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# Template epSOS-Health Care Encounter Report

Id | 1.3.6.1.4.1.12559.11.10.1.3.1.1.4 | Effective Date | 2013‑12‑20 Other versions this id: epSOS-HCER as of 2018‑11‑14 09:02:41
Status | Retired | Version Label |
Name | epSOS-HCER | Display Name | epSOS-Health Care Encounter Report
Description
epSOS Health Care Encounter Report 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 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 Healthcare Encounter Report service not only supports the patient summary extension use case, but also supports the ePrescription extension use case and the 112 emergency use case. Therefore this service description not only covers the patient summary extension, but also the ePrescription extension and the part of the 112 emergency use case where information about the emergency encounter is sent back to country A. The definition of a healthcare event can be broad. The HCER service is designed to offer a health professional in country B flexibility to record a wide range of medical information, enough to cover the most basic healthcare encounters. The service offers country A the basic contact information of the health professional in country B together with the medical information gathered during the healthcare encounter. Informing country A of a healthcare encounter in county B, of course, is done with consent of the patient.
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 21 templates
Uses | as | Name | Version
--- | --- | --- | ---
2.16.840.1.113883.3.1937.777.11.10.110 | Include | eHDSI Id | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.108 | Include | eHDSI SetId | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.100 | Include | eHDSI RecordTarget | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.102 | Include | eHDSI Author | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.104 | Include | eHDSI Custodian | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.109 | Include | eHDSI LegalAuthenticator | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.101 | Include | eHDSI Contact/Preferred HP/Legal Organization | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.112 | Include | eHDSI Participant | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.106 | Include | eHDSI DocumentationOf PCPR | DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.107 | Include | eHDSI RelatedDocument | DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.3 | Containment | eHDSI Medication Summary | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.13 | Containment | eHDSI Allergies and Other Adverse Reactions | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.12 | Containment | eHDSI List of Surgeries | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.6 | Containment | eHDSI Active Problems | DYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.4 | Containment | eHDSI Medical Devices | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.23 | Containment | eHDSI Immunizations | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.9.50 | Containment | eHDSI Health Maintenance Care Plan | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.8 | Containment | eHDSI History Of Past Illness | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.16.1 | Containment | eHDSI Social History | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 | Containment | eHDSI Pregnancy History | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 | Containment | eHDSI Vital Signs | DYNAMIC
Relationship | Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07) ref ad1bbr-
XML overview |
XML overview
Scenario | Transaction | Transaction |
--- | --- | --- | ---
Item | DT | Card | Conf | Description | Label
--- | --- | --- | --- | --- | ---
hl7:ClinicalDocument |  |  | R | CDA header |
hl7:realmCode | CS | 1 … 1 | M |  |
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. |
@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 Health Care Encounter Report |
@root | uid | 1 … 1 | F | 1.3.6.1.4.1.12559.11.10.1.3.1.1.4
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 "epSOS Health Care Encounter Report" | R1.11.6
@displayName |  | 1 … 1 | R |
@code | CONF | 1 … 1 | F | 34133-9
@codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.1 (LOINC)
| Example | <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of episode note"/>
hl7:title | ST | 1 … 1 | M | ClinicalDocument/title is used for display purposes. | R1.11.7
| Example | <title>epSOS Health Care Encounter Report 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 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 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 | 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 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. |
hl7:versionNumber |  | 0 … 1 | R |  |
Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.777.11.10.100 eHDSI RecordTarget (DYNAMIC)
hl7:recordTarget |  | 1 … 1 | M |  |
@typeCode | cs | 0 … 1 | F | RCT
@contextControlCode | cs | 0 … 1 | F | OP
hl7:patientRole |  | 1 … 1 | M |  |
@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
ehdsi-dataelement-167 | Insurance Number | eHDSI Data Set
ehdsi-dataelement-170 | National Healthcare Patient identifier (Country of Affiliation) | eHDSI Data Set
ehdsi-dataelement-239 | Social/Insurance Number | eHDSI Data Set
ehdsi-dataelement-250 | Regional/National Health Identifier | eHDSI Data Set
ehdsi-dataelement-313 | Social/Insurance Number | eHDSI Data Set
ehdsi-dataelement-316 | Regional/National Health Identifier | eHDSI Data Set
ehdsi-dataelement-353 | Insurance Number | eHDSI Data Set
ehdsi-dataelement-356 | Regional/National Health ID (Country of Affiliation) | 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
ehdsi-dataelement-156 | Number of Street | eHDSI Data Set
ehdsi-dataelement-157 | Street | eHDSI Data Set
ehdsi-dataelement-341 | Number of Street | eHDSI Data Set
ehdsi-dataelement-342 | Street | eHDSI Data Set
hl7:city |  | 0 … 1 | R | Patient's City | R1.5.3
ehdsi-dataelement-155 | City | eHDSI Data Set
ehdsi-dataelement-340 | City | eHDSI Data Set
hl7:postalCode |  | 0 … 1 | R | Patient's Postal Code | R1.5.4
ehdsi-dataelement-154 | Postal Code | eHDSI Data Set
ehdsi-dataelement-339 | Postal Code | eHDSI Data Set
hl7:state |  | 0 … 1 | R | Patient's State or Province | R1.5.5
ehdsi-dataelement-153 | State or Province | eHDSI Data Set
ehdsi-dataelement-338 | State or Province | 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
ehdsi-dataelement-152 | Country | eHDSI Data Set
ehdsi-dataelement-337 | Country | 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
ehdsi-dataelement-148 | E-mail | eHDSI Data Set
ehdsi-dataelement-150 | Telephone No | 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 |  |
@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
ehdsi-dataelement-163 | Family Name/Surname | eHDSI Data Set
ehdsi-dataelement-246 | Family Name/Surname | eHDSI Data Set
ehdsi-dataelement-309 | Family Name/Surname | eHDSI Data Set
ehdsi-dataelement-349 | Family Name/Surname | 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
ehdsi-dataelement-164 | Given Name | eHDSI Data Set
ehdsi-dataelement-247 | Given Name | eHDSI Data Set
ehdsi-dataelement-310 | Given Name | eHDSI Data Set
ehdsi-dataelement-350 | Given Name | eHDSI Data Set
hl7:administrativeGenderCode | CE.EPSOS | 1 … 1 | R | Patient's Gender | R1.2
ehdsi-dataelement-159 | Gender Code | eHDSI Data Set
ehdsi-dataelement-244 | Gender | eHDSI Data Set
ehdsi-dataelement-307 | Gender | eHDSI Data Set
ehdsi-dataelement-344 | Gender Code | 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
ehdsi-dataelement-161 | Date of Birth | eHDSI Data Set
ehdsi-dataelement-242 | Date of Birth | eHDSI Data Set
ehdsi-dataelement-346 | Date of Birth | 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. 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"/> <code code="AUNT" displayName="aunt" codeSystem="2.16.840.1.113883.5.111"/> <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:code | CE.EPSOS | 0 … 1 | R | The relationship between the patient and the guardian or other contact may be recorded in the code element | R1.7.A
| 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 | 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
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. | R1.7.4.2
@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". |
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 | 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 … * | R | from 2.16.840.1.113883.3.1937.777.11.10.102 eHDSI Author (DYNAMIC)
hl7:author |  | 1 … * | R |  |
ehdsi-dataelement-125 | Author and Organisation | 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. |
hl7:assignedAuthor |  | 1 … 1 | M |  |
ehdsi-dataelement-123 | Nature of the Patient Summary | 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
ehdsi-dataelement-303 | HP Identifier | 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 hl7:assignedAuthoringDevice containing template 2.16.840.1.113883.3.1937.777.11.10.129 eHDSI Device (DYNAMIC)
hl7:assignedPerson |  | 0 … 1 | C |  |
@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
ehdsi-dataelement-299 | Family Name/Surname | eHDSI Data Set
hl7:given |  | 1 … * | M | HP Given Name | R1.10.2
ehdsi-dataelement-300 | Given Name | 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) |
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. |
@typeCode | cs | 0 … 1 | F | CST
hl7:assignedCustodian |  | 1 … 1 | R |  |
@classCode | cs | 0 … 1 | F | ASSIGNED
hl7:representedCustodianOrganization |  | 1 … 1 | R |  |
@classCode | cs | 0 … 1 | F | ORG
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:id | II.EPSOS | 1 … 1 | R | Custodian organization Id |
