XeHDischargeReport

Template XeH Hospital Discharge Report 2021‑09‑10 14:49:32

2.16.840.1.113883.2.51.10.12

Effective Date

2021‑09‑10 14:49:32

Status

Active

Version Label

1.0

Name

XeHDischargeReport

Display Name

XeH Hospital Discharge Report

Description

A hospital discharge is the formal release of a patient from a hospital after a procedure or course of treatment. A discharge occurs whenever a patient leaves because of finalization of treatment, signs out against medical advice, transfers to another health care institution or on death.

Hospital discharge reports serve as the primary documents communicating a patient's episode of care related to hospitalization.
Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.

This specification aims to define a Common EU Hospital Discharge Report, starting from a EU Minimum Hospital Discharge Dataset as defined by the XeHealth WP5.

Context

Pathname //

Classification

CDA Document Level Template

Open/Closed

Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 0 templates, Uses 38 templates

Uses	as	Name	Version
2.16.840.1.113883.2.51.10.5	Include	XeH CDA author (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.6	Include	XeH CDA custodian (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.7	Include	XeH CDA dataEnterer (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.8	Include	XeH CDA legalAuthenticator (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.9	Include	XeH CDA recordTarget (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.11	Include	XeH inFulfillmentOf (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.14	Include	XeH Information Recipient (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.15	Containment	XeH Patient History Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.16	Containment	XeH Family History Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.23	Containment	XeH Problems Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.26	Containment	XeH Discharge Medications Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.28	Containment	XeH Discharge Diagnosis Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.29	Containment	XeH Admission Diagnosis Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.30	Containment	XeH Chief Complaint and Reason for Visit Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.31	Containment	XeH Admission Medications Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.41	Containment	XeH Medication Summary Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.48	Include	XeH Ordering Provider (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.49	Include	XeH HDR ComponentOf (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.50	Containment	XeH Hospital Discharge Physical Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.57	Containment	XeH History of Past Illness Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.65	Containment	XeH Immunizations Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.67	Containment	XeH Foreign Travel Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.82	Containment	XeH Vital Signs Section (1.0)	DYNAMIC
2.16.840.1.113883.2.51.10.83	Containment	XeH Hospital Course Section (1.0)	DYNAMIC
2.16.840.1.113883.10.12.108	Include	CDA participant	DYNAMIC
2.16.840.1.113883.10.12.110	Include	CDA documentationOf	DYNAMIC
2.16.840.1.113883.10.20.22.2.16	Containment	Hospital Discharge Studies Summary Section (2.1)	DYNAMIC
2.16.840.1.113883.10.22.2.5	Include	IPS Patient Contacts (STU1)	DYNAMIC
2.16.840.1.113883.10.22.2.7	Include	IPS CDA relatedDocument (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.2	Containment	IPS Allergies and Intolerances Section (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.4	Containment	IPS History of Procedures Section (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.6	Containment	IPS Medical Devices Section (2021)	DYNAMIC
2.16.840.1.113883.10.22.3.8	Containment	IPS Functional Status Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.9	Containment	IPS Plan of Care Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.10	Containment	IPS Social History Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.11	Containment	IPS History of Pregnancy Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.12	Containment	IPS Advance Directives Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.14	Containment	IPS Results Section (STU1)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2020‑07‑14 16:08:21)

ref

hl7ips-

Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 (2013‑12‑20)
Adaptation: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)

ref

ad1bbr-

Example

<ClinicalDocument>
  <realmCode code="ES"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="2.16.840.1.113883.10.22.1.1"/>  <id root="2.16.724.4.8.10.200.10" extension="PSCTD0160f274530a031"/>  <code displayName="Patient Summary" code="60591-5" codeSystem="2.16.840.1.113883.6.1"/>  <title>Patient Summary</title>  <effectiveTime value="20111113125600+0200"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="es-ES"/>  <setId root="2.16.724.4.8.10.200.10" extension="PSCTD0160f274530a031S"/>  <versionNumber value="2"/>  
  
  
  
  
  
  
  <component>
    <structuredBody classCode="DOCBODY">
      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>    </structuredBody>  </component></ClinicalDocument>

