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active Template  eHDSI Patient Summary

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 Effective Date 2022‑09‑12 13:44:19
Other versions this id:
Status active Active Version Label
Name eHDSIPatientSummary Display Name eHDSI Patient Summary
Description

eHDSI Patient Summary 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 10, IHE International, November 4, 2014.
  • Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules- Trial Implementation Supplement, December 3, 2014.
  • HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, HL7, July 16, 2008.

It must also be noted that although the guidelines are based on the above documents, they contain specific developments particular to the project epSOS. This document can be used as a standalone to develop the syntax of the epSOS documents; however in order to achieve the full functionality of the epSOS Semantic Services, they are to be used within the context of the deliverable 3.9.1.

Prescribed and dispensed medications, including a specification of the Medication Summary section used in the Patient Summary document, have described in the previous chapter. The following sub-paragraphs specify how other sections that may be present in a Patient Summary are implemented.

According to requirements described in the Body Data Elements, the following sections - at least - shall be present in a Patient Summary document:

  • The eHDSI Medication Summary Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.3
  • The eHDSI Allergies and Other Adverse Reactions Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.12
  • The eHDSI List of Surgeries Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.11
  • The eHDSI Active Problems Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.9
  • The eHDSI Medical Devices Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.4

Appropriated codes and/or nullFlavor values will be used in these sections to express for example that coded information is not available, either that an entry is not applicable or that information is not known, ….. See the related paragraph for further details.

Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 1 concept
Id Name Data Set
ehdsi-dataelement-121 draft Date Created draft eHDSI Data Set
Used by / Uses
Used by 0 transactions and 0 templates, Uses 23 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
2.16.840.1.113883.3.1937.777.11.10.106 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
1.3.6.1.4.1.12559.11.10.1.3.1.2.12 Containment active eHDSI Allergies and Other Adverse Reactions DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.15 Containment active eHDSI Immunizations DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.10 Containment active eHDSI History Of Past Illness DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.11 Containment active eHDSI List of Surgeries DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.9 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
1.3.6.1.4.1.12559.11.10.1.3.1.2.8 Containment active eHDSI Health Maintenance Care Plan DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.14 Containment active eHDSI Functional Status DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.13 Containment active eHDSI Social History DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.7 Containment active eHDSI Pregnancy History DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.6 Containment active eHDSI Vital Signs DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Containment active eHDSI Coded Results DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.16 Containment active eHDSI Advance Directives Section DYNAMIC
Relationship Version: template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 eHDSI Patient Summary (2020‑09‑02 10:19:44)
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
draft Patient Summary (PS) draft Request PS/Return PS draft arrowleft Return PS of country A
Item DT Card Conf Description Label
hl7:ClinicalDocument
R CDA header (eHDdotsary)
  Schematron assert role red error  
  test not(@xsi:schemaLocation)  
  Message While the XML Schema Language allows a schema location to be associated with an XML document by including a schemaLocation attribute associated with the http://www.w3.org/2001/XMLSchema-instance namespace, this is explicitly PROHIBITED by [ITS§1.4], and thus by the CDA standard.  
hl7:realmCode
CS 0 … 1 R This attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question. This element should not be used for identifying the originating country.
(eHDdotsary)
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.

(eHDdotsary)
@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 eHDSI Patient Summary (eHDdotsary)
@root
uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.1.3
  Example <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.3"/>
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

Unique identifier of this instance of the clinical document.

Following attributes can be used to uniquely identify the instance:

  • @root: A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier. Required if @nullFlavor is not present.
  • @extension: An optional character string as a unique identifier within the scope of the identifier root.

