … 1 M (epSdotsCER)
 
target
epsos-dataelement-8 draft Personal Information draft epSOS Data Set
@classCode
cs 0 … 1 F PSN
@determinerCode
cs 0 … 1 F INSTANCE
hl7:name
PN 1 … * R Patient Name R1.1
 
target
epsos-dataelement-9 draft Full Name draft epSOS Data Set
hl7:family
1 … * M Patient's Family Name/Surname R1.1.1
 
target
epsos-dataelement-13 draft Family Name/Surname draft epSOS Data Set
hl7:prefix
0 … * R Patient's Prefix R1.1.2
 
target
epsos-dataelement-263 draft Prefix draft epSOS Data Set
  Constraint If the attribute qualifier is used for this element it should be derived from epSOSEntityNamePartQualifier 2.16.840.1.113883.5.43
hl7:given
1 … * M Patient's Given Name R1.1.3
 
target
epsos-dataelement-12 draft Given name draft epSOS Data Set
hl7:administrativeGenderCode
CE.EPSOS 1 … 1 R Patient's Gender R1.2
 
target
epsos-dataelement-11 draft Gender draft epSOS Data Set
@nullFlavor
cs 0 … 1 F UNK
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.34 eHDSIAdministrativeGender (DYNAMIC)
hl7:birthTime
TS 1 … 1 M Patient's Date of Birth. The patient date of birth may be a partial date such as only the year. R1.3
 
target
epsos-dataelement-10 draft Date of Birth draft epSOS Data Set
hl7:guardian
0 … * 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 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 (eHDSIPersonalRelationship 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 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.

R1.7.A
@classCode
cs 1 … 1 F GUARD
@nullFlavor
cs 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>
hl7:templateId
II.EPSOS 1 … 1 M Template id for IHE PCC Patient Contacts R1.7.A
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:addr
AD.EPSOS 1 … 1 R The guardian’s address 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 R1.7.A
@nullFlavor
cs 0 … 1 F NI
hl7:streetAddressLine
0 … * R Guardian's Number of Street/Guardian's Number of Street R1.7dots.3.2
hl7:city
0 … 1 R Guardian's City R1.7dots.3.3
hl7:postalCode
0 … 1 R Guardian's Postal Code R1.7dots.3.4
hl7:state
0 … 1 R Guardian's State or Province R1.7dots.3.5
hl7:country
0 … 1 R Guardian's Country. When used addr.country it is always bound to the epSOSCountry value set R1.7dots.3.6
  Constraint The content of this element SHALL be selected from ValueSet epSOSCountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4
hl7:telecom
TEL 1 … * R Guardian’s telephone number / Patient e-mail address. The guardian telephone or e-mail 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. R1.7dots.4.2
 
target
epsos-dataelement-39 draft Telephone No draft epSOS Data Set
@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)
@nullFlavor
cs 0 … 1 F NI
hl7:guardianPerson
1 … 1 R R1.7.A
 
target
epsos-dataelement-34 draft Contact Person/legal guardian draft epSOS Data Set
hl7:name
PN 1 … * R Patient Guardian's Name IHE PCC
 
target
epsos-dataelement-36 draft Full Name draft epSOS Data Set
Choice 2 … * Elements to choose from:
  • hl7:family
  • hl7:given
hl7:family
1 … * R Patient Guardian's Family Name/Surname R1.7.A.1
 
target
epsos-dataelement-38 draft Family Name/Surname draft epSOS Data Set
hl7:given
1 … * R Patient Guardian's Given Name R1.7.A.2
 
target
epsos-dataelement-37 draft Given Name draft epSOS Data Set
hl7:languageCommunication
0 … * R This element is derived from the IHE template LanguageCommunication (1.3.6.1.4.1.19376.1.5.3.1.2.1), however this template does not need the element preferenceInd because the language is already said to be the "preferred language". (epSdotsCER)
hl7:languageCode
CS 1 … 1 R Patient’s preferred language
  • 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
R1.7
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.6 eHDSILanguage (DYNAMIC)
  Example <languageCode code="en-GB"/>
  Schematron assert role red 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 1 … * R from 2.16.840.1.113883.3.1937.777.11.10.102 eHDSI Author (DYNAMIC)
hl7:author
1 … * R (epSdotsCER)
 
