| Item | DT | Card | Conf | Description | Label |
|---|
hl7:ClinicalDocument
| | 1 … 1 | M | Social-medical care plan V2 Note:
This specification also conforms to the following specifications: - DMST v3.1 of the canton of Vaud (Document Médico-Social de Transmission)
- CDA-CH v2.0.3
- HL7 Clinical Document Architecture R2 (2005)
- IHE content profile "Patient Plan of Care (PPOC)", Trial Implementation, October 4, 2013
Conformity rules that are not further modelled in ART-DECOR: XML encoding
UTF-8 encoding is required. All CDA-CH V2 documents MUST start with this line:
<?xml version="1.0" encoding="UTF-8"?> Phone numbers
Phone numbers MUST be declared in the international format.
Dots (.) MUST be used as separators for grouping of number blocks.
The minus sign (-) MUST be used as a separator between public and internal telephone numbers. Purpose: Some telephone exchanges - especially in the US, allow direct dial-up of an internal telephone number after the actual connection has been established over the public telephone network.
Examples:
<telecom value="tel:+41.33.123.45.67"/>
<telecom value="tel:+1.987.654.3210-999"/>
| CDA‑ SMCP |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.25 Document Realm (DYNAMIC) |
hl7:realmCode
| CS | 1 … 1 | M | Swiss Realm (CHE) of HL7 CDA. | CDA‑CH V2 |
@code
| CONF | 1 … 1 | F | CHE |
hl7:typeId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.1.3 |
@extension
| st | 1 … 1 | F | POCD_HD000040 |
| Included | | | from 2.16.756.5.30.1.1.10.2.18 Document Template Ids CDA-CH v2.0 - structuredBody (DYNAMIC) |
hl7:templateId
| II | 0 … 1 | | CDA-CH v2.0 specification. This is an informational reference, only. | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.1.1.4 |
hl7:templateId
| II | 1 … 1 | M | CDA-CH v2.0 structuredBody | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.1.9 |
hl7:templateId
| II | 1 … 1 | M | HL7 CDA R2 (2005); contains ClinicalDocument.component as structuredBody. | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.12.2 |
hl7:templateId
| II | 1 … 1 | M | HL7 CDA R2 (2005). | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.12.1 |
| Included | | | from 2.16.756.5.30.1.1.10.2.84 Document Template Ids CDA-CH-SMCP V2 (DYNAMIC) |
hl7:templateId
| II | 0 … 1 | | CDA-CH-SMCP Social-medical care plan specification. This is an informational reference, only. | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.1.1.3.6.3 |
hl7:templateId
| II | 1 … 1 | M | CDA-CH-SMCP Social-medical care plan ART-DECOR model. | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.1.11 |
hl7:templateId
| II | 1 … 1 | M | IHE Patient Plan of Care, Trial Implementation of October 4, 2013. | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.23 Document Id (DYNAMIC) |
hl7:id
| II | 1 … 1 | M | A unique identifier for each CDA document instance. | CDA‑CH V2 |
@root
| uid | 1 … 1 | R | The document's id as Globally Unique Identifier (GUID). |
@extension
| st | 0 | NP | NP/not present |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.83 Document Code (DYNAMIC) |
hl7:code
| CE | 1 … 1 | M | The LOINC based document type of a CDA document instance including a translation to the Swiss EPR XDS.b metadata. | CDA‑SMCP |
@code
| cs | 1 … 1 | F | 56447-6 |
@codeSystem
| oid | 1 … 1 | F | 2.16.840.1.113883.6.1 |
@codeSystemName
| st | 1 … 1 | F | LOINC |
@displayName
| st | 1 … 1 | F | Plan of Care Note |
hl7:translation
| CD | 1 … 1 | R | The translation to the Swiss EPR XDS.b metadata. | CDA‑SMCP |
@code
| cs | 1 … 1 | F | 721915006 |
@codeSystem
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
@codeSystemName
| st | 1 … 1 | F | SNOMED CT |
@displayName
| st | 1 … 1 | F | Admission request |
| | CONF | |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.73 Document Title (DYNAMIC) |
hl7:title
| ST | 1 … 1 | M | The document title must read as specified, regarding the documents language: - [de]: 'Sozial-medizinischer Pflegeverlegungsbericht'
- [fr]: 'Document médico-social de transmission'
- [en]: 'Social-medical care plan'
| CDA‑SMCP |
| | Variable let | Name | languageCode | |
| | Value | substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2) | |
| | Schematron assert | role |  error | |
| | test | not($languageCode='de') or starts-with(text(),'Sozial-medizinischer Pflegeverlegungsbericht') | |
| | Message | The German title must start with 'Sozial-medizinischer Pflegeverlegungsbericht' | |
| | Schematron assert | role | error | |
| | test | not($languageCode='fr') or starts-with(text(),'Document médico-social de transmission') | |
| | Message | The French title must start with 'Document médico-social de transmission' | |
| | Schematron assert | role | error | |
| | test | not($languageCode='en') or starts-with(text(),'Social-medical care plan') | |
| | Message | The English title must start with 'Social-medical care plan' | |
hl7:effectiveTime
