Item | DT | Card | Conf | Description | Label |
---|
hl7:ClinicalDocument
| | | | | XeHDport |
hl7:realmCode
| CS | 0 … 1 | R | This element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal). Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension. | XeHDport |
| Example | Example for a French extension <realmCode code="FR"/> |
hl7:typeId
| II | 1 … 1 | M | This element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows: ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). | XeHDport |
@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 | | XeHDport |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.2.51.10.2 |
hl7:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8404) such that it | CONF8404 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.5 | CONF0042 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.5" (CONF:1198-10042). |
@extension
| st | 1 … 1 | F | 2014-06-09 | CONF2515 |
| SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1198-32515). |
hl7:id
| II | 1 … 1 | M | SHALL contain exactly one [1..1] id (CONF:1198-30932). | CONF0932 |
@root
| uid | 1 … 1 | R | This id SHALL contain exactly one [1..1] @root (CONF:1198-30933). | CONF0933 |
hl7:code
| CE.IPS | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-14833). Preferred code is 18748-4 LOINC Diagnostic Imaging Report | CONF4833 |
hl7:title
| ST | 1 … 1 | M | The Radiology Specialty Section <title> MAY be present. It is the local translation of the code@displayName. | XeHDport |
xeh:documentStatus
| CO | 0 … 1 | | | XeHDport |
| CONF | |
hl7:effectiveTime
| TS.IPS.TZ | 1 … 1 | R | ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the radiology report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision. | XeHDport |
| Example | <effectiveTime value="20080624131933.0000-0500"/> |
hl7:confidentialityCode
| CE.IPS (required) | 1 … 1 | R | ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard. | XeHDport |
| CONF | |
| Example | <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/> |
hl7:languageCode
| CS | 1 … 1 | R | ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard. | XeHDport |
| Example | Example of a report authored in American English <languageCode code="en-US"/> |
| Example | Example of a report authored in French <languageCode code="fr-FR"/> |
hl7:setId
| II | 1 … 1 | M | ClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of thisreport. | XeHDport |
| Example | <setId root="1.3.6.1.4.1.19376.1.3.4" extension="abc2"/> |
hl7:versionNumber
| INT | 1 … 1 | R | ClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning. | XeHDport |
Included | 1 … 1 | R | from 2.16.840.1.113883.3.1937.99.61.67.10.1 XeH CDA recordTarget (2020‑09‑29 12:01:13) |
hl7:recordTarget
| | 1 … 1 | R | | XeHSrget |
@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"/> <!-- Optional guardian information ; see example below--> <!-- Optional languageCommunication information see example below --> </patient> </patientRole></recordTarget> |
hl7:patientRole
| | 1 … 1 | M | | XeHSrget |
@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) | XeHSrget |
hl7:addr
| AD.IPS | 1 … * | R | The patient address. | XeHSrget |
| 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 | |
@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. | XeHSrget |
@use
| set_cs | 0 … 1 | | |
| CONF | |
@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 | | XeHSrget |
@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 | XeHSrget |
| Constraint | The Alphabetic representation of the name SHALL be always provided |
hl7:family
| | 1 … * | R | Patient's Family Name/Surname | XeHSrget |
hl7:given
| | 1 … * | R | Patient's Given Name | XeHSrget |
hl7:administrativeGenderCode
| CE.IPS | 1 … 1 | R | Patient's Gender | XeHSrget |
@nullFlavor
| cs | 0 … 1 | F | UNK |
| CONF | |
| 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. | XeHSrget |
hl7:guardian
| | 0 … * | R | The guardians of a patient.
Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact. | XeHSrget |
@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. | XeHSrget |
| CONF | |
hl7:addr
| AD.IPS | 1 … * | R | | XeHSrget |
| 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 | |
@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 | Guardian’s telecom information: e.g. telephone number; e-mail address. | XeHSrget |
@use
| set_cs | 0 … 1 | | |
| CONF | |
@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.