The @root attribute must be a UID. The allowable formats and values and procedures of this data type are strictly controlled by HL7. At this time, user-assigned identifiers may be certain character representations of ISO Object Identifiers (OID) and DCE Universally Unique Identifiers (UUID).
  • UUIDs SHALL be represented in the form XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX, where each X is a character from the set [0-9a-zA-Z].
  • 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](\.(0|[1-9][0-9]*))*.
R1.11.3
  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 "eHDSI Patient Summary Document" R1.11.6
@displayName
1 … 1 R
@code
CONF 1 … 1 F 60591-5
@codeSystem
1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient summary Document"/>
hl7:title
ST 1 … 1 M ClinicalDocument/title is used for display purposes. R1.11.7
  Example <title>epSOS Patient Summary Maria Bakker November 13, 2011</title>
hl7:effectiveTime
TS.EPSOS.TZ 1 … 1 M

Relevant times for the Patient Summary

By definition, a Patient Summary document describes the Patient Summary at the time of creation of the document, represented by the /ClinicalDocument/effectiveTime XML Element.

The time when this instance of the document has been authored may be instead recorded by the /ClinicalDocument/author/time element. (e.g. when a “spider” has collected information for generating this instance of the document; or a practitioner updated its local summary document).

Finally, the latest summary update, intended as the last date documented by this summary (e.g. the last update occurred to the PHR from which the PS data has been extracted) can be represented by the /ClinicalDocument/documentationOf/serviceEvent/effectiveTime/high XML Element (see section 2.1, CONF-2, CONF-3 and CONF-4 of the CCD specification).

R1.11.1
 
target
ehdsi-dataelement-121 draft Date Created draft eHDSI Data Set
  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.
  • The CC portion SHALL be an ISO-3166 country code in upper case.
    R.11.10
      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 language code and CC is ISO-3166 country code)  
    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.

    (eHDdotsary)
    hl7:versionNumber
    0 … 1 R (eHDdotsary)
    Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.100 eHDSI RecordTarget (DYNAMIC)
    hl7:recordTarget
    1 … 1 M (eHDdotsary)
    @typeCode
    cs 0 … 1 F RCT
    @contextControlCode
    cs 0 … 1 F OP
    hl7:patientRole
    1 … 1 M (eHDdotsary)
    @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
    ehdsi-dataelement-250 draft Regional/National Health Identifier draft eHDSI Data Set
    ehdsi-dataelement-356 draft Regional/National Health ID (Country of Affiliation) draft eHDSI Data Set
    ehdsi-dataelement-170 draft National Healthcare Patient identifier (Country of Affiliation) draft eHDSI Data Set
    ehdsi-dataelement-313 draft Social/Insurance Number draft eHDSI Data Set
    ehdsi-dataelement-239 draft Social/Insurance Number draft eHDSI Data Set
    ehdsi-dataelement-353 draft Insurance Number draft eHDSI Data Set
    ehdsi-dataelement-316 draft Regional/National Health Identifier draft eHDSI Data Set
    ehdsi-dataelement-167 draft Insurance Number draft eHDSI 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
    @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
    ehdsi-dataelement-342 draft Street draft eHDSI Data Set
    ehdsi-dataelement-157 draft Street draft eHDSI Data Set
    ehdsi-dataelement-156 draft Number of Street draft eHDSI Data Set
    ehdsi-dataelement-341 draft Number of Street draft eHDSI Data Set
    hl7:city
    0 … 1 R Patient's City R1.5.3
     
    target
    ehdsi-dataelement-155 draft City draft eHDSI Data Set
    ehdsi-dataelement-340 draft City draft eHDSI Data Set
    hl7:postalCode
    0 … 1 R Patient's Postal Code R1.5.4
     
    target
    ehdsi-dataelement-154 draft Postal Code draft eHDSI Data Set
    ehdsi-dataelement-339 draft Postal Code draft eHDSI Data Set
    hl7:state
    0 … 1 R Patient's State or Province R1.5.5
     
    target
    ehdsi-dataelement-153 draft State or Province draft eHDSI Data Set
    ehdsi-dataelement-338 draft State or Province draft eHDSI Data Set
    hl7:country
    0 … 1 R Patient's Country. When used addr.country it is always bound to the eHDSICountry value set R1.5.6
     
