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Template CZ-EU Patient Summary 2019‑11‑28 20:23:19

Id1.2.203.24341.11.10.1.1Effective Date2019‑11‑28 20:23:19
Statusdraft DraftVersion Label
NameCZ-EUPSDisplay NameCZ-EU Patient Summary
Description

Note for the readers
This template version represents the best representation of the original epSOS/EXPAND specifications in ART DECOR. However  the original epSOS/EXPAND  specifications in Microsoft Word took the original IHE Templates and added constraints in written language. This actually is not best practice in electronic Template Design because the additional constraints are not assigned to the original IHE template but rather than that are text only constraints. In order to make everything computable new Template OIDs need to be assigned to the epSOS Templates in order to cover both, the original IHE Template Design and the additional constraints from epSOS in the text and represent them electronically.
Caveat: for the above mentioned reasons this version cannot be used  for (automatic) testing/validation purposes. It shall be used however as basis for refinement (repository)

Note: there is a new version planned that covers all above and makes proper testing/validation possible

epSOS Patient Summary 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 10, IHE International, November 4, 2014.
  • Integrating the Healthcare Enterprise, Patient Care Coordination CDA Content Modules- Trial Implementation Supplement, December 3, 2014.
  • HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, HL7, July 16, 2008.
  • epSOS Patient Summary: Implementation Guide, https://art-decor.ehdsi.eu/art-decor/decor-templates--epsos-?section=templates
ContextPathname /
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 22 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.777.49.4.2Transactiondraft PS created2022‑05‑19 08:45:25
Uses as NameVersion
1.2.203.24341.11.10.2.1Includedraft CZ CDA recordTargetDYNAMIC
1.2.203.24341.11.10.2.2Includedraft CZ CDA authorDYNAMIC
1.2.203.24341.11.10.2.3Includedraft CZ CDA CustodianDYNAMIC
1.2.203.24341.11.10.2.4Includedraft CZ CDA LegalAuthenticatorDYNAMIC
1.2.203.24341.11.10.2.5Includedraft CZ Patient ContactsDYNAMIC
1.2.203.24341.11.10.2.6Includedraft CZ DocumentationOf PCPRDYNAMIC
1.2.203.24341.11.10.3.1Containmentdraft CZ Allergies and Other Adverse ReactionsDYNAMIC
1.2.203.24341.11.10.9.1Includedraft CZ CDA setIdDYNAMIC
1.2.203.24341.11.10.9.2Includedraft CZ CDA IdDYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.3Containmentactive eHDSI Medication SummaryDYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.4Containmentactive eHDSI Medical DevicesDYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.5Containmentactive eHDSI Coded ResultsDYNAMIC
1.3.6.1.4.1.12559.11.10.1.3.1.2.10Containmentactive eHDSI History Of Past IllnessDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2Containmentretired eHDSI Vital SignsDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4Containmentretired eHDSI Pregnancy HistoryDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.9.50Containmentretired eHDSI Health Maintenance Care PlanDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.6Containmentretired eHDSI Active ProblemsDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.12Containmentretired eHDSI List of SurgeriesDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.16.1Containmentretired eHDSI Social HistoryDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.17Containmentretired eHDSI Functional StatusDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.23Containmentretired eHDSI ImmunizationsDYNAMIC
2.16.840.1.113883.3.1937.777.11.10.107Includeactive eHDSI RelatedDocumentDYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 epSOS-Patient Summary (2018‑11‑14 10:53:50)
ref
epsos-

Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
RCDA headerCZ‑EUPS
 Schematron assertrolered error 
 testnot(@xsi:schemaLocation) 
 MessageZatímco jazyk XML schématu umožňuje připojit schéma k dokumentu XML zahrnutím atributu schemaLocation nastaveného na namespace http://www.w3.org/2001/XMLSchema-instance, je toto propojení výslovně ZAKÁZÁNO v [ITS§1.4 ], a tedy i ve standardu CDA. 
hl7:realmCode
CS0 … 1R(cs-CZ) realmCode vyjadřuje jurisdikci k níž je daný dokument, resp. specifikace CDA dokumentu, vázána. V české specifikaci CDA musí být použita hodnota "CZ".CZ‑EUPS
@code
cs0 … 1FCZ
hl7:typeId
II.EPSOS1 … 1M 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.

