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ref Template  eHDSI-ePrescription (PDF embedded)

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.6 Effective Date valid from 2017‑03‑11 22:32:59
Status draft Draft Version Label
Name eHDSI-Original-eP Display Name eHDSI-ePrescription (PDF embedded)
Description

< DESCRIPTION TO BE UPDATED >

Note for the readers
 
This template version represents the best representation of the original epSOS/EXPAND specifications in ART DECOR. However 
 
the original epSOS/EXPAND   specifications in Microsoft Word took the original IHE Templates and added constraints in written language. This actually is not best practice in electronic Template Design because the additional constraints are not assigned to the original IHE template but rather than that are text only constraints. In order to make everything computable new Template OIDs need to be assigned to the epSOS Templates in order to cover both, the original IHE Template Design and the additional constraints from epSOS in the text and represent them electronically.

Caveat: for the above mentioned reasons this version cannot be used  
for (automatic) testing/validation purposes. It shall be used however as basis for refinement (repository)

Note: there is a new version planned that covers all above and makes proper testing/validation possible 

epSOS ePrescription 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.

Context Pathname /
Classification Template type not specified
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 7 templates
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.110 Include draft epSOS CDA Id DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.108 Include draft epSOS CDA setId DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.100 Include draft epSOS CDA recordTarget DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.103 Include draft epSOS CDA author prescriber DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.104 Include draft epSOS CDA custodian DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.109 Include draft epSOS CDA legalAuthenticator DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.107 Include draft epSOS CDA relatedDocument DYNAMIC
notice There is an open issue with this item:
Item DT Card Conf Description Label
hl7:ClinicalDocument
R CDA header (eHD…-eP)
hl7:realmCode
CS 1 … 1 M (eHD…-eP)
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.
(eHD…-eP)
@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 1 … 1 M Template ID for eHDSI original ePrescription document.
(eHD…-eP)
@root
uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.1.6
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.110 epSOS CDA Id (DYNAMIC)
hl7:id
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 Identification 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 ePrescription" R1.11.6
@displayName
1 … 1 R
@code
CONF 1 … 1 F 57833-6
@codeSystem
1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/>
hl7:title
ST 1 … 1 M ClinicalDocument/title is used for display purposes. R1.11.7
  Example <title>epSOS ePrescription 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 epSOSConfidentiality (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 epSOS CDA setId (DYNAMIC)
hl7:setId
0 … 1 R

This attribute “represents an identifier that is common across all document revisions”.

In the case of the NCP transcoding /translation this is the ID that remains unchanged among all the existing transformations.

Implementers are recommended to use this attribute.