    target
    ehdsi-dataelement-152 draft Country draft eHDSI Data Set
    ehdsi-dataelement-337 draft Country draft eHDSI Data Set
      Constraint The content of this element SHALL be selected from ValueSet eHDSICountry 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
    ehdsi-dataelement-150 draft Telephone No draft eHDSI Data Set
    ehdsi-dataelement-148 draft E-mail draft eHDSI 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 (eHDdotsary)
    @classCode
    cs 0 … 1 F PSN
    @determinerCode
    cs 0 … 1 F INSTANCE
    hl7:name
    PN 1 … * M Patient Name R1.1
    hl7:family
    1 … * M Patient's Family Name/Surname R1.1.1
     
    target
    ehdsi-dataelement-246 draft Family Name/Surname draft eHDSI Data Set
    ehdsi-dataelement-309 draft Family Name/Surname draft eHDSI Data Set
    ehdsi-dataelement-163 draft Family Name/Surname draft eHDSI Data Set
    ehdsi-dataelement-349 draft Family Name/Surname draft eHDSI Data Set
    hl7:prefix
    0 … * R Patient's Prefix R1.1.2
      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
    ehdsi-dataelement-164 draft Given Name draft eHDSI Data Set
    ehdsi-dataelement-247 draft Given Name draft eHDSI Data Set
    ehdsi-dataelement-310 draft Given Name draft eHDSI Data Set
    ehdsi-dataelement-350 draft Given Name draft eHDSI Data Set
    hl7:administrativeGenderCode
    CE.EPSOS 1 … 1 R Patient's Gender R1.2
     
    target
    ehdsi-dataelement-244 draft Gender draft eHDSI Data Set
    ehdsi-dataelement-159 draft Gender Code draft eHDSI Data Set
    ehdsi-dataelement-307 draft Gender draft eHDSI Data Set
    ehdsi-dataelement-344 draft Gender Code draft eHDSI 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
    ehdsi-dataelement-161 draft Date of Birth draft eHDSI Data Set
    ehdsi-dataelement-346 draft Date of Birth draft eHDSI Data Set
    ehdsi-dataelement-242 draft Date of Birth draft eHDSI 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 eHDSICountry value set R1.7dots.3.6
      Constraint The content of this element SHALL be selected from ValueSet eHDSICountry 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
    @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
    hl7:name
    PN 1 … * R Patient Guardian's Name IHE PCC
    Choice 2 … * Elements to choose from:
    • hl7:family
    • hl7:given
    hl7:family
    1 … * R Patient Guardian's Family Name/Surname R1.7.A.1
    hl7:given
    1 … * R Patient Guardian's Given Name R1.7.A.2
    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". (eHDdotsary)
    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 eHDSILanguage.
    • The CC portion SHALL be an ISO-3166 country code in upper case derived by the value Set eHDSICountry.
    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 eHDSILanguage and CC is ISO-3166 eHDSICountry  
    Included 1 … * M from 2.16.840.1.113883.3.1937.777.11.10.102 eHDSI Author (DYNAMIC)
    hl7:author
    1 … * M (eHDdotsary)
     
    target
    ehdsi-dataelement-125 draft Author and Organisation draft eHDSI Data Set
    @typeCode
    cs 0 … 1 F AUT
    @contextControlCode
    cs 0 … 1 F OP
    hl7:functionCode
    CE.EPSOS 0 … 1 R 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. (eHDdotsary)
    hl7:assignedAuthor
    1 … 1 M (eHDdotsary)
     
    target
    ehdsi-dataelement-123 draft Nature of the Patient Summary draft eHDSI Data Set
    @classCode
    cs 0 … 1 F ASSIGNED
    hl7:id
    II.EPSOS 1 … * R Identification of the Healthcare Practitioner that is the author of this document or identification of an authoring device which generated this document. R1.10.5
     
    target
    ehdsi-dataelement-303 draft HP Identifier draft eHDSI 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 Telephone or e-mail <telecom> 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.