target
epsos-dataelement-67 draft Author draft epSOS Data Set
@typeCode
cs 0 … 1 F AUT
@contextControlCode
cs 0 … 1 F OP
hl7:functionCode
CE.EPSOS 0 … 1 R R1.10.6
 
target
epsos-dataelement-180 draft Author Role draft epSOS Data Set
  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. (epSdotsCER)
hl7:assignedAuthor
1 … 1 M (epSdotsCER)
@classCode
cs 0 … 1 F ASSIGNED
hl7:id
II.EPSOS 1 … * R Identification of the Healthcare Practitioner that is the author of this document. R1.10.5
 
target
epsos-dataelement-22 draft Author Identification draft epSOS Data Set
@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)
Choice 1 … 1 Elements to choose from:
hl7:assignedPerson
0 … 1 C (epSdotsCER)
@classCode
cs 0 … 1 F PSN
@determinerCode
cs 0 … 1 F INSTANCE
hl7:name
PN 1 … 1 R HP Name IHE PCC
 
target
epsos-dataelement-19 draft Author Full Name draft epSOS Data Set
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … * M HP Family Name/Surname R1.10.1
 
target
epsos-dataelement-21 draft Family Name/Surname draft epSOS Data Set
hl7:given
1 … * M HP Given Name R1.10.2
 
target
epsos-dataelement-20 draft Given Name draft epSOS Data Set
hl7:prefix
0 … * R HP Prefix R1.10.3
 
target
epsos-dataelement-273 draft Prefix draft epSOS Data Set
hl7:suffix
0 … * R HP Suffix R1.10.4
 
target
epsos-dataelement-274 draft Suffix draft epSOS Data Set
hl7:assignedAuthoringDevice
0 … 1 C Contains 2.16.840.1.113883.3.1937.777.11.10.129 eHDSI Device (DYNAMIC) (epSdotsCER)
hl7:representedOrganization
1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) R1.10.9
 
target
epsos-dataelement-23 draft Author Healthcare Facility draft epSOS Data Set
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.104 eHDSI Custodian (DYNAMIC)
hl7:custodian
1 … 1 M This elements r epresents the organization that is in charge of maintaining the document.
(epSdotsCER)
@typeCode
cs 0 … 1 F CST
hl7:assignedCustodian
1 … 1 R (epSdotsCER)
@classCode
cs 0 … 1 F ASSIGNED
hl7:representedCustodianOrganization
1 … 1 R (epSdotsCER)
@classCode
cs 0 … 1 F ORG
@determinerCode
cs 0 … 1 F INSTANCE
hl7:id
II.EPSOS 1 … 1 R Custodian organization Id (epSdotsCER)
@nullFlavor
cs 0 … 1  
hl7:name
ON 1 … 1 R Custodian organization Name
(epSdotsCER)
@nullFlavor
cs 0 … 1  
hl7:telecom
TEL 1 … 1 R

Custodian organization Telecom

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.

(epSdotsCER)
@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)
@nullFlavor
cs 0 … 1 F NI
  Example <telecom use="WP" value="tel:+45 20 7025 6161"/>
hl7:addr
AD.EPSOS 1 … 1 R Custodian Organization Address (epSdotsCER)
  Schematron assert role red error  
  test @nullFlavor or hl7:*  
  Message If addr is not nullflavored at least one sub element has to be provided  
hl7:streetAddressLine
0 … * R Street/Number of Street
(epSdotsCER)
hl7:city
0 … 1 R City
(epSdotsCER)
hl7:postalCode
0 … 1 R Postal Code
(epSdotsCER)
hl7:state
0 … 1 R State or Province
(epSdotsCER)
hl7:country
1 … 1 R Country. When used addr.country it is always bound to the epSOSCountry value set
(epSdotsCER)
  Constraint The content of this element SHALL be selected from ValueSet epSOSCountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4

Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.109 eHDSI LegalAuthenticator (DYNAMIC)
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
hl7:time
TS.EPSOS.TZ 1 … 1 M Time of signing the document R1.11.9
hl7:signatureCode
CS 1 … 1 R Signature code R1.11.9
@code
CONF 0 … 1 F S
hl7:assignedEntity
1 … 1 M The regional authority that is responsible for the legal authentication of the CDA document R1.11.9
hl7:id
1 … 1 M Unique identification of legal authenticator R1.11.9
hl7:addr
AD.EPSOS 1 … * R IHE PCC
hl7:telecom
TEL 1 … * R

Legal Authenticator's Telecom

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.

R1.10.9.4 / R1.10.9.4.1 / R1.10.9.4.2
@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)
@nullFlavor
cs 0 … 1 F NI
  Example <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
hl7:assignedPerson
1 … 1 R IHE PCC
@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 … * M HP Family Name/Surname R1.10.1
hl7:given
1 … * M 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 M Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) R1.11.9
Choice 0 … *
The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policy holders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple particpants (e.g., emergency contact and next-of-kin)
Elements to choose from:
Included from 2.16.840.1.113883.3.1937.777.11.10.101 eHDSI Contact/Preferred HP/Legal Organization (DYNAMIC)
hl7:participant
R Contact person / Preferred Health Professional to contact about patient. (epSdotsCER)
where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4']
 
target
epsos-dataelement-31 draft Legal Organization to contact draft epSOS Data Set
epsos-dataelement-34 draft Contact Person/legal guardian draft epSOS Data Set
epsos-dataelement-30 draft Preferred HP to contact draft epSOS Data Set
@typeCode
cs 1 … 1 F IND R1.8.5
  Participant typeCode
hl7:templateId
1 … 1 M (epSdotsCER)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:functionCode
0 … 1 C (epSdotsCER)
  Constraint The element is mandatory when this participant is the preferred HP
@code
CONF 0 … 1 F PCP
@codeSystem
0 … 1 F 2.16.840.1.113883.5.88 (HL7 ParticipationFunction)
hl7:time
IVL_TS.EPSOS.TZ.OPT 0 … 1 R The (epSdotsCER)
hl7:associatedEntity
R The element identifies the type of contact. The classCode attribute shall be present, and contains a value from the eHDSIRoleClass value set when used for the patient contacts; ‘PRS’ when used for “Preferred HP / Legal Organization”. (epSdotsCER)
@classCode
cs 1 … 1 R R1.8.6
  CONF
The value of @classCode shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.39 eHDSIRoleClass (DYNAMIC)
or
@classCode shall be "PRS"
hl7:code
CV.EPSOS 0 … 1 R The relationship between the patient and the guardian or other contact should be recorded in the element. The code attribute is required and comes from the HL7 PersonalRelationshipRoleType vocabulary with codeSystem (2.16.840.1.113883.5.111). The codeSystem attribute is required. The relationship between the patient and his preferred HP comes from the the full RoleCode (2.16.840.1.113883.5.111) codeSystem R1.8.6
 
target
epsos-dataelement-35 draft Role of that person draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.38 eHDSIPersonalRelationship (DYNAMIC)
hl7:addr
AD.EPSOS 1 … 1 R Patient Contact's / Preferred HP's Address R1.8.3 / R1.9.2
@nullFlavor
cs 0 … 1 F NI
  Schematron assert role red error  
  test @nullFlavor or hl7:*  
  Message If addr is not nullflavored at least one sub element has to be provided  
hl7:streetAddressLine
0 … * R Patient Contact's Street/Number of Street / Preferred HP's Street/Number of Street R1.8.3.1 / R1.8.3.2 / R1.9.2.1 / R1.9.2.2
hl7:city
0 … 1 R Patient Contact's City / Preferred HP's City R1.8.2.3 / R1.9.2.3
hl7:postalCode
0 … 1 R Patient Contact's Postal Code / Preferred HP's Postal Code R1.8.2.4 / R1.9.2.4
hl7:state
0 … 1 R Patient Contact's State or Province / Preferred HP's State or Province R1.8.2.5 / R1.9.2.5
hl7:country
0 … 1 R Patient Contact's Country / Preferred HP's Country. When used addr.country it is always bound to the epSOSCountry value set R1.8.2.6 / R1.9.2.6
hl7:telecom
TEL 1 … * R Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail element is required. If there is no information, the nullFlavor attribute shall have a value of 'UNK' 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 R1.8.4.1 / R1.8.4.2 / R1.9.3.1 / R1.9.3.2
 