Item DT Card Conf Description Label

hl7:ClinicalDocument R CDA header XeHDport

hl7:realmCode CS 0 … 1 R This attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question. This element should not be used for identifying the originating country, that could be derived for the author and custodian information. XeHDport

hl7:typeId

1 … 1

The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

XeHDport

@root uid 1 … 1 F 2.16.840.1.113883.1.3

@extension st 1 … 1 F POCD_HD000040

Example <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>

hl7:templateId II 0 … 1 R XeHDport

@root uid 1 … 1 F 2.16.840.1.113883.2.51.10.12

hl7:templateId II 0 … 1 R XeHDport

@root uid 1 … 1 F 2.16.840.1.113883.10.22.1.1

hl7:id II 1 … 1 M Unique identifier of this instance of the HDR XeHDport

hl7:code CE.IPS 1 … 1 M Determines the type of Hospital Discharge Report XeHDport

@displayName 1 … 1 R

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.2.51.13.1.1 Hospital Discharge Summary type code (DYNAMIC)

Example <hl7:code displayName="Hospital Discharge summary" code="34105-7" codeSystem="2.16.840.1.113883.6.1"/>

hl7:translation CD.IPS 0 … * R This element can be here used either to provide the originally used document code if this is the result of a transformation. XeHDport

hl7:title ST 1 … 1 M Narrative title of the document, usually shown to the user. XeHDport

Example <title>Hospital Discharge Report</title>

Example <title>Lettera di dimissione ospedaliera</title>

xeh:documentStatus CO 0 … 1 XeHDport

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.4.642.3.241 CompositionStatus (DYNAMIC)

hl7:effectiveTime TS.IPS.TZ 1 … 1 R The date/time of document creation. Where the CDA document is transformed into another format, the ClinicalDocument.effectiveTime of the original document is preserved. XeHDport

Example <hl7:effectiveTime value="20210216114633+01:00"/>

hl7:confidentialityCode CE.IPS 1 … 1 R XeHDport

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)

Example <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/>

hl7:languageCode CS 1 … 1 R Document Language Code XeHDport

Constraint The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)

Example <languageCode code="en-GB"/>

Example <languageCode code="fil-PH"/>

Schematron assert role error

test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')

Message The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code)

hl7:setId

1 … 1

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

In the case this instance is generated as result of one or more transformations (translation/transcoding) the setId is supposed to remain unchanged across all those transformations.

XeHDport

hl7:versionNumber 1 … 1 R An integer value used to version successive replacement documents. XeHDport

Included

1 … 1

from 2.16.840.1.113883.2.51.10.9 XeH CDA recordTarget (DYNAMIC)

The recordTarget represents the medical record that this document belongs to.

A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated.

hl7:recordTarget 1 … 1 M XeHCrget

@typeCode cs 0 … 1 F RCT

@contextControlCode cs 0 … 1 F OP

Example <recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole classCode="PAT">
<id root="1.2.3.999" extension="__example only__"/> <addr>
<streetAddressLine>HSE M CASSAR STR</streetAddressLine> <city>ISLA</city> <country>MT</country> </addr> <telecom use="HP" value="tel:+356124567891"/> <telecom use="WP" value="mailto:elif@foo.too.mt"/> <patient>
<name>
<family>BORG</family> <given>TANIA</given> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/> <birthTime value="19430130"/> 

</patient> </patientRole></recordTarget>

hl7:patientRole 1 … 1 M XeHCrget

@classCode cs 0 … 1 F PAT

hl7:id II 1 … * R Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) XeHCrget

hl7:addr AD.IPS 1 … * R The patient address. XeHCrget

Constraint When used for cross-border exchange the country address part has to be provided.

Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)

@nullFlavor cs 0 … 1 F NI

Constraint SHALL NOT have mixed content except for white space
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.

Schematron assert role error

test @nullFlavor or hl7:*

Message If addr is not nullflavored at least one sub element has to be provided

hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line IPSAress

Schematron assert role error

test hl7:streetAddressLine and (hl7:city or hl7:postalCode)

Message If the address line is included either the city or the zip code has to be provided

hl7:city ADXP 0 … 1 C Subject's or Organization's City IPSAress

hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code IPSAress

hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province IPSAress

hl7:country ADXP 0 … 1 C Subject's Country. IPSAress

Constraint The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

hl7:telecom TEL 1 … * R Patient’s telecom information : e.g. telephone number, e-mail address. XeHCrget

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)

@nullFlavor cs 0 … 1 F NI

Constraint 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.