    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 (eHDdotsary)
    @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
     
    target
    ehdsi-dataelement-299 draft Family Name/Surname draft eHDSI Data Set
    hl7:given
    1 … * M HP Given Name R1.10.2
     
    target
    ehdsi-dataelement-300 draft Given Name draft eHDSI Data Set
    hl7:prefix
    0 … * R HP Prefix R1.10.3
    hl7:suffix
    0 … * R HP Suffix R1.10.4
    hl7:assignedAuthoringDevice
    0 … 1 C Contains 2.16.840.1.113883.3.1937.777.11.10.129 eHDSI Device (DYNAMIC) (eHDdotsary)
    hl7:representedOrganization
    1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) R1.10.9
    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.
    (eHDdotsary)
    @typeCode
    cs 0 … 1 F CST
    hl7:assignedCustodian
    1 … 1 R (eHDdotsary)
    @classCode
    cs 0 … 1 F ASSIGNED
    hl7:representedCustodianOrganization
    1 … 1 R (eHDdotsary)
    @classCode
    cs 0 … 1 F ORG
    @determinerCode
    cs 0 … 1 F INSTANCE
    hl7:id
    II.EPSOS 1 … 1 R Custodian organization Id (eHDdotsary)
    @nullFlavor
    cs 0 … 1  
    hl7:name
    ON 1 … 1 R Custodian organization Name
    (eHDdotsary)
    @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.

    (eHDdotsary)
    @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 (eHDdotsary)
      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
    (eHDdotsary)
    hl7:city
    0 … 1 R City
    (eHDdotsary)
    hl7:postalCode
    0 … 1 R Postal Code
    (eHDdotsary)
    hl7:state
    0 … 1 R State or Province
    (eHDdotsary)
    hl7:country
    1 … 1 R Country. When used addr.country it is always bound to the eHDSICountry value set.
    (eHDdotsary)
      Constraint The content of this element SHALL be selected from ValueSet eHDSICountry 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
     
    target
    ehdsi-dataelement-176 draft Responsible of the ePrescription Data/Author Organization draft eHDSI Data Set
    ehdsi-dataelement-327 draft Responsible of the Original Clinical Document/Author Organization draft eHDSI Data Set
    ehdsi-dataelement-127 draft Legal Authenticator draft eHDSI Data Set
    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
    Included 1 … * R from 2.16.840.1.113883.3.1937.777.11.10.101 eHDSI Contact/Preferred HP/Legal Organization (DYNAMIC)
    hl7:participant
    1 … * R Contact person / Preferred Health Professional to contact about patient. (eHDdotsary)
    where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4']
    @typeCode
    cs 1 … 1 F IND R1.8.5
      Participant typeCode
    hl7:templateId
    1 … 1 M IHE Patient Contacts (IHE PCC)
    (eHDdotsary)
    @root
    uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
    hl7:functionCode
    0 … 1 C (eHDdotsary)
      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 (eHDdotsary)
    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”. (eHDdotsary)
    @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"
     
    target
    ehdsi-dataelement-135 draft Role of person draft eHDSI Data Set
    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
    ehdsi-dataelement-134 draft Relationship level draft eHDSI 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
     
    target
    ehdsi-dataelement-143 draft Address draft eHDSI Data Set
    @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 '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 R1.8.4.1 / R1.8.4.2 / R1.9.3.1 / R1.9.3.2
     
    target
    ehdsi-dataelement-332 draft Telephone No draft eHDSI Data Set
    ehdsi-dataelement-136 draft E-mail draft eHDSI Data Set
    ehdsi-dataelement-141 draft E-mail draft eHDSI Data Set
    ehdsi-dataelement-331 draft E-mail draft eHDSI Data Set
    ehdsi-dataelement-137 draft Telephone No draft eHDSI Data Set
    ehdsi-dataelement-142 draft Telephone No draft eHDSI 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 (eHDdotsary)
    hl7:name
    PN 1 … 1 R Patient Contact's Name / Preferred HP's Name IHE PCC / R1.9.1
      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
    ehdsi-dataelement-334 draft Family Name/Surname draft eHDSI Data Set
    ehdsi-dataelement-138 draft Family Name/Surname draft eHDSI Data Set
    ehdsi-dataelement-145 draft Family Name/Surname draft eHDSI Data Set
    hl7:given
    1 … * R Patient Contact's Given Name / Preferred HP's Given Name R1.8.2 / R1.9.1.2
     