| TS.CH.TZ | 1 … 1 | M | ClinicalDocument/effectiveTime MUST exist. It contains the creation date and time of the plan of care. If this document replaces a previous version (linked via parentDocument), this is the date and time of the new version. | CDA‑SMCP |
| | |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.19 Document Confidentiality Code (DYNAMIC) |
hl7:confidentialityCode
| CE (required) | 1 … 1 | M | Swiss Realm of Confidentiality Code according to the Swiss EPR regulation. | CDA‑CH V2 |
@code
| cs | 1 … 1 | R | The value of @code MUST be drawn from value set DocumentEntry.confidentialityCode |
@codeSystem
| oid | 1 … 1 | R | |
@codeSystemName
| st | 1 … 1 | R | |
@displayName
| st | 1 … 1 | R | The value of @displayName MUST be drawn from value set DocumentEntry.confidentialityCode |
| | CONF | |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.22 Document Language (DYNAMIC) |
hl7:languageCode
| CS | 1 … 1 | M | The RFC5646 based language in which the narrative texts in this CDA document instance are written. | CDA‑CH V2 |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.20 Document Set Id and Version Number (DYNAMIC) |
hl7:setId
| II | 1 … 1 | M | The setId element MUST match the document id of the very first version of that document. It MUST remain the same for all document versions. | CDA‑CH V2 |
@root
| uid | 1 … 1 | R | The root attribute MUST contain the setId as Globally Unique Identifier (GUID). |
@extension
| st | 0 | NP | NP/not present |
| | Schematron assert | role | error | |
| | test | (parent::*/hl7:versionNumber[@value='1'] and @root=parent::*/hl7:id/@root and (@extension=parent::*/hl7:id/@extension or (not(@extension) and not(parent::*/hl7:id/@extension)))) or (parent::*/hl7:versionNumber[not(@value ='1')] and ((@root=parent::*/hl7:id/@root and @extension and not(@extension=parent::*/hl7:id/@extension)) or(not(@root=parent::*/hl7:id/@root)))) | |
| | Message | The setId MUST be equal with the document id for version 1 and it MUST differ for all other versions. | |
hl7:versionNumber
| INT.NONNEG | 1 … 1 | M | The versionNumber element MUST contain the value 1 for the very first version of that document. For later versions, the version number MUST be increased by 1 each. | CDA‑CH V2 |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.76 Patient (DYNAMIC) |
hl7:recordTarget
| | 1 … 1 | M | Patient (Human Patient). | CDA‑SMCP |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.76 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.1 |
hl7:patientRole
| | 1 … 1 | R | Exactly one patient MUST be declared. | CDA‑SMCP |
| | Schematron assert | role | error | |
| | test | hl7:telecom[starts-with(@value,"tel:") and @use='HP'] | |
| | Message | The patient's primary telephone number is required. | |
hl7:id
| II | 1 … 1 | R | The patient's SSN MUST be declared. | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.32 |
| | MUST contain the OID of the Swiss SSN. |
@extension
| st | 1 … 1 | R | MUST contain the SSN itself. |
| | |
hl7:id
| II | 0 … * | | Other patient identifications SHALL be declared, if known. | CDA‑SMCP |
@root
| uid | 1 … 1 | R | MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 1 … 1 | R | MUST contain the patient number itself. The number MUST be unique within the system that has issued the number. |
hl7:addr
| AD | 1 … 1 | R | The patient's home address MUST be declared.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | CDA‑SMCP |
| | |
@nullFlavor
| cs | 0 … 1 | F | NI |
| | |
@use
| set_cs | 1 … 1 | F | HP |
| | Schematron assert | role | error | |
| | test | not(@nullFlavor='NI') or (@use='HP') | |
| | Message | Either a valid home address or @nullFlavor="NI" (homeless) is required. | |
hl7:addr
| AD | 0 … * | | Other patient addresses CAN be declared if this is helpful for the recipient.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | CDA‑SMCP |
hl7:telecom
| TEL | 1 … * | R | Means of communication of the patient (phone, eMail, ...). | CDA‑SMCP |
| | |
hl7:patient
| | 1 … 1 | R | Exactly one patient MUST be declared. | CDA‑SMCP |
hl7:name
| PN | 1 … * | R | The patient's name MUST be declared. | CDA‑SMCP |
hl7:family
| ENXP | 1 … 1 | R | The patient's family name. | CDA‑SMCP |
| | |
hl7:given
| ENXP | 1 … 1 | R | The patient's given name. | CDA‑SMCP |
| | |
hl7:administrativeGenderCode
| CE | 1 … 1 | R | The patient's gender according to the Swiss EPR XDS.b metadata. | CDA‑SMCP |
| | |
| | CONF | |
hl7:birthTime
| TS | 1 … 1 | R | The patient's birthdate MUST be declared. | CDA‑SMCP |
| | |
hl7:maritalStatusCode
| CE | 0 … 1 | | The patient's marital status CAN be declared. | CDA‑SMCP |
| | |
| | CONF | |
hl7:religiousAffiliationCode
| CE | 0 … 1 | | The patient's religion CAN be declared. | CDA‑SMCP |
@nullFlavor
| cs | 1 … 1 | F | OTH |
hl7:originalText
| ED | 1 … 1 | R | Religion and/or confession of the patient as plain text. | CDA‑SMCP |
| | |
hl7:languageCommunication
| | 0 … 1 | | The patient's mother tonge.