|
hl7:guardianPerson
| | 1 … 1 | R | | XeHSrget |
hl7:name
| PN | 1 … * | R | Patient Guardian's Name | XeHSrget |
hl7:family
| ENXP | 1 … * | R | Patient Guardian's Family Name/Surname | XeHSrget |
hl7:given
| ENXP | 1 … * | R | Patient Guardian's Given Name | XeHSrget |
hl7:languageCommunication
| | 0 … * | R | | XeHSrget |
hl7:languageCode
| CS | 1 … 1 | R | Patient’s language | XeHSrget |
| Constraint | The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted |
| CONF | |
| Example | British English <languageCode code="en-GB"/> |
| Example | Amurdak (Australia) <languageCode code="amg-AU"/> |
| 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 … * | R | from 2.16.840.1.113883.3.1937.99.61.67.10.2 XeH CDA author (DYNAMIC)
At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the radiology report was produced. The radiology report can be authored by a software system or by a person or by both. |
hl7:author
| | 1 … * | R | | XeHSthor |
@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> <!-- template 'IPS CDA Organization' (dynamic) --> </representedOrganization></author> |
hl7:functionCode
| CE.IPS | 0 … 1 | R | | XeHSthor |
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. | XeHSthor |
| Example | <time value="201212290600+0100"/> |
hl7:assignedAuthor
| | 1 … 1 | R | | XeHSthor |
@classCode
| cs | 0 … 1 | F | ASSIGNED |
hl7:id
| II | 1 … * | R | Author Identifier(s) | XeHSthor |
@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. | XeHSthor |
| CONF | |
| 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 | | XeHSthor |
| 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 | | XeHSthor |
@use
| set_cs | 0 … 1 | | |
| CONF | |
@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
| | 0 … 1 | C | | XeHSthor |
@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 | XeHSthor |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
hl7:family
| | 1 … * | R | | XeHSthor |
hl7:given
| | 1 … * | R | | XeHSthor |
hl7:assignedAuthoringDevice
| | 0 … 1 | C | Contains 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) | XeHSthor |
| 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) | XeHSthor |
Included | 0 … 1 | | from 2.16.840.1.113883.3.1937.99.61.67.10.12 XeH CDA dataEnterer (DYNAMIC) |
hl7:dataEnterer
| | 0 … 1 | R | | XeHSerer |
hl7:time
| TS.IPS.TZ | 1 … 1 | R | Time of entering the data into the originating system | XeHSerer |
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. | XeHSerer |
hl7:id
| | 0 … * | R | Unique identification of the data enterer | XeHSerer |
hl7:addr
| AD.IPS | 1 … * | R | | XeHSerer |
hl7:telecom
| TEL.IPS | 1 … * | R | | XeHSerer |
hl7:assignedPerson
| | 1 … 1 | R | | XeHSerer |
@classCode
| cs | 0 … 1 | F | PSN |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:name
| PN | 1 … * | M | Name of the data enterer | XeHSerer |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
hl7:family
| | 1 … * | R | Family Name/Surname | XeHSerer |
hl7:given
| | 1 … * | R | Given Name | XeHSerer |
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) | XeHSerer |
Included | 1 … 1 | R | from 2.16.840.1.113883.3.1937.99.61.67.10.5 XeH CDA custodian (DYNAMIC)
ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the radiology report. |
hl7:custodian
| | 1 … 1 | R | | XeHSdian |
@typeCode
| cs | 0 … 1 | F | CST |
| Example | <custodian typeCode="CST"> <assignedCustodian classCode="ASSIGNED"> <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE"> <!-- template 'IPS CDA Organization' (dynamic) --> </representedCustodianOrganization> </assignedCustodian></custodian> |
hl7:assignedCustodian
| | 1 … 1 | R | | XeHSdian |
@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) | XeHSdian |
@classCode
| cs | 0 … 1 | F | ORG |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
Included | 0 … * | | from 2.16.840.1.113883.3.1937.99.61.67.10.15 XeH Information Recipient (DYNAMIC) |
hl7:informationRecipient
| | 0 … * | | | XeHSient |
hl7:templateId
| II | 1 … 1 | M | | XeHSient |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.99.61.67.10.15 |