(eHD…-eP)
hl7:versionNumber
0 … 1 R (eHD…-eP)
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.100 epSOS CDA recordTarget (DYNAMIC)
hl7:recordTarget
1 … 1 M (eHD…-eP)
  target
epsos-dataelement-5 Patient Data epSOS Data Set
@typeCode
0 … 1 F RCT
@contextControlCode
0 … 1 F OP
hl7:patientRole
1 … 1 M (eHD…-eP)
  target
epsos-dataelement-26 Contact Information epSOS Data Set
@classCode
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-7 National Health Care patient ID (country of affiliation) epSOS Data Set
epsos-dataelement-234 National Health Care patient ID (country of treatment) epSOS Data Set
epsos-dataelement-235 Other Identifier epSOS Data Set
epsos-dataelement-6 Identification epSOS Data Set
hl7:addr
AD.EPSOS 1 … 1 R The patient address <addr> 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 Address epSOS Data Set
@nullFlavor
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 Street epSOS Data Set
epsos-dataelement-52 Number of Street epSOS Data Set
hl7:city
0 … 1 R Patient's City R1.5.3
  target
epsos-dataelement-55 City epSOS Data Set
hl7:postalCode
0 … 1 R Patient's Postal Code R1.5.4
  target
epsos-dataelement-53 Postal Code epSOS Data Set
hl7:state
0 … 1 R Patient's State or Province R1.5.5
  target
epsos-dataelement-56 State or Province 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 Country epSOS Data Set
hl7:telecom
TEL 1 … * R Patient’s telephone number / Patient e-mail address. The patient 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 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-300 Telecom epSOS Data Set
epsos-dataelement-28 Telephone No epSOS Data Set
epsos-dataelement-29 Email epSOS Data Set
@use
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 epSOSTelecomAddress (DYNAMIC)
@nullFlavor
0 … 1 F NI
hl7:patient
1 … 1 M (eHD…-eP)
  target
epsos-dataelement-8 Personal Information epSOS Data Set
@classCode
0 … 1 F PSN
@determinerCode
0 … 1 F INSTANCE
hl7:name
PN 1 … * R Patient Name R1.1
  target
epsos-dataelement-9 Full Name epSOS Data Set
hl7:family
1 … * M Patient's Family Name/Surname R1.1.1
  target
epsos-dataelement-13 Family Name/Surname epSOS Data Set
hl7:prefix
0 … * R Patient's Prefix R1.1.2
  target
epsos-dataelement-263 Prefix 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 Given name epSOS Data Set
hl7:administrativeGenderCode
CE.EPSOS 1 … 1 R Patient's Gender R1.2
  target
epsos-dataelement-11 Gender epSOS Data Set
@nullFlavor
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 epSOSAdministrativeGender (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 Date of Birth 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 (epSOSPersonalRelationship 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
1 … 1 F GUARD
@nullFlavor
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
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 <addr> 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
0 … 1 F NI
hl7:streetAddressLine
0 … * R Guardian's Number of Street/Guardian's Number of Street R1.7….3.2
hl7:city
0 … 1 R Guardian's City R1.7….3.3
hl7:postalCode
0 … 1 R Guardian's Postal Code R1.7….3.4
hl7:state
0 … 1 R Guardian's State or Province R1.7….3.5
hl7:country
0 … 1 R Guardian's Country. When used addr.country it is always bound to the epSOSCountry value set R1.7….3.6
hl7:telecom
TEL 1 … * R Guardian’s telephone number / Patient e-mail address. The guardian 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 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. R1.7….4.2
  target
epsos-dataelement-39 Telephone No epSOS Data Set
@use
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 epSOSTelecomAddress (DYNAMIC)
@nullFlavor
0 … 1 F NI
hl7:guardianPerson
1 … 1 R R1.7.A
  target
epsos-dataelement-34 Contact Person/legal guardian epSOS Data Set
hl7:name
PN 1 … * R Patient Guardian's Name IHE PCC
  target
epsos-dataelement-36 Full Name 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 Family Name/Surname epSOS Data Set
hl7:given
1 … * R Patient Guardian's Given Name R1.7.A.2
  target
epsos-dataelement-37 Given Name epSOS Data Set
hl7:languageCommunication
1 … * 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". (eHD…-eP)
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
  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 … * M from 2.16.840.1.113883.3.1937.777.11.10.103 epSOS CDA author prescriber (DYNAMIC)
hl7:author
1 … * M (eHD…-eP)
@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 epSOSHealthcareProfessionalRoles (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. (eHD…-eP)
hl7:assignedAuthor
1 … 1 R (eHD…-eP)
@classCode
cs 0 … 1 F ASSIGNED
  Schematron assert role red error  
  test @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice  
  Message If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for "ClinicalDocument/author/assignedAuthor/id/@NullFlavor" SHALL be "NA" "Not applicable" 2.16.840.1.113883.5.1008 NullFlavor STATIC.  
hl7:id
II.EPSOS 1 … * R HP ID number 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 epSOSTelecomAddress (DYNAMIC)
hl7:assignedPerson
1 … 1 M (eHD…-eP)
@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 epSOS CDA Organization (DYNAMIC) R1.10.9
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.104 epSOS CDA custodian (DYNAMIC)
hl7:custodian
1 … 1 M (eHD…-eP)
@typeCode
0 … 1 F CST
hl7:assignedCustodian
1 … 1 R (eHD…-eP)
@classCode
0 … 1 F ASSIGNED
hl7:representedCustodianOrganization
1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9
@classCode
0 … 1 F ORG
@determinerCode
0 … 1 F INSTANCE
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.109 epSOS CDA 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
0 … 1 R 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.EPSOS 1 … * R IHE PCC
hl7:assignedPerson
1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.113 CDA Person (DYNAMIC) 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 … * 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 M Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.11.9
treeblank treeblank treeblank where [not(@nullFlavor)]
Included 1 … 1 M from 2.16.840.1.113883.3.1937.777.11.10.107 epSOS CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
1 … 1 M (eHD…-eP)
@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 (eHD…-eP)
@classCode
0 … 1 F DOCCLIN
@moodCode
0 … 1 F EVN
hl7:id
II.EPSOS 1 … * R (eHD…-eP)
hl7:code
CD.EPSOS 0 … 1 R (eHD…-eP)
@codeSystem
CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:text
ED 0 … 1 R (eHD…-eP)
hl7:setId
II.EPSOS 0 … 1 R (eHD…-eP)
hl7:versionNumber
INT 0 … 1 R (eHD…-eP)
hl7:component
1 … 1 M (eHD…-eP)
hl7:nonXMLBody
1 … 1 M (eHD…-eP)
@classCode
cs 1 … 1 F DOCBODY
@moodCode
cs 1 … 1 F EVN
hl7:text
1 … 1 M This element is used in this template to embed the PDF representation of the original document produced in the Country of Affiliation (Country A). The reference element shall never be used for this template.
(eHD…-eP)
@mediaType
cs 1 … 1 F application/pdf
@representation
cs 1 … 1 F B64
  Constraint The encoding rules of the pdf, including the allowed pdf formats, SHALL be the same defined by the IHE XDS-SD profile
hl7:reference
NP (eHD…-eP)