CZ‑EUPS
@root
uid1 … 1F2.16.840.1.113883.1.3
@extension
st1 … 1FPOCD_HD000040
 Example<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
hl7:templateId
II.EPSOS1 … 1MTemplate ID for CZ-EU  Patient Summary documentCZ‑EUPS
@root
uid1 … 1F1.2.203.24341.11.10.1.1
 Example<templateId root="1.2.203.24341.11.10.1.1"/>
hl7:templateId
II.EPSOS1 … 1MTemplate ID for epSOS Patient Summary documentCZ‑EUPS
@root
uid1 … 1F1.3.6.1.4.1.12559.11.10.1.3.1.1.3
 Example<templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.3"/>
Included1 … 1M from 1.2.203.24341.11.10.9.2 CZ CDA Id (DYNAMIC)
hl7:id
1 … 1M

The ClinicalDocument/id element is an instance identifier data type. The root attribute is an OID. If there is a value in @extension, then the root uniquely identifies the scope of the extension. If there is no value in @extension then @root SHALL uniquely identify the document

UUIDs SHALL be represented in the form XXXXXXXX-XXXX-XXXX-XXXX-XXXXXXXXXXXX, where each X is a character from the set [A-F0-9].

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])(.([1-9][0-9]*|0))+.

R1.11.3
 Example<id extension="a621" root="2.16.840.1.113883.3.1937.777.11.9999"/>
 Example<id root="AF58C270-6F80-477A-AB05-47BCFFBC62F7"/>
hl7:code
CV.EPSOS1 … 1MDetermines the document type "epSOS Patient Summary Document"R1.11.6
@displayName
1 … 1R
@code
CONF1 … 1F60591-5
@codeSystem
1 … 1F2.16.840.1.113883.6.1
 Example<code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient summary Document"/>
hl7:title
ST1 … 1MClinicalDocument/title is used for display purposes.R1.11.7
 Example<title>Pacientský Souhrn, Jan Zdravý, 13.10.2011</title>
hl7:effectiveTime
TS.EPSOS.TZ1 … 1M

Relevant times for the Patient Summary

By definition, a Patient Summary document describes the Patient Summary at the time of creation of the document, represented by the /ClinicalDocument/effectiveTime XML Element.

The time when this instance of the document has been authored may be instead recorded by the /ClinicalDocument/author/time element. (e.g. when a “spider” has collected information for generating this instance of the document; or a practitioner updated its local summary document).

Finally, the latest summary update, intended as the last date documented by this summary (e.g. the last update occurred to the PHR from which the PS data has been extracted) can be represented by the /ClinicalDocument/documentationOf/serviceEvent/effectiveTime/high XML Element (see section 2.1, CONF-2, CONF-3 and CONF-4 of the CCD specification).

R1.11.1
 Example<effectiveTime value="20111113125600+0200"/>
hl7:confidentialityCode
CE.EPSOS1 … 1RClinicalDocument/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
CS1 … 1MDocument 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
 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="cs-CZ"/>
 Schematron assertrolered error 
 testmatches(@code,'[a-z]{2}-[A-Z]{2}') 
 MessageThe language code SHALL be in the form nn-CC where nn is ISO-639-1 epSOSLanguage and CC is ISO-3166 epSOSCountry 
Included0 … 1 from 1.2.203.24341.11.10.9.1 CZ CDA setId (DYNAMIC)
hl7:setId
0 … 1R

This attribute “represents an identifier that is common across all document revisions”.

In the case of the NCP transcoding /translation this is the ID that remains unchanged among all the existing transformations.

Implementers are recommended to use this attribute.