hl7:templateId
| II | 0 … * | R | | XeHSient |
hl7:intendedRecipient
| | 1 … 1 | R | | XeHSient |
hl7:id
| II | 0 … * | R | | XeHSient |
hl7:addr
| AD | 1 … * | | | XeHSient |
hl7:telecom
| TEL | 1 … * | | | XeHSient |
hl7:informationRecipient
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) | XeHSient |
hl7:receivedOrganization
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) | XeHSient |
Included | 0 … 1 | R | from 2.16.840.1.113883.3.1937.99.61.67.10.3 XeH CDA legalAuthenticator (DYNAMIC)
The ClinicalDocument/legalAuthenticator MAY be present. When present, it SHALL be in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. This element carries the person who has legally authenticated the report, and the organization represented by this person. The sub-element time carries the date&time this legal authentication took place. The sub-element signatureCode carries the “signed” (S) status If this entity happens also to be one of the validators of the radiology results in the report, it SHALL also be documented as a validator. |
hl7:legalAuthenticator
| | 0 … 1 | R | | XeHSator |
| 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 | XeHSator |
hl7:signatureCode
| CS | 0 … 1 | R | Signature code | XeHSator |
@code
| CONF | 0 … 1 | F | S |
hl7:assignedEntity
| | 0 … 1 | R | The entity that is responsible for the legal authentication of the CDA document | XeHSator |
hl7:id
| | 1 … * | R | Unique identification of legal authenticator | XeHSator |
hl7:addr
| AD.IPS | 1 … * | R | | XeHSator |
hl7:telecom
| TEL.IPS | 1 … * | R | | XeHSator |
hl7:assignedPerson
| | 1 … 1 | R | | XeHSator |
@classCode
| cs | 0 … 1 | F | PSN |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:name
| PN | 1 … * | R | Name of the legal authenticator | XeHSator |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
hl7:family
| | 1 … * | R | HP Family Name/Surname | XeHSator |
hl7:given
| | 1 … * | R | HP Given Name | XeHSator |
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) | XeHSator |
Included | 0 … * | R | from 2.16.840.1.113883.2.51.10.44 XeH Results Validator (DYNAMIC) |
hl7:authenticator
| | 0 … * | R | | XeHCator |
@typeCode
| cs | 1 … 1 | F | AUTHEN |
hl7:templateId
| II | 1 … 1 | M | | XeHCator |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.3.1.5 |
hl7:time
| TS | 1 … 1 | R | | XeHCator |
hl7:signatureCode
| CS | 1 … 1 | R | | XeHCator |
hl7:assignedEntity
| | 1 … 1 | R | | XeHCator |
@classCode
| cs | 0 … 1 | F | ASSIGNED |
hl7:id
| II | 1 … * | R | | XeHCator |
hl7:code
| CE.IPS (preferred) | 0 … 1 | R | A code, which identifies the profession/competence/specialty of the author when it is a person.
| XeHCator |
| CONF | |
hl7:addr
| AD | 1 … * | R | | XeHCator |
hl7:telecom
| TEL | 1 … * | R | | XeHCator |
| Schematron assert | role | error | |
| test | not(hl7:assignedPerson) or hl7:assignedPerson/hl7:name | |
| Message | the <name/> sub-element of <assignedPerson/> SHALL be present. | |
hl7:assignedPerson
| | 0 … 1 | R | Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC) | XeHCator |
hl7:representedOrganization
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) | XeHCator |
Included | 0 … * | | from 2.16.840.1.113883.3.1937.99.61.67.10.4 XeH Ordering/Referring Provider (DYNAMIC)
ClinicalDocument/participant(s) MAY be present. When present, this element SHALL be in accordance with the HL7 CDA R2 standard with a time element and further constrained by this specification to require the presence of name, addr and telecom. In particular, when the ordering provider of the order (or group of orders) fulfilled by this radiology report is present in the CDA, it SHALL be documented as a participant with the attribute typeCode valued “REF” (referrer). |
hl7:participant
| | 0 … * | | Referral Ordering Physician | XeHOider |
@typeCode
| cs | 1 … 1 | F | REF |
hl7:templateId
| II | 1 … 1 | | | XeHOider |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.99.61.67.10.4 |
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:addr
