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ref Template  epSOS CDA author

Id 2.16.840.1.113883.3.1937.777.11.10.102 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name epSOSCDAauthor Display Name epSOS CDA author
Description

A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).

For definition “The author element represents the creator of the clinical document. If the role of the actor is the entry of information from his or her own knowledge or application of skills, that actor is the author. If one actor provides information to another actor who filters, reasons, or algorithmically creates new information, then that second actor is also an author, having created information from his or her own knowledge or skills. [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March 2009].

According to this definition, not any device that generates the electronic document has to be considered as an author:

  • a spider collecting and filtering information from different repositories, according to defined rules and policies, for the scope of creating a Patient Summary is definitely a document author (and maybe the only one for this document);
  • an application that transforms a prescription record into a epSOS eP CDA may not be an author instead;
  • The NCP that modifies the concepts conveyed, should appear as one of the authors.
  • The author of the parent document is often also an author of the document generated through a transformation process (in that case also the author time should be the same).

Further to this, is therefore possible to determine the Nature of Patient Summary as follows [Excluding the NCPs as authors]:

  • if there is a person author only, there the Patient Summary is the result of a practitioner clinical act;
  • if there is a device author only, the summary was automatically generated according to well defined rules defined by the responsible organization;
  • if there are both a person and a device as authors, the summary was created via a mixed approach.

The CDA provides a mechanism to better specify who authored what within the document, allowing the specification of authorship at the whole document level, at the section level and finally at the entry level. In any case is not required to repeat this information for each level, taking advantage of the context conduction propriety. Infact “context that is specified on an outer tag holds true for all nested tags, unless overridden on a nested tag. Context specified on a tag within the CDA body always overrides context propagated from an outer tag. For instance, the specification of authorship at a document section level overrides all authorship propagated from outer tags.” (HL7 CDA R2 Standard).


/ClinicalDocument/author/assignedAuthor
/ClinicalDocument/documentationOf/serviceEvent/performer (this applies to the prescriber and the dispenser).

The template ID referenced here refers to HP information in the /ClinicalDocument/documentationOf/serviceEvent/performer structure. In this document, the same requriements apply to the person author of the document (if there is one), and to the prescrober and dispenser (see body).

When there is no HP but we have the method of assembly of data by a device, such as the “spider” method, we have the following expression; ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice.

When the data is collected from different sources & pre-existing documents that are part of a bigger system. In that case the organization responsible of that collection “signed” the PS as responsible.

ClinicalDocument/author/assignedAuthor/representedOrganization

Classification CDA Header Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 9 concepts
Id Name Data Set
epsos-dataelement-180 Author Role epSOS Data Set
epsos-dataelement-67 Author epSOS Data Set
epsos-dataelement-22 Author Identification epSOS Data Set
epsos-dataelement-19 Author Full Name epSOS Data Set
epsos-dataelement-20 Given Name epSOS Data Set
epsos-dataelement-21 Family Name/Surname epSOS Data Set
epsos-dataelement-273 Prefix epSOS Data Set
epsos-dataelement-274 Suffix epSOS Data Set
epsos-dataelement-23 Author Healthcare Facility epSOS Data Set
Used by / Uses
Used by 0 transactions and 15 templates, Uses 2 templates
Used by as Name Version
1.3.6.1.4.1.12559.11.10.1.3.1.1.2 Include draft epSOS-eDispensation 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 Include draft epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 Include draft epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 Include draft epSOS-Medication Related Overview 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.7 Include draft eHDSI-Patient Summary (PDF embedded) 2017‑03‑11 18:41:31
1.3.6.1.4.1.19376.1.5.3.1.4.2 Include draft Comment 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.12 link draft Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23 link draft Section Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5 link draft Problem 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 link draft Problem Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.6 link draft Section Active Problems 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8 link draft Section History of Past Illness 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6 link draft Allergies And Intolerances 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 link draft Allergy and Intolerance Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13 link draft Section Allergies and Other Adverse Reactions 2013‑12‑20
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.129 Containment draft CDA Device DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.111 Containment draft epSOS CDA Organization DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.102 (2005‑09‑07)
Example
Example
<author>
  <time value="20121229"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr>
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:(+39)051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
  </assignedAuthor>
</author>
notice There is an open issue with this item:
Item DT Card Conf Description Label
hl7:author
1 … * R (epS…hor)
  target
epsos-dataelement-67 Author 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 Author Role 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 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. (epS…hor)
hl7:assignedAuthor
1 … 1 R (epS…hor)
@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
  target
epsos-dataelement-22 Author Identification 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 epSOSTelecomAddress (DYNAMIC)
Choice 0 … 1 Elements to choose from:
hl7:assignedPerson
R (epS…hor)
@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 Author Full Name epSOS Data Set
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … * R HP Family Name/Surname R1.10.1
  target
epsos-dataelement-21 Family Name/Surname epSOS Data Set
hl7:given
1 … * R HP Given Name R1.10.2
  target
epsos-dataelement-20 Given Name epSOS Data Set
hl7:prefix
0 … * R HP Prefix R1.10.3
  target
epsos-dataelement-273 Prefix epSOS Data Set
hl7:suffix
0 … * R HP Suffix R1.10.4
  target
epsos-dataelement-274 Suffix epSOS Data Set
hl7:assignedAuthoringDevice
R Contains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC) (epS…hor)
hl7:representedOrganization
1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9
  target
epsos-dataelement-23 Author Healthcare Facility epSOS Data Set