Contains 2.16.756.5.30.1.1.10.2.85 Mother Tongue (DYNAMIC) | CDA‑SMCP |
| | |
hl7:languageCommunication
| | 0 … 1 | | The patient's capabilities in French communication.
Contains 2.16.756.5.30.1.1.10.2.86 French Communication (DYNAMIC) | CDA‑SMCP |
| | |
hl7:languageCommunication
| | 0 … * | | Other patient's language skills CAN be declared. | CDA‑SMCP |
hl7:languageCode
| CS | 0 … 1 | | | CDA‑SMCP |
| | CONF | |
hl7:modeCode
| CE | 0 … 1 | | | CDA‑SMCP |
| | CONF | |
hl7:proficiencyLevelCode
| CE | 0 … 1 | | | CDA‑SMCP |
| | CONF | |
hl7:preferenceInd
| BL | 0 … 1 | | | CDA‑SMCP |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.74 Author (DYNAMIC) |
hl7:author
| | 1 … 1 | M | Information about the author of the document. The author MAY be a person or a device. At least one author MUST be declared. | CDA‑SMCP |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.74 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.9.23 |
hl7:functionCode
| CE | 1 … 1 | R | The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.
If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, nullFlavor='NAV' MUST be used. In this case, the originalText element MUST contain the description of the role.
Translations to other vocabularies are allowed. | CDA‑SMCP |
@nullFlavor
| st | 0 … 1 | F | NAV |
@code
| cs | 0 … 1 | | |
@codeSystem
| oid | 0 … 1 | F | 2.16.840.1.113883.6.96 |
@codeSystemName
| st | 0 … 1 | F | SNOMED CT |
@displayName
| st | 0 … 1 | | |
| | CONF | |
| | Example | <functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/> |
| | Example | <functionCode nullFlavor="NAV">
<originalText>Home helper</originalText></functionCode> |
| | Example | <functionCode nullFlavor="NAV">
<originalText>Laboratory technician</originalText> <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode> |
| | Schematron assert | role | error | |
| | test | (@code and @codeSystem) or (@nullFlavor='NAV') | |
| | Message | Either a code with its code system or nullFlavor='NAV' is required. | |
| | Schematron assert | role | error | |
| | test | not(@nullFlavor) or (hl7:originalText) | |
| | Message | Other Caregivers description MUST be declared in the originalText element in case of nullFlavor. | |
hl7:translation
| | 0 … * | | A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7) | CDA‑SMCP |
@code
| cs | 1 … 1 | R | |
@codeSystem
| oid | 1 … 1 | R | |
@codeSystemName
| st | 1 … 1 | R | |
@displayName
| st | 1 … 1 | R | |
hl7:translation
| | 0 … 1 | | Use this translation when the author is the patient itself (e.g. by reporting a self medication or a medical problem). | CDA‑SMCP |
@code
| cs | 1 … 1 | F | 116154003 |
@codeSystem
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
@codeSystemName
| st | 1 … 1 | F | SNOMED CT |
@displayName
| st | 1 … 1 | F | Patient (person) |
hl7:time
| TS.CH.TZ | 1 … 1 | R | Timestamp of the authorship. | CDA‑SMCP |
hl7:assignedAuthor
| | 1 … 1 | R | | CDA‑SMCP |
| | Schematron assert | role | error | |
| | test | not(hl7:assignedAuthoringDevice/hl7:softwareName) or (hl7:representedOrganization) | |
| | Message | For device authors the element representedOrganization is REQUIRED. | |
| | Schematron assert | role | error | |
| | test | hl7:telecom[starts-with(@value,"tel:")] | |
| | Message | The phone number of the person who issued the document is required. | |
hl7:id
| II | 1 … 1 | R | The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared. | CDA‑SMCP |
@nullFlavor
| cs | 0 … 1 | F | NAV |
| | Temporarily unknown, will be filled later. |
@root
| cs | 0 … 1 | F | 2.51.1.3 |
| | OID for GS1 GLN. |
@extension
| st | 0 … 1 | | The GS1 GLN. |
| | Schematron assert | role | error | |
| | test | (@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') | |
| | Message | Either the GS1 GLN or nullFlavor='NAV' is REQUIRED | |
hl7:id
| II | 0 … * | | Other ids are allowed. | CDA‑SMCP |
@root
| cs | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 0 … 1 | | The id itself. It MUST be unique within the issuing system. |
hl7:addr
| AD | 0 … * | | Address of the authors organization.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | CDA‑SMCP |
hl7:telecom
| TEL | 1 … * | R | Means of communication of the author (phone, eMail, ...). | CDA‑SMCP |
| | |
| Choice | 1 … 1 | | Elements to choose from: |
hl7:assignedPerson
| | 0 … 1 | | The author as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑SMCP |
| | |
hl7:assignedAuthoringDevice
| | 0 … 1 | | The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC) | CDA‑SMCP |
hl7:representedOrganization
| | 0 … 1 | | The author's organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC) | CDA‑SMCP |
| Included | 0 … 1 | | from 2.16.756.5.30.1.1.10.2.7 Data Enterer (DYNAMIC) |
hl7:dataEnterer
| | 0 … 1 | | Information about the person that entered information in this CDA document. It SHALL be declared, when data recorded in this document has been entered by a person other than the author but only when this is relevant for some reason. | CDA‑CH V2 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.7 |
hl7:time
| TS.CH.TZ | 0 … 1 | | Timestamp of the data input. | CDA‑CH V2 |
hl7:assignedEntity
| | 1 … 1 | R | Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) | CDA‑CH V2 |
| Included | 1 … 1 | R | from 2.16.756.5.30.1.1.10.2.3 Custodian (DYNAMIC) |
hl7:custodian
| | 1 … 1 | R | The organization in whose name this CDA document has been created (corresponds to the sender of a letter). | CDA‑CH V2 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.3 |
hl7:assignedCustodian
| | 1 … 1 | R | | CDA‑CH V2 |
hl7:representedCustodianOrganization
| | 1 … 1 | R | | CDA‑CH V2 |
hl7:id
| II | 1 … * | M | The custodian's id. | CDA‑CH V2 |
@root
| uid | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 0 … 1 | | Contains the ID itself. The ID MUST be unique within the system that issued the ID. |
hl7:name
| ON | 1 … 1 | R | The custodian's name. | CDA‑CH V2 |
hl7:telecom
| TEL | 0 … 1 | | The custodian's means of communication (phone, eMail, ...). | CDA‑CH V2 |
hl7:addr
| AD | 0 … 1 | | The custodian's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | CDA‑CH V2 |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.75 Recipient (DYNAMIC) |
hl7:informationRecipient
| | 1 … 1 | M | The laboratory report MUST contain at least one receiver. | CDA‑SMCP |
@typeCode
| cs | 1 … 1 | R | The main recipient of the document MUST be specified using typeCode 'PRCP' (primary recipient). Other receivers (copy to; Cc) MUST be specified using typeCode 'TRC' (tracker). |
| | CONF | |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.4 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.75 |
hl7:intendedRecipient
| | 1 … 1 | M | | CDA‑SMCP |
hl7:id
| II | 0 … * | R | The recipients's identification(s). | CDA‑SMCP |
@extension
| st | 1 … 1 | R | MUST contain the recipient identification number itself. The number MUST be unique within the system that has issued the number. |
@root
| uid | 1 … 1 | R | MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
hl7:addr
| AD | 0 … * | | The recipients's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | CDA‑SMCP |
hl7:telecom
| TEL | 0 … * | | The recipients's means of communication (phone, eMail, ...). | CDA‑SMCP |
hl7:informationRecipient
| | 0 … 1 | | The addressee person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑SMCP |
| | |
hl7:receivedOrganization
| | 0 … 1 | | The addressee organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC) | CDA‑SMCP |
| | Schematron assert | role | error | |
| | test | hl7:informationRecipient[not(@nullFlavor)] or hl7:receivedOrganization[not(@nullFlavor)] | |
| | Message | Either the recipients person or organization MUST be declared. | |
| Included | 1 … 1 | M | from 2.16.756.5.30.1.1.10.2.82 Legal Authenticator (DYNAMIC) |
hl7:legalAuthenticator
| | 1 … 1 | M | Information about the legal authenticator of a CDA document. A legal authenticator MUST be a person. | CDA‑SMCP |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.82 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.5 |
hl7:time
| TS.CH.TZ | 1 … 1 | R | Timestamp of the signature. | CDA‑SMCP |
| | |
hl7:signatureCode
| CS | 1 … 1 | R | | CDA‑SMCP |
@code
| cs | 1 … 1 | F | S |
@codeSystem
| oid | 0 | NP | NP/not present |
@codeSystemName
| st | 0 | NP | NP/not present |
@displayName
| st | 0 | NP | NP/not present |
| | CONF | |
hl7:assignedEntity
| | 1 … 1 | R | | CDA‑SMCP |
hl7:code
| CE | 0 … 1 | | If declared, the code MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.
If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, the code 133932002 (Other Caregiver) MUST be used. In this case, the originalText element MUST contain the description of the role.