Example <telecom use="HP" value="tel:+356124567891"/>

Example <telecom use="WP" value="mailto:elif@foo.too.mt"/>

Example <telecom nullFlavor="NI"/>

hl7:patient 1 … 1 M XeHCrget

@classCode cs 0 … 1 F PSN

@determinerCode cs 0 … 1 F INSTANCE

Example

Japanese example (Person Name)

<patient>
  <name use="IDE">
    <family>木村</family>    <given>通男</given>  </name>  <name use="SYL">
    <family>きむら</family>    <given>みちお</given>  </name>  <name use="ABC">
    <family>KIMURA</family>    <given>MICHIO</given>  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient>

hl7:name PN 1 … * M Patient Name XeHCrget

Constraint The Alphabetic representation of the name SHALL be always provided

hl7:family 1 … * R Patient's Family Name/Surname XeHCrget

hl7:given 1 … * R Patient's Given Name XeHCrget

hl7:administrativeGenderCode CE.IPS 1 … 1 R Patient's Gender XeHCrget

@nullFlavor cs 0 … 1 F UNK

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)

Example <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
<translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>

hl7:birthTime TS 1 … 1 R Patient's Date of Birth. The patient date of birth may be a partial date such as only the year. XeHCrget

hl7:guardian

0 … *

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

XeHCrget

@classCode cs 1 … 1 F GUARD

Example <guardian classCode="GUARD">
<code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/> <addr nullFlavor="NI"/> <telecom use="MC" value="tel:+33-12345678"/> <guardianPerson>
<name>
<family>Curie</family> <given>Marie</given> </name> </guardianPerson></guardian>

hl7:code CD.IPS 0 … 1 R The relationship between the patient and the guardian or other contact may be recorded in the element. XeHCrget

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)

hl7:addr AD.IPS 1 … * R XeHCrget

Constraint 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.

Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)

@nullFlavor cs 0 … 1 F NI

Schematron assert role error

test @nullFlavor or hl7:*

Message If addr is not nullflavored at least one sub element has to be provided

hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line IPSAress

Schematron assert role error

test hl7:streetAddressLine and (hl7:city or hl7:postalCode)

Message If the address line is included either the city or the zip code has to be provided

hl7:city ADXP 0 … 1 C Subject's or Organization's City IPSAress

hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code IPSAress

hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province IPSAress

hl7:country ADXP 0 … 1 C Subject's Country. IPSAress

hl7:telecom TEL 1 … * R Guardian’s telecom information: e.g. telephone number; e-mail address. XeHCrget

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)

@nullFlavor cs 0 … 1 F NI

hl7:guardianPerson 1 … 1 R XeHCrget

hl7:name PN 1 … * R Patient Guardian's Name XeHCrget

hl7:family ENXP 1 … * R Patient Guardian's Family Name/Surname XeHCrget

hl7:given ENXP 1 … * R Patient Guardian's Given Name XeHCrget

hl7:languageCommunication 0 … * R XeHCrget

hl7:languageCode CS 1 … 1 R Patient’s language XeHCrget

Constraint The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)

Example

British English

Example

Amurdak (Australia)

Schematron assert role error

test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')

Message The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code)

Included 1 … * M from 2.16.840.1.113883.2.51.10.5 XeH CDA author (DYNAMIC)
Represents the humans and/or machines that authored the document.

