Back To Index  <<  Back To Templates

active Template  epSOS-Patient Summary

Id 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 Effective Date 2013‑12‑20
Other versions this id:
  • epSOS-PS as of 2018‑11‑14 10:53:50
Status active Active Version Label
Name epSOS-PS Display Name epSOS-Patient Summary
Description

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 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 Medication Summary Section 1.3.6.1.4.1.12559.11.10.1.3.1.2.3

The Allergies and Other Adverse Reactions Section 1.3.6.1.4.1.19376.1.5.3.1.3.13

The Coded List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.12

The Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6

The Medical Devices Coded 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 5 concepts
Id Name Data Set
epsos-dataelement-16 draft Clinical Data draft epSOS Data Set
epsos-dataelement-298 draft Language draft epSOS Data Set
epsos-dataelement-65 draft Date Created draft epSOS Data Set
epsos-dataelement-297 draft Confidentiality draft epSOS Data Set
epsos-dataelement-296 draft Type draft epSOS Data Set
Used by / Uses
Used by 0 transactions and 0 templates, Uses 22 templates
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.110 Include active epSOS CDA Id DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.108 Include active epSOS CDA setId DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.100 Include active epSOS CDA recordTarget DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.102 Include active epSOS CDA author DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.104 Include active epSOS CDA custodian DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.109 Include active epSOS CDA legalAuthenticator DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.101 Include active epSOS CDA Contact/Preferred HP/Legal Organization DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.106 Include active epSOS CDA documentationOf PCPR DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.107 Include active epSOS CDA relatedDocument DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 Containment active Section Medication Summary DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.13 Containment active Section Allergies and Other Adverse Reactions DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.23 Containment active Section Immunizations DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.8 Containment active Section History of Past Illness DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.12 Containment active Section Coded List of Surgeries DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment active Section Active Problems DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.4 Containment active Section Medical Devices Coded DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.9.50 Containment active Section Health Maintenance Care Plan DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.17 Containment active Section Functional Status DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.16.1 Containment active Section Coded Social History DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Containment active Section Pregnancy History DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Containment active Section Coded Vital Signs DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Containment active Section Coded Results 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
notice There are open issues with this item:
Item DT Card Conf Description Label
hl7:ClinicalDocument
R CDA header (epSdots-PS)
hl7:realmCode
CS 0 … 1 R (epSdots-PS)
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.
(epSdots-PS)
@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 Patient Summary document (epSdots-PS)
@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 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 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 Patient Summary Document" R1.11.6
 
target
epsos-dataelement-296 draft Type draft epSOS Data Set
@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
epsos-dataelement-65 draft Date Created draft epSOS 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
 
target
epsos-dataelement-297 draft Confidentiality draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.31 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
 
target
epsos-dataelement-298 draft Language draft epSOS Data Set
  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.

(epSdots-PS)
hl7:versionNumber
0 … 1 R (epSdots-PS)
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 (epSdots-PS)
 
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 (epSdots-PS)
 
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
  Schematron assert role red error  
  test count(concat(text(), '1.0.3166.1') = doc('include/voc-1.3.6.1.4.1.12559.11.10.1.3.1.42.4-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem)) = 1  
  Message The value of the addr.country has to be bound to the epSOSCountry value set  
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 epSOSTelecomAddress (DYNAMIC)
@nullFlavor
cs 0 … 1 F NI
hl7:patient
1 … 1 M (epSdots-PS)
 
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 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 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 (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
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
  Schematron assert role red error  
  test count(concat(text(), '1.0.3166.1') = doc('include/voc-1.3.6.1.4.1.12559.11.10.1.3.1.42.4-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem)) = 1  
  Message The value of the addr.country has to be bound to the epSOSCountry value set  
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 epSOSTelecomAddress (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". (epSdots-PS)
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 epSOSLanguage (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 epSOS CDA author (DYNAMIC)
hl7:author
1 … * R (epSdots-PS)
 
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 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. (epSdots-PS)
hl7:assignedAuthor
1 … 1 R (epSdots-PS)
@classCode
cs 0 … 1 F ASSIGNED
  Schematron assert role red error  
  test @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice  
  Message At least an assignedPerson or an assignedAuthoringDevice has to be provided, otherwise a nullFlavor shall be present.  
hl7:id
II.EPSOS 1 … * R Identification of the Healthcare Practitioner that is the author of this document. R1.10.5
 