target
epsos-dataelement-40 draft Email draft epSOS Data Set
epsos-dataelement-50 draft Email draft epSOS Data Set
epsos-dataelement-43 draft Email draft epSOS Data Set
epsos-dataelement-41 draft Telephone No draft epSOS Data Set
epsos-dataelement-39 draft Telephone No draft epSOS Data Set
epsos-dataelement-49 draft Telephone No draft epSOS Data Set
@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)
@nullFlavor
cs 0 … 1 F NI
  Example <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
Choice 1 … 1 Elements to choose from:
  • hl7:associatedPerson
  • hl7:scopingOrganization
hl7:associatedPerson
R (epSdotsCER)
hl7:name
PN 1 … 1 R Patient Contact's Name / Preferred HP's Name IHE PCC / R1.9.1
 
target
epsos-dataelement-46 draft Full Name draft epSOS Data Set
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
Choice 2 … * Elements to choose from:
  • hl7:family
  • hl7:given
hl7:family
1 … * R Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname R1.8.1 / R1.9.1.1
 
target
epsos-dataelement-38 draft Family Name/Surname draft epSOS Data Set
epsos-dataelement-48 draft Family Name/Surname draft epSOS Data Set
hl7:given
1 … * R Patient Contact's Given Name / Preferred HP's Given Name R1.8.2 / R1.9.1.2
 
target
epsos-dataelement-37 draft Given Name draft epSOS Data Set
epsos-dataelement-47 draft Given Name draft epSOS Data Set
hl7:scopingOrganization
R (epSdotsCER)
hl7:name
ON 1 … 1 R Organization's Name R1.9.1
 
target
epsos-dataelement-33 draft Organization Name draft epSOS Data Set
Included from 2.16.840.1.113883.3.1937.777.11.10.112 eHDSI Participant (DYNAMIC)
hl7:participant
0 … * R (epSdotsCER)
@typeCode
cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)
@contextControlCode
1 … 1 F OP
hl7:functionCode
CE.EPSOS 0 … 1 R (epSdotsCER)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
IVL_TS 0 … 1 R (epSdotsCER)
hl7:associatedEntity
1 … 1 R (epSdotsCER)
@classCode
cs 1 … 1 R
  CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)
hl7:id
II.EPSOS 0 … * R (epSdotsCER)
hl7:code
CE.EPSOS 0 … 1 R (epSdotsCER)
@codeSystem
CONF 0 … 1 F 2.16.840.1.113883.5.111 (RoleCode)
hl7:addr
AD 0 … * R (epSdotsCER)
hl7:telecom
TEL 0 … * R (epSdotsCER)
hl7:associatedPerson
0 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.113 eHDSI Person (DYNAMIC) (epSdotsCER)
hl7:scopingOrganization
0 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) (epSdotsCER)
Included 1 … 1 R from 2.16.840.1.113883.3.1937.777.11.10.106 eHDSI DocumentationOf PCPR (DYNAMIC)
hl7:documentationOf
1 … 1 R (epSdotsCER)
@typeCode
cs 1 … 1 F DOC
hl7:serviceEvent
1 … 1 R (epSdotsCER)
@classCode
cs 1 … 1 F PCPR
@moodCode
cs 1 … 1 F EVN
hl7:id
II.EPSOS 0 … * R (epSdotsCER)
hl7:code
CE.EPSOS 0 … 1 R (epSdotsCER)
Choice 1 … 1 Elements to choose from:
  • hl7:effectiveTime[hl7:high]
  • hl7:effectiveTime[@nullFlavor or @value]
hl7:effectiveTime
IVL_TS  … 1 R (epSdotsCER)
where [hl7:high]
hl7:low
TS 0 … 1 R (epSdotsCER)
hl7:high
TS 1 … 1 R (epSdotsCER)
hl7:effectiveTime
TS  … 1 R (epSdotsCER)
where [@nullFlavor or @value]
hl7:performer
0 … * R represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors (epSdotsCER)
@typeCode
cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)
hl7:functionCode
CE.EPSOS 1 … 1 R (epSdotsCER)
  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
IVL_TS 0 … 1 R (epSdotsCER)
hl7:assignedEntity
1 … 1 M (epSdotsCER)
hl7:id
II.EPSOS 1 … * R HP ID number (epSdotsCER)
hl7:code
CE.EPSOS 0 … 1 R HP Specialty (epSdotsCER)
hl7:addr
AD.EPSOS 1 … * R IHE PCC
hl7:telecom
TEL 1 … * R