CZCDdotsetId
hl7:versionNumber
0 … 1R(cs-CZ) Atributy id, setId a versionNumber identifikují klinický dokument. Atribut id reprezentuje identitu konkrétního CDA dokumentu. Dva dokumenty se stejným id musí tedy mít totožný obsah (mohou se ale např. lišit použitou kódovou sadou). Atribut versionNumber může být použit pro rozlišení verze dokumentu v případech, kdy dochází k jeho změnám. V takovém případě by se využil také atribut setId, který by měl mít u obou dokumentů (původní i nové verze) stejnou hodnotu. Relace na původní dokument by pak byla zaznamenána v elementu relatedDocument. CZ‑EUPS
Included1 … 1M from 1.2.203.24341.11.10.2.1 CZ CDA recordTarget (DYNAMIC)
hl7:recordTarget
1 … 1MCZCDdotsrget
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
hl7:patientRole
1 … 1MCZCDdotsrget
@classCode
cs0 … 1FPAT
hl7:id
II.EPSOS1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)R1.4 / R1.4.1 / R1.4.2
hl7:addr
AD.EPSOS1 … 1RThe 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
cs0 … 1FNI
hl7:streetAddressLine
0 … *RPatient's Number of Street/Patient's Number of StreetR1.5.1 / R1.5.2
hl7:city
0 … 1RPatient's CityR1.5.3
hl7:postalCode
0 … 1RPatient's Postal CodeR1.5.4
hl7:state
0 … 1RPatient's State or ProvinceR1.5.5
hl7:country
0 … 1RPatient's Country. When used addr.country it is always bound to the epSOSCountry value setR1.5.6
 Schematron assertrolered error 
 testcount(concat(text(), '1.0.3166.1') = doc('include/voc-1.3.6.1.4.1.12559.11.10.1.3.1.42.4-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem)) = 1 
 MessageThe value of the addr.country has to be bound to the eHDSICountry value set 
hl7:telecom
TEL1 … *RPatient’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
@use
set_cs0 … 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
cs0 … 1FNI
hl7:patient
1 … 1MCZCDdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … *RPatient NameR1.1
hl7:family
1 … *MPatient's Family Name/SurnameR1.1.1
hl7:prefix
0 … *RPatient's PrefixR1.1.2
 ConstraintIf the attribute qualifier is used for this element it should be derived from epSOSEntityNamePartQualifier 2.16.840.1.113883.5.43
hl7:given
1 … *MPatient's Given NameR1.1.3
hl7:administrativeGenderCode
CE.EPSOS1 … 1RPatient's GenderR1.2
@nullFlavor
cs0 … 1FUNK
 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
TS1 … 1MPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.R1.3
hl7:guardian
0 … *R Other patient contacts are described using the /ClinicalDocument/participant structure. The element defines the type of contact. R1.7.A
@classCode
cs1 … 1FGUARD
@nullFlavor
cs0 … 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"/>  <addr>
    <streetAddressLine>Václavské nám. 1</streetAddressLine>    <city>Praha</city>    <postalCode>150 00</postalCode>    <country>CZ</country>  </addr>  <telecom value="tel:+452070256161"/>  <telecom value="mailto:jsmith@myprovider.co.uk"/>  <guardianPerson>
    <name>
      <given>Jana</given>      <family>Koprová Králová</family>    </name>  </guardianPerson></guardian>
hl7:templateId
II.EPSOS1 … 1MTemplate id for IHE PCC Patient ContactsR1.7.A
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:addr
AD.EPSOS1 … 1RThe 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 presentR1.7.A
@nullFlavor
cs0 … 1FNI
hl7:streetAddressLine
0 … *RGuardian's Number of StreetR1.7dots.3.2
hl7:city
0 … 1RGuardian's CityR1.7dots.3.3
hl7:postalCode
0 … 1RGuardian's Postal CodeR1.7dots.3.4
hl7:state
0 … 1RGuardian's State or ProvinceR1.7dots.3.5
hl7:country
0 … 1RGuardian's Country. When used addr.country it is always bound to the epSOSCountry value setR1.7dots.3.6
 Schematron assertrolered error 
