Item | DT | Card | Conf | Description | Label |
---|
hl7:ClinicalDocument
| | 1 … 1 | M | | CDA‑ckup |
| Variable let | Name | languageCode | |
| Value | substring(cda:ClinicalDocument/cda:languageCode/@code,1,2) | |
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 | HL7 CDA R2, 2005 | CDA‑ckup |
@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 2.16.756.5.30.1.1.1.1.3.6.3.10.2.13 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.13" (DYNAMIC) |
|
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 2.16.756.5.30.1.1.1.1.3.6.3.10.2.13 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.13" (DYNAMIC) |
|
Included | 1 … 1 | M | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.1 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.1" (DYNAMIC) |
|
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‑ckup |
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 2.16.756.5.30.1.1.1.1.3.6.3.10.2.4 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.4" (DYNAMIC) |
|
Included | 1 … 1 | M | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.2 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.2" (DYNAMIC) |
|
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 2.16.756.5.30.1.1.1.1.3.6.3.10.2.3 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.3" (DYNAMIC) |
|
Included | 1 … 1 | M | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.12 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.12" (DYNAMIC) |
|
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 | 0 … 1 | R | from 2.16.756.5.30.1.1.10.2.16 Order Reference - inFulfillmentOf (DYNAMIC) |
hl7:inFulfillmentOf
| | 0 … 1 | R | 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 | | | from 2.16.756.5.30.1.1.10.2.46 Health Service - documentationOf (DYNAMIC) |
hl7:documentationOf
| | 0 … * | | 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 | 1 … 1 | R | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.7 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.7" (DYNAMIC) |
|
Included | 0 … 1 | | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.8 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.8" (DYNAMIC) |
|
Included | 0 … 1 | | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.9 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.9" (DYNAMIC) |
|
Included | 0 … 1 | | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.10 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.10" (DYNAMIC) |
|
Included | 2 … * | | from 2.16.756.5.30.1.1.1.1.3.6.3.10.2.11 (DYNAMIC) |
| Include | | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.2.11" (DYNAMIC) |
|
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‑ckup |
hl7:structuredBody
| | 1 … 1 | R | | CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.1" (DYNAMIC) |
| CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.2" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Review of Systems This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.3" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Coded Functional Status Assessment This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.4" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Social History This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.5" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Active Problems This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.6" (DYNAMIC) |
| CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.17" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Allergies and Other Adverse Reactions Section This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.7" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Treatment Plan This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.8" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Provider Orders This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.9" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Advance Directives Section This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.10" (DYNAMIC) |
| CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.11" (DYNAMIC) |
| CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.12" (DYNAMIC) |
| CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.13" (DYNAMIC) |
| CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.14" (DYNAMIC) |
| CDA‑ckup |
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 | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.15" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Medications (list of active) This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.16" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Ability to work This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.18" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 1 … 1 | R | Transport Mode This section is required for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.19" (DYNAMIC) |
| CDA‑ckup |
hl7:component
| | 0 … 1 | | Remarks This section is optional for CDA-CH-SMCP. Contains | Error: Cannot find template "2.16.756.5.30.1.1.1.1.3.6.3.10.3.20" (DYNAMIC) |
| CDA‑ckup |