The role of the author can also be recorded in the Author.functionCode or AssignedAuthor.code attribute.
If either of these attributes is included, they should be equivalent to or further specialize the role inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply "Physician Progress Note" and the value of Author.functionCode is "rounding physician"), and shall not conflict with the role inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

hl7:author 1 … * M XeHCthor

@typeCode cs 0 … 1 F AUT

@contextControlCode cs 0 … 1 F OP

Example <author>
<time value="201212290600+0100"/> <assignedAuthor>
<id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/> <addr use="WP">
<streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country> </addr> <telecom use="WP" value="tel:+39-051-34343434"/> <assignedPerson>
<name>
<given>Paolo</given> <family>Rossi</family> </name> </assignedPerson> </assignedAuthor> <representedOrganization>

</representedOrganization></author>

hl7:functionCode CE.IPS 0 … 1 R Function of the author (e.g. "Physician on duty", ...). Binding of this element is left open and needs to be set according to project policies. XeHCthor

hl7:time TS.IPS.TZ 1 … 1 R The author/time element represents the start time of the author’s participation in the creation of the clinical document. XeHCthor

Example <time value="201212290600+0100"/>

hl7:assignedAuthor 1 … 1 R XeHCthor

@classCode cs 0 … 1 F ASSIGNED

hl7:id II 1 … * R Author Identifier(s)

in case the author is a device, the UDI Device Identifier MAY be specified as a second id element. XeHCthor

@nullFlavor cs 0 … 1

hl7:code CE.IPS (extensible) 0 … 1 R A code, which identifies the profession/competence/specialty of the author when it is a person. XeHCthor

CONF

The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)

Example <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>

hl7:addr AD.IPS 1 … * R XeHCthor

Example <addr use="WP">
<streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country></addr>

hl7:telecom TEL.IPS 1 … * R XeHCthor

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)

@value st 0 … 1

Example <telecom use="WP" value="tel:+39-051-34343434"/>

Example <telecom nullFlavor="NI"/>

Choice

1 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice containing template 2.16.840.1.113883.2.51.10.90 XeH CDA Device (DYNAMIC)

hl7:assignedPerson 0 … 1 C XeHCthor

@classCode cs 0 … 1 F PSN

@determinerCode cs 0 … 1 F INSTANCE

hl7:name PN 1 … * R Name of the person (e.g. the Healthcare Professional) authoring this document XeHCthor

Example <name>
<given>John</given> <family>Español Smith</family></name>

hl7:family 1 … * R XeHCthor

hl7:given 1 … * R XeHCthor

hl7:assignedAuthoringDevice 0 … 1 C Contains 2.16.840.1.113883.2.51.10.90 XeH CDA Device (DYNAMIC) XeHCthor

Example <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
<softwareName displayName="Turriano"/></assignedAuthoringDevice>

hl7:representedOrganization 0 … 1 R Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) XeHCthor

Included 0 … 1 from 2.16.840.1.113883.2.51.10.7 XeH CDA dataEnterer (DYNAMIC)
Represents the participant who has transformed a dictated note into text.

hl7:dataEnterer 0 … 1 R XeHCerer

hl7:time TS.IPS.TZ 1 … 1 R Time of entering the data into the originating system XeHCerer

hl7:assignedEntity 0 … 1 R Represents the participant who has transformed a dictated note into text. A person entering the data into the originating system. XeHCerer

hl7:id 0 … * R Unique identification of the data enterer XeHCerer

hl7:addr AD.IPS 1 … * R XeHCerer

hl7:telecom TEL.IPS 1 … * R XeHCerer

hl7:assignedPerson 1 … 1 R XeHCerer

@classCode cs 0 … 1 F PSN

@determinerCode cs 0 … 1 F INSTANCE

hl7:name PN 1 … * M Name of the data enterer XeHCerer

Example <name>
<given>John</given> <family>Español Smith</family></name>

hl7:family 1 … * R Family Name/Surname XeHCerer

hl7:given 1 … * R Given Name XeHCerer

hl7:representedOrganization 0 … 1 R Organization the data enterer is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) XeHCerer

Included 1 … 1 M from 2.16.840.1.113883.2.51.10.6 XeH CDA custodian (DYNAMIC)

Represents the organization that is in charge of maintaining the document.
The custodian is the steward that is entrusted with the care of the document.

hl7:custodian 1 … 1 M XeHCdian

@typeCode cs 0 … 1 F CST

Example <custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">

</representedCustodianOrganization> </assignedCustodian></custodian>

hl7:assignedCustodian 1 … 1 R XeHCdian

@classCode cs 0 … 1 F ASSIGNED

hl7:representedCustodianOrganization 1 … 1 R Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) XeHCdian