Translations to other vocabularies are allowed. | CDA‑SMCP |
@code
| cs | 1 … 1 | R | |
@codeSystem
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
@codeSystemName
| st | 1 … 1 | F | SNOMED CT |
@displayName
| st | 1 … 1 | R | |
| | CONF | |
| | Example | <functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/> |
| | Example | <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
<originalText>Home helper</originalText></functionCode> |
| | Example | <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
<originalText>Laboratory technician</originalText> <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode> |
| | Schematron assert | role | error | |
| | test | not(@code='133932002') or (originalText/text()) | |
| | Message | Other Caregivers description MUST be declared in the originalText element. | |
| Included | 0 … 1 | C | from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY. |
hl7:originalText
| ED | 0 … 1 | C | | CDA‑CH V2 |
hl7:reference
| TEL | 1 … 1 | M | The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] | CDA‑CH V2 |
@value
| | 1 … 1 | R | Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element. |
| | Schematron assert | role | error | |
| | test | starts-with(@value,'#') | |
| | Message | The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element. | |
| | Variable let | Name | idvalue | |
| | Value | substring-after(@value,'#') | |
| | Schematron assert | role | error | |
| | test | ancestor::hl7:structuredBody//*[@ID=$idvalue] | |
| | Message | No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). | |
| | Schematron assert | role | error | |
| | test | parent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text() | |
| | Message | The originalText content MUST be identical to the narrative text for this reference. | |
hl7:translation
| | 0 … * | | A translation of the code to another coding system. | CDA‑SMCP |
@code
| cs | 1 … 1 | R | |
@codeSystem
| oid | 1 … 1 | R | |
@codeSystemName
| st | 1 … 1 | R | |
@displayName
| st | 1 … 1 | R | |
hl7:addr
| AD | 1 … * | R | The assigned entity's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | CDA‑SMCP |
hl7:telecom
| TEL | 1 … * | R | The assigned entity's means of communication (phone, eMail, ...). | CDA‑SMCP |
hl7:assignedPerson
| | 1 … 1 | R | The assigned person.
Contains 2.16.756.5.30.1.1.10.9.53 Person Name Information Compilation - eCH-0011 with Suffix (DYNAMIC) | CDA‑SMCP |
| | |
hl7:representedOrganization
| | 0 … 1 | | The assigned organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC) | CDA‑SMCP |
| Included | 0 … * | | from 2.16.756.5.30.1.1.10.2.6 Authenticator (DYNAMIC) |
hl7:authenticator
| | 0 … * | | Information about an authenticator of a CDA document. An authenticator MUST be a person. | CDA‑CH V2 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.6 |
hl7:time
| TS.CH.TZ | 1 … 1 | R | Timestamp of the signature. | CDA‑CH V2 |
hl7:signatureCode
| CS | 1 … 1 | R | | CDA‑CH V2 |
@code
| cs | 1 … 1 | F | S |
@codeSystem
| oid | 0 | NP | NP/not present |
@codeSystemName
| st | 0 | NP | NP/not present |
@displayName
| st | 0 | NP | NP/not present |
| | CONF | |
hl7:assignedEntity
| | 1 … 1 | R | Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) | CDA‑CH V2 |
| Included | 1 … 1 | R | from 2.16.756.5.30.1.1.10.2.77 Insurance - Illness (DYNAMIC) |
hl7:participant
| | 1 … 1 | R | Information on the patient's Health Insurance (HIA). | CDA‑SMCP |
| | |
@typeCode
| cs | 1 … 1 | F | COV |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.77 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.15 |
hl7:time
| IVL_TS.CH.TZ | 0 … 1 | | Validity period of contract. | CDA‑SMCP |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of contract. | CDA‑SMCP |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of contract. | CDA‑SMCP |
hl7:associatedEntity
| | 1 … 1 | R | | CDA‑SMCP |
@classCode
| cs | 1 … 1 | F | PAYOR |
hl7:id
| II | 1 … 1 | R | The id of the contract ([ge]: Versichertennummer; [fr]: Numéro d'assuré). | CDA‑SMCP |
| | |
@root
| uid | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 0 … 1 | | The id itself. It MUST be unique within the issuing system. |
hl7:code
| CE | 1 … 1 | R | The underlying law for the contract. | CDA‑SMCP |
@displayName
| st | 1 … 1 | F | Federal Act on Health Insurance (HIA) |
@code
| cs | 1 … 1 | F | 832.10 |
@codeSystemName
| st | 1 … 1 | F | ins-laws |
@codeSystem
| oid | 1 … 1 | F | 2.16.756.5.30.2.1.1.11 |
hl7:associatedPerson
| | 0 … 1 | | Contact person at the insurance company.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑SMCP |
hl7:scopingOrganization
| | 0 … 1 | | The insurance company.