Performer's Telecom

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.

R1.10.8
@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)
@nullFlavor
cs 0 … 1 F NI
  Example <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
hl7:assignedPerson
0 … 1 Contains 2.16.840.1.113883.3.1937.777.11.10.113 eHDSI Person (DYNAMIC) (epSdotsCER)
hl7:representedOrganization
0 … 1 Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) (epSdotsCER)
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.107 eHDSI RelatedDocument (DYNAMIC)
hl7:relatedDocument
1 … 1 M (epSdotsCER)
@typeCode
cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument
1 … 1 R (epSdotsCER)
@classCode
cs 0 … 1 F DOCCLIN
@moodCode
cs 0 … 1 F EVN
hl7:id
II.EPSOS 1 … * R Identifier of the national version of the document.
(epSdotsCER)
hl7:code
CD.EPSOS 0 … 1 R (epSdotsCER)
@codeSystem
CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:text
ED 0 … 1 R (epSdotsCER)
hl7:setId
II.EPSOS 0 … 1 R (epSdotsCER)
hl7:versionNumber
INT 0 … 1 R (epSdotsCER)
hl7:component
1 … 1 M (epSdotsCER)
hl7:structuredBody
1 … 1 M

the component/structuredBody SHALL contain at least one [1..*] component/section.
the component/structuredBody SHALL conform to the section constraints below

  • MAY contain zero or one [0..1] Medication Summary Section (templateId: 1.3.6.1.4.1.12559.11.10.1.3.1.2.3).
  • MAY contain zero or one [0..1] Allergies and Other Adverse Reactions Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.13).
  • MAY contain zero or one [0..1] Coded List of Surgeries Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.12).
  • MAY contain zero or one [0..1] Active Problems Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.6).
  • MAY contain zero or one [0..1] Medical Devices Coded Section (templateId: 1.3.6.1.4.1.12559.11.10.1.3.1.2.4).
  • MAY contain zero or one [0..1] Immunizations Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.23).
  • MAY contain zero or one [0..1] Health Maintenance Care Plan Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.9.50).
  • MAY contain zero or one [0..1] History of Past Illness Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.8).
  • MAY contain zero or one [0..1] Coded Social History Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.16.1).
  • MAY contain zero or one [0..1] Pregnancy History Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4).
  • MAY contain zero or one [0..1] Coded Vital Signs Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2).
  • MAY contain zero or one [0..1] Coded Results Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.28)
(epSdotsCER)
@classCode
cs 0 … 1 F DOCBODY
Choice 1 … * Elements to choose from:
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 eHDSI Medication Summary (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.13 eHDSI Allergies and Other Adverse Reactions (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.12 eHDSI List of Surgeries (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 eHDSI Active Problems (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 eHDSI Medical Devices (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.23 eHDSI Immunizations (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 eHDSI Health Maintenance Care Plan (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.8 eHDSI History Of Past Illness (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 eHDSI Social History (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 eHDSI Pregnancy History (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 eHDSI Vital Signs (DYNAMIC) (epSdotsCER)
hl7:component
0 … 1 R Contains
alert Error: Cannot find template "1.3.6.1.4.1.19376.1.5.3.1.3.28" (DYNAMIC)
(epSdotsCER)