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 epSOSTelecomAddress (DYNAMIC)
Choice 0 … 1 Elements to choose from:
hl7:assignedPerson
R (epSdots-PS)
@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
R Contains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC) (epSdots-PS)
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 draft Author Healthcare Facility draft epSOS Data Set
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 (epSdots-PS)
@typeCode
0 … 1 F CST
hl7:assignedCustodian
1 … 1 R (epSdots-PS)
@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
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 epSOSTelecomAddress (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 epSOS CDA Organization (DYNAMIC) R1.11.9
treeblank treeblank treeblank where [not(@nullFlavor)]
Included 1 … * R from 2.16.840.1.113883.3.1937.777.11.10.101 epSOS CDA Contact/Preferred HP/Legal Organization (DYNAMIC)
hl7:participant
1 … * R Contact person / Preferred Health Professional to contact about patient. (epSdots-PS)
treeblank 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 (epSdots-PS)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:functionCode
0 … 1 C (epSdots-PS)
  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 (epSdots-PS)
hl7:associatedEntity
R The element identifies the type of contact. The classCode attribute shall be present, and contains a value from the epSOSRoleClass value set when used for the patient contacts; ‘PRS’ when used for “Preferred HP / Legal Organization”. (epSdots-PS)
@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 epSOSRoleClass (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 epSOSPersonalRelationship (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 epSOSTelecomAddress (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 (epSdots-PS)
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 (epSdots-PS)
hl7:name
ON 1 … 1 R Organization's Name R1.9.1
 
target
epsos-dataelement-33 draft Organization Name draft epSOS Data Set
Included 1 … 1 R from 2.16.840.1.113883.3.1937.777.11.10.106 epSOS CDA documentationOf PCPR (DYNAMIC)
hl7:documentationOf
1 … 1 R (epSdots-PS)
@typeCode
cs 1 … 1 F DOC
hl7:serviceEvent
1 … 1 R (epSdots-PS)
@classCode
cs 1 … 1 F PCPR
@moodCode
cs 1 … 1 F EVN
hl7:id
II.EPSOS 0 … * R (epSdots-PS)
hl7:code
CE.EPSOS 0 … 1 R (epSdots-PS)
Choice 1 … 1 Elements to choose from:
  • hl7:effectiveTime[hl7:high]
  • hl7:effectiveTime[@nullFlavor or @value]
hl7:effectiveTime
IVL_TS  … 1 R (epSdots-PS)
treeblank treeblank treeblank treeblank where [hl7:high]
hl7:low
TS 0 … 1 R (epSdots-PS)
hl7:high
TS 1 … 1 R (epSdots-PS)
hl7:effectiveTime
TS  … 1 R (epSdots-PS)
treeblank treeblank treeblank treeblank 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 (epSdots-PS)
@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 (epSdots-PS)
  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
IVL_TS 0 … 1 R (epSdots-PS)
hl7:assignedEntity
1 … 1 M (epSdots-PS)
hl7:id
II.EPSOS 1 … * R HP ID number (epSdots-PS)
hl7:code
CE.EPSOS 0 … 1 R HP Specialty (epSdots-PS)
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 epSOSTelecomAddress (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 CDA Person (DYNAMIC) (epSdots-PS)
hl7:representedOrganization
0 … 1 Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) (epSdots-PS)
Included 1 … * M from 2.16.840.1.113883.3.1937.777.11.10.107 epSOS CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
1 … * M (epSdots-PS)
@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 (epSdots-PS)
@classCode
0 … 1 F DOCCLIN
@moodCode
0 … 1 F EVN
hl7:id
II.EPSOS 1 … * R (epSdots-PS)
hl7:code
CD.EPSOS 0 … 1 R (epSdots-PS)
@codeSystem
CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:text
ED 0 … 1 R (epSdots-PS)
hl7:setId
II.EPSOS 0 … 1 R (epSdots-PS)
hl7:versionNumber
INT 0 … 1 R (epSdots-PS)
hl7:component
1 … 1 M (epSdots-PS)
hl7:structuredBody
1 … 1 M (epSdots-PS)
 
target
epsos-dataelement-16 draft Clinical Data draft epSOS Data Set
@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 Section Medication Summary (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.12559.11.10.1.3.1.2.3'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.8']]]
hl7:component
1 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.13 Section Allergies and Other Adverse Reactions (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.1.2'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.13']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.23 Section Immunizations (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.23'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.6']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.8 Section History of Past Illness (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.8']]]
hl7:component
1 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.12 Section Coded List of Surgeries (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.12'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.11']]]
hl7:component
1 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 Section Active Problems (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.6'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.11']]]
hl7:component
1 … 1 R Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 Section Medical Devices Coded (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.12559.11.10.1.3.1.2.4'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.7'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 Section Health Maintenance Care Plan (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.1.10'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.31'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.9.50']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.17 Section Functional Status (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.17'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.5']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 Section Coded Social History (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.16.1'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.16'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.15']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Section Pregnancy History (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Section Coded Vital Signs (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.25']]]
hl7:component
0 … 1 Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Section Coded Results (DYNAMIC) (epSdots-PS)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '1.3.6.1.4.1.12559.11.10.1.3.1.2.5']]]