Included 0 … * from 2.16.840.1.113883.2.51.10.14 XeH Information Recipient (DYNAMIC)

Represents a recipient who should receive a copy of the document.

hl7:informationRecipient 0 … * XeHIient

hl7:templateId II 1 … 1 M XeHIient

@root uid 1 … 1 F 2.16.840.1.113883.2.51.10.14

hl7:templateId II 1 … 1 M XeHIient

@root uid 1 … 1 F 2.16.840.1.113883.3.1937.99.61.67.10.15

hl7:templateId II 0 … * R XeHIient

hl7:intendedRecipient 1 … 1 R XeHIient

hl7:id II 0 … * R XeHIient

hl7:addr AD 1 … * R XeHIient

hl7:telecom TEL 1 … * R XeHIient

hl7:informationRecipient 0 … 1 Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC) XeHIient

hl7:receivedOrganization 0 … 1 Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) XeHIient

Included

0 … 1

from 2.16.840.1.113883.2.51.10.8 XeH CDA legalAuthenticator (DYNAMIC)

Represents a participant who has legally authenticated the document.

In the case where a local document is transformed into a CDA document for exchange, authentication occurs on the local document, and that fact is reflected in the exchanged CDA document. A CDA document can reflect the unauthenticated, authenticated, or legally authenticated state.
The unauthenticated state exists when no authentication information has been recorded (i.e., it is the absence of being either authenticated or legally authenticated).

hl7:legalAuthenticator 0 … 1 R XeHCator

Example <legalAuthenticator>
<time value="20111013150937-0800"/> <signatureCode code="S"/> <assignedEntity>
<id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/> <assignedPerson>
<name>
<given>John</given> <family>Español Smith</family> </name> </assignedPerson> <representedOrganization>
<name>Healthcare Facility's name</name> <addr>
<country>NL</country> <streetName>Duinweg</streetName> <houseNumber>23</houseNumber> <postalCode>7364 RX</postalCode> <city>Amsterdam</city> </addr> </representedOrganization> </assignedEntity></legalAuthenticator>

hl7:time TS.IPS.TZ 1 … 1 M Time of signing the document XeHCator

hl7:signatureCode CS 1 … 1 R Signature code XeHCator

@code CONF 0 … 1 F S

hl7:assignedEntity 0 … 1 R The entity that is responsible for the legal authentication of the CDA document XeHCator

hl7:id 1 … * R Unique identification of legal authenticator XeHCator

hl7:code CE.IPS (preferred) A code, which identifies the profession/competence/specialty of the author when it is a person. XeHCator

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)

hl7:addr AD.IPS 1 … * R XeHCator

hl7:telecom TEL.IPS 1 … * R XeHCator

hl7:assignedPerson 1 … 1 R Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC) XeHCator

hl7:representedOrganization 1 … 1 M Organization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) XeHCator

Included 0 … * from 2.16.840.1.113883.2.51.10.48 XeH Ordering Provider (DYNAMIC)
Referring Physiscian

hl7:participant 0 … * Referral Ordering Physician XeHOider

@typeCode cs 1 … 1 F REF

hl7:templateId II 1 … 1 XeHOider

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.6

hl7:templateId II 1 … 1 XeHOider

@root uid 1 … 1 F 2.16.840.1.113883.2.51.10.48

hl7:time IVL_TS 1 … 1 R This element represents the date and time the order was placed. Time MAY be present. XeHOider

hl7:associatedEntity 1 … 1 XeHOider

hl7:code CE.IPS (preferred) 0 … 1 A code, which identifies the profession/competence/specialty of the author when it is a person. XeHOider

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)

hl7:addr AD 1 … * R The address of this person (referral ordering physician) SHALL be present. XeHOider

hl7:telecom TEL 1 … * R The telecom of this person (referral ordering physician) SHALL be present. XeHOider

hl7:associatedPerson 0 … 1 R Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC) XeHOider

hl7:scopingOrganization 0 … 1 Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) XeHOider