    target
    ehdsi-dataelement-146 draft Given Name draft eHDSI Data Set
    ehdsi-dataelement-335 draft Given Name draft eHDSI Data Set
    ehdsi-dataelement-139 draft Given Name draft eHDSI Data Set
    hl7:scopingOrganization
    R (eHDdotsary)
    hl7:name
    ON 1 … 1 R Organization's Name R1.9.1
     
    target
    ehdsi-dataelement-144 draft OR Name of the Legal organization draft eHDSI Data Set
    ehdsi-dataelement-333 draft OR Name of the Legal organization draft eHDSI Data Set
    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 (eHDdotsary)
    @typeCode
    cs 1 … 1 F DOC
    hl7:serviceEvent
    1 … 1 R (eHDdotsary)
    @classCode
    cs 1 … 1 F PCPR
    @moodCode
    cs 1 … 1 F EVN
    hl7:id
    II.EPSOS 0 … * R (eHDdotsary)
    hl7:code
    CE.EPSOS 0 … 1 R (eHDdotsary)
    Choice 1 … 1 Elements to choose from:
    • hl7:effectiveTime[hl7:high]
    • hl7:effectiveTime[@nullFlavor or @value]
    hl7:effectiveTime
    IVL_TS 0 … 1 C (eHDdotsary)
    where [hl7:high]
    hl7:low
    TS 0 … 1 R (eHDdotsary)
    hl7:high
    TS 1 … 1 R (eHDdotsary)
    hl7:effectiveTime
    TS 0 … 1 C (eHDdotsary)
    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 (eHDdotsary)
    @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 (eHDdotsary)
      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 (eHDdotsary)
    hl7:assignedEntity
    1 … 1 M (eHDdotsary)
    hl7:id
    II.EPSOS 1 … * R HP ID number (eHDdotsary)
    hl7:code
    CE.EPSOS 0 … 1 R HP Specialty (eHDdotsary)
    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) (eHDdotsary)
    hl7:representedOrganization
    0 … 1 Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) (eHDdotsary)
    Included 1 … * M from 2.16.840.1.113883.3.1937.777.11.10.107 eHDSI RelatedDocument (DYNAMIC)
    hl7:relatedDocument
    1 … * M (eHDdotsary)
     
    target
    ehdsi-dataelement-321 draft Related Document draft eHDSI Data Set
    ehdsi-dataelement-131 draft Related Document draft eHDSI Data Set
    ehdsi-dataelement-174 draft Related Document draft eHDSI Data Set
    @typeCode
    cs 1 … 1 F XFRM
    hl7:parentDocument
    1 … 1 R (eHDdotsary)
    @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.
    (eHDdotsary)
    hl7:code
    CD.EPSOS 0 … 1 R (eHDdotsary)
    @codeSystem
    CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
    hl7:text
    ED 0 … 1 R (eHDdotsary)
    hl7:setId
    II.EPSOS 0 … 1 R (eHDdotsary)
    hl7:versionNumber
    INT 0 … 1 R (eHDdotsary)
    hl7:component
    1 … 1 M (eHDdotsary)
    hl7:structuredBody
    1 … 1 M (eHDdotsary)
    @classCode
    cs 0 … 1 F DOCBODY
    hl7:component
    1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 eHDSI Medication Summary (DYNAMIC) (eHDdotsary)
    hl7:component
    1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.12 eHDSI Allergies and Other Adverse Reactions (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.15 eHDSI Immunizations (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.10 eHDSI History Of Past Illness (DYNAMIC) (eHDdotsary)
    hl7:component
    1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.11 eHDSI List of Surgeries (DYNAMIC) (eHDdotsary)
    hl7:component
    1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.9 eHDSI Active Problems (DYNAMIC) (eHDdotsary)
    hl7:component
    1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 eHDSI Medical Devices (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.8 eHDSI Health Maintenance Care Plan (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.14 eHDSI Functional Status (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.13 eHDSI Social History (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.7 eHDSI Pregnancy History (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.6 eHDSI Vital Signs (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.5 eHDSI Coded Results (DYNAMIC) (eHDdotsary)
    hl7:component
    0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.16 eHDSI Advance Directives Section (DYNAMIC) (eHDdotsary)