Contains 2.16.756.5.30.1.1.10.9.26 Organization Compilation with GLN, name, addr and telecom (DYNAMIC) | CDA‑SMCP |
| | |
| Included | 0 … 1 | | from 2.16.756.5.30.1.1.10.2.78 Insurance - Accident (DYNAMIC) |
hl7:participant
| | 0 … 1 | | Information on the patient's Accident Insurance (AIA). | CDA‑SMCP |
| | |
@typeCode
| cs | 1 … 1 | F | COV |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.78 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.15 |
hl7:time
| IVL_TS.CH.TZ | 0 … 1 | | Validity period of contract. | CDA‑SMCP |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of contract. | CDA‑SMCP |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of contract. | CDA‑SMCP |
hl7:associatedEntity
| | 1 … 1 | R | | CDA‑SMCP |
@classCode
| cs | 1 … 1 | F | PAYOR |
hl7:id
| II | 1 … 1 | R | The id of the contract ([ge]: Versichertennummer; [fr]: Numéro d'assuré). | CDA‑SMCP |
| | |
@root
| uid | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 0 … 1 | | The id itself. It MUST be unique within the issuing system. |
hl7:code
| CE | 1 … 1 | R | The underlying law for the contract. | CDA‑SMCP |
@displayName
| st | 1 … 1 | F | Federal Act on Accident Insurance (AIA) |
@code
| cs | 1 … 1 | F | 832.20 |
@codeSystemName
| st | 1 … 1 | F | ins-laws |
@codeSystem
| oid | 1 … 1 | F | 2.16.756.5.30.2.1.1.11 |
hl7:associatedPerson
| | 0 … 1 | | Contact person at the insurance company.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑SMCP |
hl7:scopingOrganization
| | 0 … 1 | | The insurance company.
Contains 2.16.756.5.30.1.1.10.9.26 Organization Compilation with GLN, name, addr and telecom (DYNAMIC) | CDA‑SMCP |
| | |
| Included | 0 … 1 | | from 2.16.756.5.30.1.1.10.2.79 Insurance - Complementary (DYNAMIC) |
hl7:participant
| | 0 … 1 | | Information on the patient's complementary insurance (Insurance Policies Act, IPA). | CDA‑SMCP |
| | |
@typeCode
| cs | 1 … 1 | F | COV |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.79 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.15 |
hl7:time
| IVL_TS.CH.TZ | 0 … 1 | | Validity period of contract. | CDA‑SMCP |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of contract. | CDA‑SMCP |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of contract. | CDA‑SMCP |
hl7:associatedEntity
| | 1 … 1 | R | | CDA‑SMCP |
@classCode
| cs | 1 … 1 | F | PAYOR |
hl7:id
| II | 1 … 1 | R | The id of the contract ([ge]: Versichertennummer; [fr]: Numéro d'assuré). | CDA‑SMCP |
| | |
@root
| uid | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 0 … 1 | | The id itself. It MUST be unique within the issuing system. |
hl7:code
| CE | 1 … 1 | R | The underlying law for the contract. | CDA‑SMCP |
@displayName
| st | 1 … 1 | F | Federal Act on Insurance Policies (Insurance Policies Act, IPA) |
@code
| cs | 1 … 1 | F | 221.229.1 |
@codeSystemName
| st | 1 … 1 | F | ins-laws |
@codeSystem
| oid | 1 … 1 | F | 2.16.756.5.30.2.1.1.11 |
hl7:associatedPerson
| | 0 … 1 | | Contact person at the insurance company.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑SMCP |
hl7:scopingOrganization
| | 0 … 1 | | The insurance company.
Contains 2.16.756.5.30.1.1.10.9.26 Organization Compilation with GLN, name, addr and telecom (DYNAMIC) | CDA‑SMCP |
| | |
| Included | 0 … 1 | | from 2.16.756.5.30.1.1.10.2.80 Employer (DYNAMIC) |
hl7:participant
| | 0 … 1 | | Information on the employer. | CDA‑SMCP |
@typeCode
| cs | 1 … 1 | F | IND |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.80 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.40 |
hl7:templateId
| | 1 … * | M | | CDA‑SMCP |
@root
| cs | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.41 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.2.2 |
hl7:time
| IVL_TS.CH.TZ | 0 … 1 | | Validity period of contract. | CDA‑SMCP |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of the contract. | CDA‑SMCP |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of the contract. | CDA‑SMCP |
hl7:associatedEntity
| | 1 … 1 | R | | CDA‑SMCP |
@classCode
| cs | 1 … 1 | F | CON |
hl7:id
| II | 0 … 1 | R | The id of the contract ([ge]: Mitarbeiternummer; [fr]: Numéro d'employé). | CDA‑SMCP |
@root
| uid | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 0 … 1 | | The id itself. It MUST be unique within the issuing system. |
hl7:code
| CE | 1 … 1 | R | | CDA‑SMCP |
@code
| cs | 1 … 1 | R | |
@codeSystem
| oid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.3 |
@codeSystemName
| st | 1 … 1 | F | IHERoleCode |
@displayName
| st | 0 | NP | NP/not present |
| | CONF | | The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.77 IHERoleCode Employer and School Contacts (DYNAMIC) |
|
hl7:associatedPerson
| | 0 … 1 | | Contact person at the employer, school or other affiliated (e.g., volunteer) organization.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑SMCP |
hl7:scopingOrganization
| | 1 … 1 | | The employer, school or other affiliated (e.g., volunteer) organization.