Included 0 … * from 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (DYNAMIC)
Patient contacts, such as Next-of-Kin, Emergency contact, etc.

hl7:participant 0 … * R Patient contacts or the Preferred Health Professional to contact in case of emergency. IPSCacts

where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']

@typeCode cs 1 … 1 F IND

Example <participant typeCode="IND">
<templateId root="2.16.840.1.113883.10.22.2.5"/> <associatedEntity classCode="NOK">
<addr>
<streetAddressLine>Promenade des Anglais 111</streetAddressLine> <city>Lyon</city> <postalCode>69001</postalCode> <country>FR</country> </addr> <telecom value="tel:(+33)555-20036" use="WP"/> <associatedPerson>
<name>
<given>Martha</given> <family>Mum</family> </name> </associatedPerson> </associatedEntity></participant>

hl7:templateId II 1 … 1 M IPSCacts

@root uid 1 … 1 F 2.16.840.1.113883.10.22.2.5

hl7:functionCode 0 … 1 C The element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency. IPSCacts

@code CONF 0 … 1 F PCP

@codeSystem 0 … 1 F 2.16.840.1.113883.5.88

hl7:associatedEntity R The element identifies the type of contact. IPSCacts

@classCode cs 1 … 1 R

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes (DYNAMIC)

Example <associatedEntity classCode="ECON">
<addr>
<streetAddressLine>Karl Strasse</streetAddressLine> <city>Freiberg</city> <postalCode>09599</postalCode> <country>DE</country> </addr> <telecom value="tel:+49-761-11110000" use="WP"/> <associatedPerson>
<name>
<given>Arzt</given> <family>Guter</family> </name> </associatedPerson></associatedEntity>

hl7:code CV.IPS 0 … 1 R This element indicates the relationship between the patient and this participant. IPSCacts

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.54 IPS Personal Relationship (DYNAMIC)

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)

Example <code code="AUNT" displayName="θεία" codeSystem="2.16.840.1.113883.5.111"/>

hl7:addr AD.IPS 1 … * R Patient Contact's / Preferred HP's Address IPSCacts

Schematron assert role error

test @nullFlavor or hl7:*

Message If addr is not nullflavored at least one sub element has to be provided

Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)

@nullFlavor cs 0 … 1 F NI

Schematron assert role error

test @nullFlavor or hl7:*

Message If addr is not nullflavored at least one sub element has to be provided

hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line IPSAress

Schematron assert role error

test hl7:streetAddressLine and (hl7:city or hl7:postalCode)

Message If the address line is included either the city or the zip code has to be provided

hl7:city ADXP 0 … 1 C Subject's or Organization's City IPSAress

hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code IPSAress

hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province IPSAress

hl7:country ADXP 0 … 1 C Subject's Country. IPSAress

hl7:telecom TEL 1 … * R Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail element is required. IPSCacts

@use set_cs 0 … 1

CONF

The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)

@nullFlavor cs 0 … 1 F NI

Example <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>

Choice

1 … 2

Elements to choose from:

hl7:associatedPerson
hl7:scopingOrganization

hl7:associatedPerson 0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided IPSCacts

hl7:name PN 1 … * R Patient Contact's Name / Preferred HP's Name IPSCacts

Example <name>
<given>John</given> <family>Español Smith</family></name>

hl7:family 1 … * R Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname IPSCacts

hl7:given 1 … * R Patient Contact's Given Name / Preferred HP's Given Name IPSCacts

hl7:scopingOrganization 0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided IPSCacts

hl7:name ON 1 … * R Organization's Name IPSCacts

Included

0 … *

from 2.16.840.1.113883.10.12.108 CDA participant (DYNAMIC)

Other participants, such as Primary care physician, insurance, etc.

hl7:participant 0 … * CDAppant

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)

@contextControlCode cs 0 … 1 F OP

hl7:functionCode CE 0 … 1 CDAppant

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)

hl7:time IVL_TS 0 … 1 CDAppant

hl7:associatedEntity 1 … 1 CDAppant

@classCode cs 1 … 1 R

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)

hl7:id II 0 … * CDAppant

hl7:code CE 0 … 1 CDAppant

CONF

shall be drawn from concept domain "RoleCode"

hl7:addr AD 0 … * CDAppant

hl7:telecom TEL 0 … * CDAppant

hl7:associatedPerson 0 … 1 Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) CDAppant

hl7:scopingOrganization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) CDAppant

