| Item | DT | Card | Conf | Description | Label |
|---|
hl7:ClinicalDocument
| | 1 … 1 | M | | chpc Care |
| | 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 | chpcCare |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.1.3 |
@extension
| st | 1 … 1 | F | POCD_HD000040 |
hl7:templateId
| II | 1 … 1 | M | IHE Patient Plan of Care, Trial Implementation of October 4, 2013 | chpcCare |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 |
hl7:templateId
| II | 1 … 1 | M | Swiss Realm of IHE Patient Plan of Care | chpcCare |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.1.8 |
hl7:templateId
| II | 1 … 1 | M | | chpcCare |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.1.1.4 |
| | CDA-CH V2 specification. |
hl7:templateId
| II | 1 … 1 | M | CDA-CH V2 ART-DECOR model. | chpcCare |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.1.9 |
| 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 |
hl7:code
| CE | 1 … 1 | M | The LOINC code for this document is 56447-6 Plan of Care Note. | chpcCare |
@code
| st | 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 |
| | The displayName of the code MUST be specified for tracking purposes. However, processing is NOT ALLOWED. Instead, a processing system is to display a user readable language translation of the code from the value set. |
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. | chpcCare |
| 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 | 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 | 0 … * | | from 2.16.756.5.30.1.1.10.2.14 Insurance Card - participant (DYNAMIC) |
hl7:participant
| | 0 … * | | Information on a patient's insurance card. | CDA‑CH V2 |
@typeCode
| cs | 1 … 1 | F | HLD |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.1.10.2.14 |
hl7:time
| IVL_TS.CH.TZ | 1 … 1 | R | Validity period of the insurance card. | CDA‑CH V2 |
hl7:low
| TS.CH.TZ | 1 … 1 | | | CDA‑CH V2 |
@nullFlavor
| cs | 1 … 1 | F | NASK |
hl7:high
| TS.CH.TZ | 1 … 1 | R | Expiration date of the insurance card. | CDA‑CH V2 |
hl7:associatedEntity
| | 1 … 1 | R | | CDA‑CH V2 |
@classCode
| cs | 1 … 1 | F | POLHOLD |
hl7:id
| II | 1 … 1 | R | The insurance card's id. | CDA‑CH V2 |
@root
| uid | 1 … 1 | F | 2.16.756.5.30.1.123.100.1.1.1 |
@extension
| st | 1 … 1 | R | Number of the insurance card. |
hl7:associatedPerson
| | 0 … 1 | | Family and given name on the insurance card.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | CDA‑CH V2 |
hl7:scopingOrganization
| | 0 … 1 | | The insurance company which issued the insurance card.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC) | CDA‑CH V2 |
| Included | 0 … * | | from 2.16.756.5.30.1.1.10.2.15 Insurance - participant (DYNAMIC) |
hl7:participant
| | 0 … * | | Information on a patient's insurance. | CDA‑CH V2 |
@typeCode
| cs | 1 … 1 | F | COV |
hl7:templateId
| II | 1 … 1 | M | | CDA‑CH V2 |
@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 the contract. | CDA‑CH V2 |
hl7:low
| TS.CH.TZ | 1 … 1 | R | Start of the contract. | CDA‑CH V2 |
hl7:high
| TS.CH.TZ | 1 … 1 | R | End of the contract. | CDA‑CH V2 |
hl7:associatedEntity
| | 1 … 1 | R | | CDA‑CH V2 |
@classCode
| cs | 1 … 1 | F | PAYOR |
hl7:id
| II | 1 … 1 | R | The id of the contract ([ge]: Versichertennummer; [fr]: Numéro d'assuré). | 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 | The underlying law for the contract. | CDA‑CH V2 |
@nullFlavor
| cs | 0 … 1 | F | NAV |
@code
| cs | 0 … 1 | | 832.10, 832.20, 221.229.1, 833.1, 831.20 |
@codeSystem
| oid | 0 … 1 | F | 2.16.756.5.30.2.1.1.11 |
@codeSystemName
| st | 0 … 1 | F | ins-laws |
@displayName
| st | 0 … 1 | | Federal Act on Health Insurance (HIA), Federal Act on Accident Insurance (AIA), Federal Act on Insurance Policies (Insurance Policies Act, IPA), Federal Act on Military Insurance (MilIA), Federal Act on Invalidity Insurance (InvIA) |
| | Schematron assert | role | error | |
| | test | (@nullFlavor='NAV' and not(@codeSystem or @codeSystemName or @code or @displayName)) or (@codeSystem='2.16.756.5.30.2.1.1.11' and @codeSystemName='ins-laws' and @code and @displayName) | |
| | Message | Either a valid insurance law or nullFlavor="NAV" is REQUIRED. | |
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‑CH V2 |
hl7:scopingOrganization
| | 1 … 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‑CH V2 |
| 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 | | chpcCare |
hl7:structuredBody
| | 1 … 1 | R | | chpcCare |
hl7:component
| | 1 … 1 | R | Assessments
This section should include all assessments performed.