@nullFlavor | cs | 0 … 1 |  |
hl7:name | ON | 1 … 1 | R | Custodian organization Name |
@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. |
@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 |
| Schematron assert | role | 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 |
hl7:city |  | 0 … 1 | R | City |
hl7:postalCode |  | 0 … 1 | R | Postal Code |
hl7:state |  | 0 … 1 | R | State or Province |
hl7:country |  | 1 … 1 | R | Country. When used addr.country it is always bound to the eHDSICountry value 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
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
ehdsi-dataelement-127 | Legal Authenticator | eHDSI Data Set
ehdsi-dataelement-176 | Responsible of the ePrescription Data/Author Organization | eHDSI Data Set
ehdsi-dataelement-327 | Responsible of the Original Clinical Document/Author Organization | 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
Choice | 0 … * |  | 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 2.16.840.1.113883.3.1937.777.11.10.101 eHDSI Contact/Preferred HP/Legal Organization (DYNAMIC) hl7:participant included from template 2.16.840.1.113883.3.1937.777.11.10.112 eHDSI Participant (DYNAMIC)
Included |  |  | from 2.16.840.1.113883.3.1937.777.11.10.101 eHDSI Contact/Preferred HP/Legal Organization (DYNAMIC)
hl7:participant |  |  | R | Contact person / Preferred Health Professional to contact about patient. |
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) |
@root | uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:functionCode |  | 0 … 1 | C |  |
| 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 element may be present and indicates the time of the participation. |
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”. |
@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"
ehdsi-dataelement-135 | Role of person | 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
ehdsi-dataelement-134 | Relationship level | 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
ehdsi-dataelement-143 | Address | eHDSI Data Set
@nullFlavor | cs | 0 … 1 | F | NI
| Schematron assert | role | 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 eHDSICountry 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
ehdsi-dataelement-136 | E-mail | eHDSI Data Set
ehdsi-dataelement-137 | Telephone No | eHDSI Data Set
ehdsi-dataelement-141 | E-mail | eHDSI Data Set
ehdsi-dataelement-142 | Telephone No | eHDSI Data Set
ehdsi-dataelement-331 | E-mail | eHDSI Data Set
ehdsi-dataelement-332 | Telephone No | 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 |  |
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
ehdsi-dataelement-138 | Family Name/Surname | eHDSI Data Set
ehdsi-dataelement-145 | Family Name/Surname | eHDSI Data Set
ehdsi-dataelement-334 | Family Name/Surname | eHDSI Data Set
hl7:given |  | 1 … * | R | Patient Contact's Given Name / Preferred HP's Given Name | R1.8.2 / R1.9.1.2
ehdsi-dataelement-139 | Given Name | eHDSI Data Set
ehdsi-dataelement-146 | Given Name | eHDSI Data Set
ehdsi-dataelement-335 | Given Name | eHDSI Data Set
hl7:scopingOrganization |  |  | R |  |
hl7:name | ON | 1 … 1 | R | Organization's Name | R1.9.1
ehdsi-dataelement-144 | OR Name of the Legal organization | eHDSI Data Set
ehdsi-dataelement-333 | OR Name of the Legal organization | eHDSI Data Set
Included |  |  | from 2.16.840.1.113883.3.1937.777.11.10.112 eHDSI Participant (DYNAMIC)
hl7:participant |  | 0 … * | R |  |
@typeCode | cs | 1 … 1 | R |
| CONF |
The value of @typeCode SHALL be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)
@contextControlCode |  | 1 … 1 | F | OP
hl7:functionCode | CE.EPSOS | 0 … 1 | R |  |
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time | IVL_TS | 0 … 1 | R |  |
hl7:associatedEntity |  | 1 … 1 | R |  |
@classCode | cs | 1 … 1 | R |
| CONF |
The value of @classCode SHALL be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)
hl7:id | II.EPSOS | 0 … * | R |  |
hl7:code | CE.EPSOS | 0 … 1 | R |  |
@codeSystem | CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 (RoleCode)
hl7:addr | AD | 0 … * | R |  |
hl7:telecom | TEL | 0 … * | R |  |
hl7:associatedPerson |  | 0 … 1 | R | Contains 2.16.840.1.113883.3.1937.777.11.10.113 eHDSI Person (DYNAMIC) |
hl7:scopingOrganization |  | 0 … 1 | R | Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) |
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 |  |
@typeCode | cs | 1 … 1 | F | DOC
hl7:serviceEvent |  | 1 … 1 | R |  |
@classCode | cs | 1 … 1 | F | PCPR
@moodCode | cs | 1 … 1 | F | EVN
hl7:id | II.EPSOS | 0 … * | R |  |
hl7:code | CE.EPSOS | 0 … 1 | R |  |
Choice | 1 … 1 |  | Elements to choose from: hl7:effectiveTime[hl7:high] hl7:effectiveTime[@nullFlavor or @value]
hl7:effectiveTime | IVL_TS | 0 … 1 | C |  |
where [hl7:high] |
hl7:low | TS | 0 … 1 | R |  |