Included 0 … * from 2.16.840.1.113883.2.51.10.11 XeH inFulfillmentOf (DYNAMIC)
Reference to the order that is fulfilled by this document.

hl7:inFulfillmentOf 0 … * XeHintOf

@typeCode cs 0 … 1 F FLFS

hl7:order 1 … 1 R XeHintOf

@classCode cs 0 … 1 F ACT

@moodCode cs 1 … 1 F RQO

hl7:id II 1 … * R Identifier of the order XeHintOf

hl7:code CE 0 … 1 Type of order XeHintOf

hl7:priorityCode CE 0 … 1 XeHintOf

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)

Included 0 … * from 2.16.840.1.113883.10.12.110 CDA documentationOf (DYNAMIC)
Reference to the ServiceEvent(s) based on which this document has been created.

hl7:documentationOf 0 … * CDAdonOf

@typeCode cs 1 … 1 F DOC

hl7:serviceEvent 1 … 1 CDAdonOf

@classCode cs 1 … 1 F ACT

@moodCode cs 1 … 1 F EVN

hl7:id II 0 … * CDAdonOf

hl7:code CE 0 … 1 CDAdonOf

CONF

shall be drawn from concept domain "ActCode"

hl7:effectiveTime IVL_TS 0 … 1 CDAdonOf

hl7:performer 0 … * CDAdonOf

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)

hl7:functionCode CE 0 … 1 CDAdonOf

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)

hl7:time IVL_TS 0 … 1 CDAdonOf

hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) CDAdonOf

Included 0 … 2 R from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)
A reference to a ParentDocument representing the source of a document revision, addenda, or transformation.

Constraint

A conformant CDA document can have:

a single relatedDocument with typeCode "APND"; OR
a single relatedDocument with typeCode "RPLC"; OR
a single relatedDocument with typeCode "XFRM"; OR
a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; OR
a combination of two relatedDocuments with typeCodes "XFRM" and "APND".

No other combinations are allowed.

hl7:relatedDocument 0 … 2 R IPSCment

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)

hl7:parentDocument 1 … 1 R IPSCment

@classCode cs 0 … 1 F DOCCLIN

@moodCode cs 0 … 1 F EVN

hl7:id II 1 … * R IPSCment

hl7:code CD.IPS 0 … 1 R IPSCment

@codeSystem CONF 0 … 1 F 2.16.840.1.113883.6.1

hl7:text ED 0 … 1 R IPSCment

hl7:setId II 0 … 1 R IPSCment

hl7:versionNumber INT 0 … 1 R IPSCment

Included

1 … 1

from 2.16.840.1.113883.2.51.10.49 XeH HDR ComponentOf (DYNAMIC)

A reference to the clinical encounter during which the documented act(s) or ServiceEvent occurred.

Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note.

hl7:componentOf 1 … 1 R XeHHntOf

@typeCode cs 0 … 1 F COMP

hl7:encompassingEncounter 1 … 1 R XeHHntOf

@classCode cs 0 … 1 F ENC

@moodCode cs 0 … 1 F EVN

hl7:id II 1 … * R Identifier of the encounter (e.g. identifier of the hospital stay) XeHHntOf

hl7:code CE (extensible) 0 … 1 Code describing the kind of clinical encounter during which the documented act(s) or ServiceEvent occurred. XeHHntOf

CONF

The value of @code should be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)

hl7:effectiveTime IVL_TS 1 … 1 R XeHHntOf

hl7:low IVXB_TS 1 … 1 R Start date time of the encounter (e.g. date of admission) XeHHntOf

hl7:high IVXB_TS 1 … 1 R End date time of the encounter (e.g. date of discharge) XeHHntOf

hl7:dischargeDispositionCode CE (extensible) 0 … 1 R Depict the disposition of the patient at the time of hospital discharge (e.g., discharged to home, expired, against medical advice, etc.). XeHHntOf

CONF

The value of @code should be drawn from value set 2.16.840.1.113883.4.642.3.259 Discharge disposition (DYNAMIC)

hl7:responsibleParty

0 … 1

The provider (person or organization) who has primary responsibility for the encounter. The responsible provider is not necessarily present in an encounter, but is accountable for the action through the power to delegate, and the duty to review actions with the performing participant.