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 IHE Assessments Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Physical Examination
The physical examination section should be present when a physical examination is performed during the assessment of the patient.
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 IHE Detailed Physical Examination Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Medical Devices, External Devices
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 IHE Medical Devices Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Review of Systems
The review of systems section should be present when a review of systems is performed during the assessment of the patient.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 IHE Review of Systems Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Coded Functional Status Assessment
This section should be present when any assessments of functional status are performed on the patient.
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1 IHE Coded Functional Status Assessment Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Family History
This section should be present when there is relevant family history.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.14 IHE Family Medical History Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Social History
This section should be present when there is relevant social history.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.16 IHE Social History Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Active Problems
The problem list section includes any nursing and physician diagnoses that are relevant to or being addressed by the PPOC. We recommend using the SNOMED CT Nursing Value Set when recording nursing problems in entries in the Active Problem section. See http://www.nlm.nih.gov/research/umls/Snomed/nursing_problemlist_subset.html
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Chief complaint
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 IHE Chief Complaint Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Allergies and Other Adverse Reactions Section
This section should be present and record the presence or absence of any allergies.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.13 IHE Allergies and Other Adverse Reactions Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Treatment Plan
The treatment plan section contains a description of the planned care and goals.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.31 IHE Care Plan Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Provider Orders
References any orders that are to be implemented, including those for treatment (e.g., medications, therapy or therapeutic encounters, et cetera), monitoring (testing, monitoring, et cetera), or education.
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1 IHE Provider Orders Section (DYNAMIC) | chpcCare |
| Choice | 1 … 1 | | Advance Directives Section
This section should be present and record the presence or absence of any advance directives. Both the coded and narrative text values should be collected if available. Elements to choose from: |
hl7:component
| | 0 … 1 | | Advance Directives Section
Narr. Text: This section should be present and record the presence or absence of any advance directives. Both the coded and narrative text values should be collected if available.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.34 IHE Advance directives section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Advance Directives Section
Coded: This section should be present and record the presence or absence of any advance directives. Both the coded and narrative text values should be collected if available.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.35 IHE Coded Advance directives section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Procedures and Interventions
This section should be present when procedures and interventions have been performed.
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 IHE Procedures and Interventions Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Coded Results
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.28 IHE Coded Results Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Diet and Nutrition
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.20.2.2 IHE Diet and Nutrition Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Hospital Admission Diagnosis
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.3 IHE Hospital Admission Diagnosis Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Discharge Diagnosis
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.7 IHE Discharge Diagnosis Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Intake and Output
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.20.2.3 IHE Intake and Output Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Medications Administered
This section should be present when medications have been administered.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.21 IHE Medications Administered Section (DYNAMIC) | chpcCare |
hl7:component
| | 1 … 1 | R | Medications (list of active)
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.19 IHE Medications section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Fluids Administered
This section should be present when fluids have been administered.
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 IHE Intravenous Fluids Administered Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | History of Past Illness Section
This section should be present when there is relevant history of past illness.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.8 IHE History of Past Illness Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Coded List of Surgeries Section
This section should be present when there is relevant surgical history.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.12 IHE Coded List of Surgeries section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Immunizations Section
This section should be present to record relevant immunization status.
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.23 IHE Immunizations Section (DYNAMIC) | chpcCare |
hl7:component
| | 0 … 1 | | Patient Instructions
The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and the consents the patient signed.
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.9.38 IHE Patient Education Section (DYNAMIC) | chpcCare |
Under pre-publication review
IHE Medical Devices Section (2016)