The implementers must be familiar with the context of the project, as it shall not
be repeated in this document. The implementers must also be familiar with the content
of the following documents:
CDA Release 2.0 Normative Web Edition, May, 2005
HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), HL7,
April 1, 2007.
Integrating the Healthcare Enterprise, Patient Care Coordination Technical Framework,
Volume 1 and Volume 2- Revision 5, IHE International, August 10, 2009.
Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules-
Trial Implementation Supplement, August 10, 2009.
HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, HL7,
July 16, 2008.
The Medication Related Overview (MRO) is a document for informational purposes only
that supports all possible information that might be needed in the process of prescribing,
dispensing (and possibly even administering) medication to the patient in a foreign
country.
The absolute minimum set of medical information in the MRO consists of all the coded
prescriptions and medication dispenses available in country A. Other useful information
for the medication process, such as allergies and intolerances, are in the extended
data set of the MRO.
Context
Pathname /
Classification
CDA Document Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 17 templates
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.
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]*))*.
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.
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.
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.
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
<guardianclassCode="GUARD"> <templateIdroot="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><telecomvalue="tel:+452070256161"/><telecomvalue="mailto:jsmith@myprovider.co.uk"/><guardianPerson> <name> <given>John</given><family>Español Smith</family></name></guardianPerson></guardian>
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
R1.7.3.2
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 eHDSICountry
value set
R1.7.3.6
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
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.
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".
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.
Identification of the Healthcare Practitioner that is the author of this document
or identification of an authoring device which generated this document.
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.
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.
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.
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.
The participant element identifies other supporting participants, including parents,
relatives, caregivers, insurance policy holders, guarantors, and other participants
related in some way to the patient. A supporting person or organization is an individual
or an organization with a relationship to the patient. A supporting person who is
playing multiple roles would be recorded in multiple particpants (e.g., emergency
contact and next-of-kin)
Elements to choose from:
hl7:participant[hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4'] included from
template 2.16.840.1.113883.3.1937.777.11.10.101eHDSI Contact/Preferred HP/Legal Organization (DYNAMIC)
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”.
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
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
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
(epSMRO)
@typeCode
cs
1 … 1
R
CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601x_ServiceEventPerformer (DYNAMIC)
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.