hl7:high | TS | 1 … 1 | R |  |
hl7:effectiveTime | TS | 0 … 1 | C |  |
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 |
@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 |  |
| 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 |  |
hl7:assignedEntity |  | 1 … 1 | M |  |
hl7:id | II.EPSOS | 1 … * | R | HP ID number |
hl7:code | CE.EPSOS | 0 … 1 | R | HP Specialty |
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) |
hl7:representedOrganization |  | 0 … 1 |  | Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) |
Included | 1 … 1 | M | from 2.16.840.1.113883.3.1937.777.11.10.107 eHDSI RelatedDocument (DYNAMIC)
hl7:relatedDocument |  | 1 … 1 | M |  |
ehdsi-dataelement-131 | Related Document | eHDSI Data Set
ehdsi-dataelement-174 | Related Document | eHDSI Data Set
ehdsi-dataelement-321 | Related Document | eHDSI Data Set
@typeCode | cs | 1 … 1 | F | XFRM
hl7:parentDocument |  | 1 … 1 | R |  |
@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. |
hl7:code | CD.EPSOS | 0 … 1 | R |  |
@codeSystem | CONF | 0 … 1 | F | 2.16.840.1.113883.6.1 (LOINC)
hl7:text | ED | 0 … 1 | R |  |
hl7:setId | II.EPSOS | 0 … 1 | R |  |
hl7:versionNumber | INT | 0 … 1 | R |  |
hl7:component |  | 1 … 1 | M |  |
hl7:structuredBody |  | 1 … 1 | M | the component/structuredBody SHALL contain at least one [1..*] component/section. the component/structuredBody SHALL conform to the section constraints below MAY contain zero or one [0..1] Medication Summary Section (templateId: 1.3.6.1.4.1.12559.11.10.1.3.1.2.3). MAY contain zero or one [0..1] Allergies and Other Adverse Reactions Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.13). MAY contain zero or one [0..1] Coded List of Surgeries Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.12). MAY contain zero or one [0..1] Active Problems Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.6). MAY contain zero or one [0..1] Medical Devices Coded Section (templateId: 1.3.6.1.4.1.12559.11.10.1.3.1.2.4). MAY contain zero or one [0..1] Immunizations Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.23). MAY contain zero or one [0..1] Health Maintenance Care Plan Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.9.50). MAY contain zero or one [0..1] History of Past Illness Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.8). MAY contain zero or one [0..1] Coded Social History Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.16.1). MAY contain zero or one [0..1] Pregnancy History Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4). MAY contain zero or one [0..1] Coded Vital Signs Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2). MAY contain zero or one [0..1] Coded Results Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.28) |
@classCode | cs | 0 … 1 | F | DOCBODY
Choice | 1 … * |  | Elements to choose from: hl7:component containing template 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 eHDSI Medication Summary (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.3.13 eHDSI Allergies and Other Adverse Reactions (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.3.12 eHDSI List of Surgeries (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.3.6 eHDSI Active Problems (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 eHDSI Medical Devices (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.3.23 eHDSI Immunizations (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 eHDSI Health Maintenance Care Plan (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.3.8 eHDSI History Of Past Illness (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 eHDSI Social History (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 eHDSI Pregnancy History (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 eHDSI Vital Signs (DYNAMIC) hl7:component containing template 1.3.6.1.4.1.19376.1.5.3.1.3.28 (DYNAMIC)
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 eHDSI Medication Summary (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.13 eHDSI Allergies and Other Adverse Reactions (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.12 eHDSI List of Surgeries (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 eHDSI Active Problems (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 eHDSI Medical Devices (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.23 eHDSI Immunizations (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 eHDSI Health Maintenance Care Plan (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.8 eHDSI History Of Past Illness (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 eHDSI Social History (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 eHDSI Pregnancy History (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 eHDSI Vital Signs (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains
| Error: Cannot find template "1.3.6.1.4.1.19376.1.5.3.1.3.28" (DYNAMIC)