 testcount(concat(text(), '1.0.3166.1') = doc('include/voc-1.3.6.1.4.1.12559.11.10.1.3.1.42.4-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem)) = 1 
 MessageThe value of the addr.country has to be bound to the epSOSCountry value set 
hl7:telecom
TEL1 … *RGuardian’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.R1.7dots.4.2
@use
set_cs0 … 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
cs0 … 1FNI
hl7:guardianPerson
1 … 1RR1.7.A
hl7:name
PN1 … *RPatient Guardian's NameIHE PCC
Choice2 … *Elements to choose from:
  • hl7:family
  • hl7:given
hl7:family
1 … *RPatient Guardian's Family Name/SurnameR1.7.A.1
hl7:given
1 … *RPatient Guardian's Given NameR1.7.A.2
hl7:languageCommunication
0 … *RThis 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".CZCDdotsrget
hl7:languageCode
CS1 … 1RPatient’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 epSOSLanguage.
  • The CC portion SHALL be an ISO-3166 country code in upper case derived by the value Set epSOSCountry
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 assertrolered error 
 testmatches(@code,'[a-z]{2}-[A-Z]{2}') 
 MessageThe language code SHALL be in the form nn-CC where nn is ISO-639-1 epSOSLanguage and CC is ISO-3166 epSOSCountry 
Included1 … *M from 1.2.203.24341.11.10.2.2 CZ CDA author (DYNAMIC)
hl7:author
1 … *MCZCDdotsthor
@typeCode
cs0 … 1FAUT
@contextControlCode
cs0 … 1FOP
hl7:functionCode
CE.EPSOS0 … 1RR1.10.6
 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.TZ1 … 1RThe 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.CZCDdotsthor
hl7:assignedAuthor
1 … 1RCZCDdotsthor
@classCode
cs0 … 1FASSIGNED
 Schematron assertrolered error 
 test@nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice 
 MessageAt least an assignedPerson or an assignedAuthoringDevice has to be provided, otherwise a nullFlavor shall be present. 
hl7:id
II.EPSOS1 … *RIdentification of the Healthcare Practitioner that is the author of this document.R1.10.5
@nullFlavor
cs0 … 1FNA
hl7:code
CE.EPSOS0 … 1RHP SpecialtyR1.10.7
hl7:addr
AD.EPSOS1 … *RIHE PCC
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 1.2.203.24341.11.1.3 CZ-AddressUse (DYNAMIC)
 Example<addr use="WP">
  <streetAddressLine>Palackého nám. 1</streetAddressLine>  <city>Praha</city>  <postalCode>12801</postalCode>  <country>CZ</country></addr>
hl7:telecom
TEL.EPSOS1 … *RAttribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLSchemeIHE PCC / R1.10.8 / R1.10.8.1 / R1.10.8.2
@use
set_cs0 … 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)
Choice0 … 1Elements to choose from:
hl7:assignedPerson
RCZCDdotsthor
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1RHP NameIHE PCC
 Example<name>
  <given>Anežka</given>  <family>Hodinová Spurná</family></name>
hl7:family
1 … *MHP Family Name/SurnameR1.10.1
hl7:given
1 … *MHP Given NameR1.10.2
hl7:prefix
0 … *RHP PrefixR1.10.3
hl7:suffix
0 … *RHP SuffixR1.10.4
hl7:assignedAuthoringDevice
RContains 1.2.203.24341.11.10.4.1 CZ Device (DYNAMIC)CZCDdotsthor
hl7:representedOrganization
1 … 1RContains 1.2.203.24341.11.10.9.3 CZ CDA Organization (DYNAMIC)R1.10.9
Included1 … 1M from 1.2.203.24341.11.10.2.3 CZ CDA Custodian (DYNAMIC)
hl7:custodian
1 … 1M This elements represents the organization that is in charge of maintaining the document. CZCudotsdian
@typeCode
cs0 … 1FCST
hl7:assignedCustodian
1 … 1RCZCudotsdian
@classCode
cs0 … 1FASSIGNED
hl7:representedCustodianOrganization
1 … 1RCZCudotsdian
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II.EPSOS1 … 1RCustodian organization IdCZCudotsdian
@nullFlavor
cs0 … 1 
hl7:name
ON1 … 1RCustodian organization Name
CZCudotsdian
@nullFlavor
cs0 … 1 
hl7:telecom
TEL1 … 1R