Contains 2.16.756.5.30.1.1.10.9.27 Organization Compilation with name, addr, telecom (DYNAMIC) | CDA‑SMCP |
| | |
| Included | 2 … * | | from 2.16.756.5.30.1.1.10.2.81 Patient Contact (DYNAMIC) |
hl7:participant
| | 2 … * | | Information on a patient contact. | CDA‑SMCP |
| | |
@typeCode
| cs | 1 … 1 | F | IND |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.81 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.43 |
hl7:templateId
| II | 1 … 1 | R | | CDA‑SMCP |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.2.4 |
hl7:time
| IVL_TS.CH.TZ | 0 … 1 | | Validity period of the participation. | CDA‑SMCP |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of participation. | CDA‑SMCP |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of participation. | CDA‑SMCP |
hl7:associatedEntity
| | 1 … 1 | R | Either the contact person or the contact's organization SHALL be present. | CDA‑SMCP |
@classCode
| cs | 1 … 1 | R | The classCode attribute SHALL be present, and contains a value from the following set:
AGNT: agents of the patient
CAREGIVER: care givers
ECON: emergency contacts
NOK: next of kin
PRS: other relations |
| | |
hl7:code
| CE | 1 … 1 | R | The contact's role. | CDA‑SMCP |
| | |
@nullFlavor
| cs | 0 … 1 | | |
@code
| cs | 0 … 1 | | |
@codeSystem
| oid | 0 … 1 | F | 2.16.840.1.113883.5.111 |
@codeSystemName
| st | 0 … 1 | F | HL7RoleCode |
@displayName
| st | 0 … 1 | | |
| | Schematron assert | role | error | |
| | test | (not(@nullFlavor) and @displayName and @code and @codeSystem and @codeSystemName) or (@nullFlavor and not(@displayName or @code or @codeSystem or @codeSystemName)) | |
| | Message | Either nullFlavor or a valid code is required. | |
hl7:addr
| AD | 0 … * | | The contact's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | CDA‑SMCP |
| | |
hl7:telecom
| TEL | 0 … * | | The contact's means of communication (phone, eMail, ...). | CDA‑SMCP |
| | |
hl7:associatedPerson
| | 0 … 1 | C | The contact person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑SMCP |
| | |
hl7:scopingOrganization
| | 0 … 1 | C | The contact's organization.
Contains 2.16.756.5.30.1.1.10.9.27 Organization Compilation with name, addr, telecom (DYNAMIC) | CDA‑SMCP |
| | |
| | Schematron assert | role | error | |
| | test | @classCode=('AGNT','CAREGIVER','ECON','NOK','PRS') | |
| | Message | The classCode attribute shall be present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or other relations respectively. | |
| Included | 0 … 1 | | from 2.16.756.5.30.1.1.10.2.16 Order Reference - inFulfillmentOf (DYNAMIC) |
hl7:inFulfillmentOf
| | 0 … 1 | | Reference to one or more orders which led to the creation of this CDA document. It SHALL be declared, when the order reference is relevant for some reason. | CDA‑CH V2 |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.16 |
hl7:order
| | 1 … 1 | R | | CDA‑CH V2 |
hl7:id
| II | 1 … * | R | Order number. | CDA‑CH V2 |
@root
| uid | 1 … 1 | R | Either the same GUID (order id) or the same OID (order issuing system) as the order itself. |
@extension
| st | 0 … 1 | | Contains the order ID itself. The ID MUST be unique within the system that issued the ID. |
| Included | 0 … 1 | | from 2.16.756.5.30.1.1.10.2.46 Health Service - documentationOf (DYNAMIC) |
hl7:documentationOf
| | 0 … 1 | | Information about a health service describing the context of this CDA document. | CDA‑CH V2 |
@typeCode
| cs | 1 … 1 | F | DOC |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.46 |
hl7:serviceEvent
| | 1 … 1 | R | | CDA‑CH V2 |
@classCode
| cs | 1 … 1 | F | ACT |
@moodCode
| cs | 1 … 1 | F | EVN |
hl7:id
| II | 0 … * | | Health service identifiers such as case number ([ge]: Fallnummer; [fr]: Numéro de cas), consultation id, episode id, etc. | CDA‑CH V2 |
@root
| uid | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
@extension
| st | 0 … 1 | | The id itself. It MUST be unique within the issuing system. |
hl7:code
| CE | 1 … 1 | R | As long as the eventCodeList for the Swiss EPR metadata is not defined yet by the FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), the nullFlavor='NAV' MUST be used in this template. Other codes MAY be declared as translation. | CDA‑CH V2 |
@nullFlavor
| st | 1 … 1 | F | NAV |
@code
| cs | 0 | NP | NP/not present |
@codeSystem
| oid | 0 | NP | NP/not present |
@codeSystemName
| st | 0 | NP | NP/not present |
@displayName
| st | 0 | NP | NP/not present |
hl7:translation
| | 0 … * | | A translation of the code to another coding system. | CDA‑CH V2 |
@code
| cs | 1 … 1 | R | |
@codeSystem
| oid | 1 … 1 | R | |
@codeSystemName
| st | 1 … 1 | R | |
@displayName
| st | 1 … 1 | R | |
hl7:effectiveTime
| IVL_TS.CH.TZ | 1 … 1 | R | Duration of the health service. | CDA‑CH V2 |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of the health service. | CDA‑CH V2 |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of the health service. | CDA‑CH V2 |
| Included | 0 … * | | from 2.16.756.5.30.1.1.10.9.31 Performer (DYNAMIC) |
hl7:performer
| | 0 … * | | Information about a healthcare provider who was the primary performer of the act. | cdacrmer |
@typeCode
| cs | 1 … 1 | F | PRF |
hl7:templateId
| II | 1 … 1 | M | | cdacrmer |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.9.31 |
hl7:templateId
| | 1 … 1 | R | | cdacrmer |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.1.24.3.5 |
hl7:templateId
| | 1 … 1 | R | | cdacrmer |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.12.323 |
hl7:time
| IVL_TS.CH.TZ | 0 … 1 | | Duration of the performance. | cdacrmer |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of the performance. | cdacrmer |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of the performance. | cdacrmer |
hl7:assignedEntity
| | 1 … 1 | R | Contains 2.16.756.5.30.1.1.10.9.32 Assigned Entity Compilation with id, name, addr, telecom, person and organization (DYNAMIC) | cdacrmer |