When the responsible party is an organization, the responsible party is reflected by the presence of a scoping Organization, without a playing entity.

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)

XeHHntOf

@typeCode cs 0 … 1 F RESP

hl7:encounterParticipant 0 … 1 R Admitter XeHHntOf

@typeCode cs 1 … 1 F ADM

hl7:time IVL_TS 0 … 1 The time when the participation occurred XeHHntOf

hl7:assignedEntity 1 … 1 R The clinician assigned to the role (e.g. Admitter) by the scoping organization (e.g the hospital)

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) XeHHntOf

hl7:encounterParticipant 0 … 1 R Discharger XeHHntOf

@typeCode cs 1 … 1 F DIS

hl7:time IVL_TS 0 … 1 The time when the participation occurred XeHHntOf

hl7:encounterParticipant 0 … 1 R Attender XeHHntOf

@typeCode cs 1 … 1 F ATND

hl7:time IVL_TS 0 … 1 The time when the participation occurred XeHHntOf

hl7:encounterParticipant 0 … * R Other clinicians directly associated with the encounter. XeHHntOf

@typeCode cs 1 … 1 R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)

hl7:time IVL_TS 0 … 1 The time when the participation occurred XeHHntOf

hl7:location

0 … 1

The location where the service is done. May be a static building (or room therein) or a moving location (e.g., ambulance, helicopter, aircraft, train, truck, ship, etc.)

The setting of an encounter (e.g. cardiology clinic, primary care clinic, rehabilitation hospital, skilled nursing facility) can be expressed in HealthCareFacility.code. Note that setting and physical location are not the same.

XeHHntOf

@typeCode cs 0 … 1 F LOC

hl7:healthCareFacility 1 … 1 R XeHHntOf

@classCode cs 0 … 1 F SDLOC

hl7:id II 0 … * XeHHntOf

hl7:code CE 0 … 1 XeHHntOf

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)

hl7:location 0 … 1 Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) XeHHntOf

hl7:serviceProviderOrganization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) XeHHntOf

hl7:component 1 … 1 M XeHDport

hl7:structuredBody 1 … 1 M Note: the proposed order of the sections hereafter indicated is not mandatory XeHDport

@classCode cs 0 … 1 F DOCBODY

hl7:component 0 … 1 R ========== HISTORICAL AND ADMISSION RELATED SECTIONS BEGIN ========
Contains 2.16.840.1.113883.2.51.10.15 XeH Patient History Section (DYNAMIC) XeHDport

hl7:component 0 … 1 R Contains 2.16.840.1.113883.2.51.10.29 XeH Admission Diagnosis Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.30 XeH Chief Complaint and Reason for Visit Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.23 XeH Problems Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.31 XeH Admission Medications Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.65 XeH Immunizations Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.57 XeH History of Past Illness Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.16 XeH Family History Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.67 XeH Foreign Travel Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC) XeHDport

hl7:component 0 … 1 ========== HISTORICAL AND ADMISSION RELATED SECTIONS END ========

========== HOSPITALIZATION RELATED SECTIONS BEGIN ========
Contains 2.16.840.1.113883.2.51.10.83 XeH Hospital Course Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.41 XeH Medication Summary Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.82 XeH Vital Signs Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC) XeHDport

hl7:component 0 … 1 ========== DISCHARGE RELATED SECTIONS BEGIN ========

Contains 2.16.840.1.113883.2.51.10.28 XeH Discharge Diagnosis Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.50 XeH Hospital Discharge Physical Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.2.51.10.26 XeH Discharge Medications Section (DYNAMIC) XeHDport

hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC) XeHDport

hl7:component 0 … 1 ========== DISCHARGE RELATED SECTIONS END ========

Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (DYNAMIC) XeHDport

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Template XeH Hospital Discharge Report 2021‑09‑10 14:49:32