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.

CZCudotsdian
@use
set_cs0 … 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
cs0 … 1FNI
 Example<telecom use="WP" value="tel:+420 207 025 616"/>
hl7:addr
AD.EPSOS1 … 1RCustodian Organization AddressCZCudotsdian
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
0 … *RStreet/Number of Street
CZCudotsdian
hl7:city
0 … 1RCity
CZCudotsdian
hl7:postalCode
0 … 1RPostal Code
CZCudotsdian
hl7:state
0 … 1RState or Province
CZCudotsdian
hl7:country
1 … 1RCountry. When used addr.country it is always bound to the eHDSICountry value set
CZCudotsdian
 ConstraintThe content of this element SHALL be selected from ValueSet epSOSCountry urn:oid:1.3.6.1.4.1.12559.11.10.1.3.1.42.4

Included1 … 1M from 1.2.203.24341.11.10.2.4 CZ CDA LegalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
1 … 1MThe 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
hl7:time
TS.EPSOS.TZ1 … 1MTime of signing the documentR1.11.9
hl7:signatureCode
CS1 … 1RSignature codeR1.11.9
@code
CONF0 … 1FS
hl7:assignedEntity
1 … 1MThe entity that is responsible for the legal authentication of the CDA documentR1.11.9
hl7:id
1 … 1MUnique identification of legal authenticatorR1.11.9
hl7:addr
AD.EPSOS1 … *RIHE PCC
hl7:telecom
TEL1 … *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_cs0 … 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
cs0 … 1FNI
 Example<telecom use="WP" value="tel:+420 207 025 616"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
hl7:assignedPerson
1 … 1RIHE PCC
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1RName of the legal authenticatorIHE PCC
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … *MFamily Name/SurnameR1.10.1
hl7:given
1 … *MGiven NameR1.10.2
hl7:prefix
0 … *RPrefixR1.10.3
hl7:suffix
0 … *RSuffixR1.10.4
hl7:representedOrganization
1 … 1MContains 1.2.203.24341.11.10.9.3 CZ CDA Organization (DYNAMIC)R1.11.9
Included1 … *R from 1.2.203.24341.11.10.2.5 CZ Patient Contacts (DYNAMIC)
hl7:participant
1 … *RPatient contacts or the Preferred Health Professional to contact about patient.CZCodotstion
where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4']
@typeCode
cs1 … 1FINDR1.8.5
 Participant typeCode
hl7:templateId
1 … 1MCZCodotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:functionCode
0 … 1CThe element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.CZCodotstion
 ConstraintThe element is mandatory when this participant is the preferred HP
@code
CONF0 … 1FPCP
@codeSystem
0 … 1F2.16.840.1.113883.5.88
hl7:time
IVL_TS.EPSOS.TZ.OPT0 … 1RThe CZCodotstion
hl7:associatedEntity
RThe 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”.CZCodotstion
@classCode
cs1 … 1RR1.8.6
 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"
hl7:code
CV.EPSOS0 … 1RThe 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) codeSystemR1.8.6
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.38 eHDSIPersonalRelationship (DYNAMIC)
hl7:addr
AD.EPSOS1 … 1RPatient Contact's / Preferred HP's AddressR1.8.3 / R1.9.2
@nullFlavor
cs0 … 1FNI
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
0 … *RPatient Contact's Street/Number of Street / Preferred HP's Street/Number of StreetR1.8.3.1 / R1.8.3.2 / R1.9.2.1 / R1.9.2.2
hl7:city
0 … 1RPatient Contact's City / Preferred HP's CityR1.8.2.3 / R1.9.2.3
hl7:postalCode
0 … 1RPatient Contact's Postal Code / Preferred HP's Postal CodeR1.8.2.4 / R1.9.2.4
hl7:state
0 … 1RPatient Contact's State or Province / Preferred HP's State or ProvinceR1.8.2.5 / R1.9.2.5
hl7:country
0 … 1RPatient Contact's Country / Preferred HP's Country. When used addr.country it is always bound to the eHDSICountry value setR1.8.2.6 / R1.9.2.6
hl7:telecom
TEL1 … *RPatient 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 presentR1.8.4.1 / R1.8.4.2 / R1.9.3.1 / R1.9.3.2
@use
set_cs0 … 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
cs0 … 1FNI
 Example<telecom use="WP" value="tel:+420 207 025 616"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