| Included | 0 … * | | from 2.16.756.5.30.1.1.10.2.13 Document Replacement - relatedDocument (DYNAMIC) |
hl7:relatedDocument
| | 0 … * | | Relationship to another CDA-CH V2 based document that is replaced by the current one. Notes: For correction of wrong information, a new document that replaces the earlier document MUST be created. The new document corrects previously incorrect information. This also applies to the case where information in the CDA header has been corrected (e.g., if the original document has been issued to the wrong patient). While processing the new document at the recipient, all values from the previous document MUST be interpreted as deprecated (deleted/marked as deleted/deprecated) and all values in the new document MUST be marked as valid: - Values that were only contained in the previous document have to be treated as deleted.
- Values that are present in both documents are overwritten with the contents of the new document.
- Values that are only contained in the new document are to be added.
| CDA‑CH V2 |
@typeCode
| cs | 1 … 1 | F | RPLC |
| | Indicates that it is a relationship to another document that needs to be replaced. |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.13 |
hl7:parentDocument
| | 1 … 1 | R | Relationship to the document that needs to be replaced. | CDA‑CH V2 |
hl7:id
| II | 1 … 1 | M | The id of the document to be replaced MUST be declared. | CDA‑CH V2 |
@root
| uid | 1 … 1 | R | The id (GUID) of the document to be replaced. |
@extension
| st | 0 | NP | NP/not present |
hl7:setId
| II | 1 … 1 | M | The setId of the document to be replaced MUST be declared. | CDA‑CH V2 |
@extension
| st | 0 | NP | NP/not present |
@root
| uid | 1 … 1 | R | The setId (GUID) of the document to be replaced and MUST be identical with the content of the setId of the current document. |
| | Schematron assert | role | error | |
| | test | (@root=/hl7:ClinicalDocument/hl7:setId/@root) and not(@extension) and not(/hl7:ClinicalDocument/hl7:setId/@extension) | |
| | Message | ClinicalDocument/setId: MUST be identical to the one of the replaced document | |
hl7:versionNumber
| INT | 1 … 1 | M | The version number of the document to be replaced. | CDA‑CH V2 |
| | Schematron assert | role | error | |
| | test | /hl7:ClinicalDocument/hl7:versionNumber/@value > @value | |
| | Message | ClinicalDocument/versionNumber: MUST be higher than the one of the replaced document | |
hl7:component
| | 1 … 1 | R | | CDA‑SMCP |
hl7:structuredBody
| | 1 … 1 | R | | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Assessments
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.54 Assessments Section - plain text (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Medical Devices, External Devices
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.55 Medical Devices Section - plain text (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Review of Systems
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.56 Review of Systems Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Coded Functional Status Assessment
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.57 Functional Status Assessment Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Social History
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.58 Social History Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Active Problems
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.59 Active Problems Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Chief complaint
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.70 Chief Complaint Section - plain text (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Allergies and Other Adverse Reactions Section
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.60 Allergies and other Adverse Reactions Section - plain text (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Treatment Plan
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.61 Care Plan Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Provider Orders
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.62 Provider Orders Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Advance Directives Section
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.63 Advance Directives Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Coded Results
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.64 Results Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Diet and Nutrition
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.65 Diet and Nutrition Section - plain text (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Admission Diagnosis
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.66 Admission Diagnosis Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Discharge Diagnosis
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.67 Discharge Diagnosis Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Intake and Output
This section is required by IHE PPOC but not used for CDA-CH-SMCP. Therefore it contains fixed contents.
Contains 2.16.756.5.30.1.1.10.3.68 Intake and Output Section - plain text (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Medications (list of active)
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.69 Medications Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Ability to work
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.71 Ability To Work Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 1 … 1 | R | Transport Mode
This section is required for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.72 Transport Mode Section - coded (DYNAMIC) | CDA‑SMCP |
hl7:component
| | 0 … 1 | | Remarks
This section is optional for CDA-CH-SMCP.
Contains 2.16.756.5.30.1.1.10.3.73 Remarks Section - coded (DYNAMIC) | CDA‑SMCP |
Draft
Custodian (2020)