Choice1 … 1Elements to choose from:
  • hl7:associatedPerson
  • hl7:scopingOrganization
hl7:associatedPerson
RCZCodotstion
hl7:name
PN1 … 1RPatient Contact's Name / Preferred HP's NameIHE PCC / R1.9.1
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Choice2 … *Elements to choose from:
  • hl7:family
  • hl7:given
hl7:family
1 … *RPatient Contact's Family Name/Surname / Preferred HP's Family Name/SurnameR1.8.1 / R1.9.1.1
hl7:given
1 … *RPatient Contact's Family Name/Surname / Preferred HP's Family Name/SurnameR1.8.2 / R1.9.1.2
hl7:scopingOrganization
RCZCodotstion
hl7:name
ON1 … 1ROrganization's NameR1.9.1
Included1 … 1R from 1.2.203.24341.11.10.2.6 CZ DocumentationOf PCPR (DYNAMIC)
hl7:documentationOf
1 … 1RCZDodotsPCPR
@typeCode
cs1 … 1FDOC
hl7:serviceEvent
1 … 1RCZDodotsPCPR
@classCode
cs1 … 1FPCPR
@moodCode
cs1 … 1FEVN
hl7:id
II.EPSOS0 … *RCZDodotsPCPR
hl7:code
CE.EPSOS0 … 1RCZDodotsPCPR
Choice1 … 1Elements to choose from:
  • hl7:effectiveTime[hl7:high]
  • hl7:effectiveTime[@nullFlavor or @value]
hl7:effectiveTime
IVL_TS … 1RCZDodotsPCPR
where [hl7:high]
hl7:low
TS0 … 1RCZDodotsPCPR
hl7:high
TS1 … 1RCZDodotsPCPR
hl7:effectiveTime
TS … 1RCZDodotsPCPR
where [@nullFlavor or @value]
hl7:performer
0 … *RIt 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 counselorsCZDodotsPCPR
@typeCode
cs1 … 1R
 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.EPSOS1 … 1R(cs-CZ) Typ zdravotnického pracovníkaCZDodotsPCPR
 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_TS0 … 1RCZDodotsPCPR
hl7:assignedEntity
1 … 1MCZDodotsPCPR
hl7:id
II.EPSOS1 … *RHP ID numberCZDodotsPCPR
hl7:code
CE.EPSOS0 … 1RHP SpecialtyCZDodotsPCPR
hl7:addr
AD.EPSOS1 … *R(cs-CZ) Adresa poskytovateleIHE PCC
hl7:telecom
TEL1 … *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_cs0 … 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
cs0 … 1FNI
 Example<telecom use="WP" value="tel:+420 207 025 616"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
hl7:assignedPerson
0 … 1Contains 1.2.203.24341.11.10.2.7 CZ CDA Person (DYNAMIC)CZDodotsPCPR
hl7:representedOrganization
0 … 1Contains 1.2.203.24341.11.10.9.3 CZ CDA Organization (DYNAMIC)CZDodotsPCPR
Included1 … *M from 2.16.840.1.113883.3.1937.777.11.10.107 eHDSI RelatedDocument (DYNAMIC)
hl7:relatedDocument
1 … *MeHDSdotsment
@typeCode
cs1 … 1FXFRM
hl7:parentDocument
1 … 1ReHDSdotsment
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:id
II.EPSOS1 … *RIdentifier of the national version of the document.
eHDSdotsment
hl7:code
CD.EPSOS0 … 1ReHDSdotsment
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1ReHDSdotsment
hl7:setId
II.EPSOS0 … 1ReHDSdotsment
hl7:versionNumber
INT0 … 1ReHDSdotsment
hl7:component
1 … 1MCZ‑EUPS
hl7:structuredBody
1 … 1MCZ‑EUPS
@classCode
cs0 … 1FDOCBODY
hl7:component
1 … 1RContains 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 eHDSI Medication Summary (DYNAMIC)CZ‑EUPS
hl7:component
1 … 1RContains 1.2.203.24341.11.10.3.1 CZ Allergies and Other Adverse Reactions (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.23 eHDSI Immunizations (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.10 eHDSI History Of Past Illness (DYNAMIC)CZ‑EUPS
hl7:component
1 … 1RContains 1.3.6.1.4.1.19376.1.5.3.1.3.12 eHDSI List of Surgeries (DYNAMIC)CZ‑EUPS
hl7:component
1 … 1RContains 1.3.6.1.4.1.19376.1.5.3.1.3.6 eHDSI Active Problems (DYNAMIC)CZ‑EUPS
hl7:component
1 … 1RContains 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 eHDSI Medical Devices (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 eHDSI Health Maintenance Care Plan (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.17 eHDSI Functional Status (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 eHDSI Social History (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 eHDSI Pregnancy History (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 eHDSI Vital Signs (DYNAMIC)CZ‑EUPS
hl7:component
0 … 1Contains 1.3.6.1.4.1.12559.11.10.1.3.1.2.5 eHDSI Coded Results (DYNAMIC)CZ‑EUPS