| AD | 0 … * | R | The address of this person (referral ordering physician) SHALL be present. | XeHOider |
hl7:telecom
| TEL | 0 … * | R | The telecom of this person (referral ordering physician) SHALL be present. | XeHOider |
| Schematron assert | role | error | |
| test | not(hl7:assignedPerson) or hl7:assignedPerson/hl7:name | |
| Message | The <name> sub-element SHALL be present when <assignedPerson> present. | |
hl7:associatedPerson
| | 0 … 1 | R | | XeHOider |
hl7:scopingOrganization
| | 0 … 1 | | | XeHOider |
Included | 0 … * | | from 1.2.840.10008.9.1.10.8 DICOM inFulfillmentOf (DYNAMIC) MAY contain zero or more [0..*] inFulfillmentOf (CONF:1198-30936).An inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group. |
hl7:inFulfillmentOf
| | 0 … * | R | | DICOntOf |
@typeCode
| cs | 0 … 1 | | |
hl7:order
| | 1 … 1 | R | | DICOntOf |
hl7:id
| II | 1 … 1 | R | | DICOntOf |
@extension
| st | 1 … 1 | R | |
@root
| uid | 1 … 1 | R | |
ps3-20:accessionNumber
| II | 1 … 1 | R | | DICOntOf |
@extension
| st | 1 … 1 | R | |
@root
| uid | 1 … 1 | R | |
hl7:code
| CE | 0 … 1 | | | DICOntOf |
hl7:priorityCode
| CE | 0 … 1 | | | DICOntOf |
| CONF | |
Included | 0 … * | | from 2.16.840.1.113883.10.12.110 CDA documentationOf (DYNAMIC) SHALL contain exactly one [1..1] documentationOf (CONF:1198-8416) such that itEach serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure. |
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 | |
hl7:functionCode
| CE | 0 … 1 | | | CDAdonOf |
| CONF | |
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) MAY contain zero or more relatedDocumentA DIR may have three types of parent document: • A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. • An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. • A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document. |
hl7:relatedDocument
| | 0 … 2 | R | | IPSCment |
@typeCode
| cs | 1 … 1 | R | |
| CONF | |
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 | 0 … 1 | | from 2.16.840.1.113883.3.1937.99.61.67.10.7 XeH ComponentOf (DYNAMIC) MAY contain zero or one [0..1] componentOf (CONF:1198-30939).The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used. |
hl7:componentOf
| | 0 … 1 | | | XeHSntOf |
@typeCode
| cs | 0 … 1 | F | COMP |
hl7:encompassingEncounter
| | 1 … 1 | R | | XeHSntOf |
@classCode
| cs | 0 … 1 | F | ENC |
@moodCode
| cs | 0 … 1 | F | EVN |
hl7:id
| II | 0 … * | R | Identifier of the encounter (e.g. identifier of the hospital stay) | XeHSntOf |
hl7:code
| CE | 0 … 1 | | Code describing the kind of clinical encounter during which the documented act(s) or ServiceEvent occurred.
| XeHSntOf |
| CONF | |
hl7:effectiveTime
| IVL_TS | 1 … 1 | R | | XeHSntOf |
hl7:low
| IVXB_TS | 1 … 1 | R | Start date time of the encounter (e.g. date of admission) | XeHSntOf |
hl7:high
| IVXB_TS | 1 … 1 | R | End date time of the encounter (e.g. date of discharge)
| XeHSntOf |
hl7:dischargeDispositionCode
| CE | 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.).
| XeHSntOf |
| CONF | shall be drawn from concept domain "EncounterDischargeDisposition" |
|
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) | XeHSntOf |
@typeCode
| cs | 0 … 1 | F | RESP |
hl7:encounterParticipant
| | 0 … * | | Represents clinicians directly associated with the encounter (e.g. by initiating, terminating, or overseeing it).
| XeHSntOf |
@typeCode
| cs | 1 … 1 | R | |
| CONF | |
hl7:time
| IVL_TS | 0 … 1 | | The time when the participation occurred
| XeHSntOf |
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) | XeHSntOf |
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. | XeHSntOf |
@typeCode
| cs | 0 … 1 | F | LOC |
hl7:healthCareFacility
| | 1 … 1 | R | | XeHSntOf |
@classCode
| cs | 0 … 1 | F | SDLOC |
hl7:id
| II | 0 … * | | | XeHSntOf |
hl7:code
| CE | 0 … 1 | | | XeHSntOf |
| CONF | |
hl7:location
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) | XeHSntOf |
hl7:serviceProviderOrganization
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) | XeHSntOf |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:1198-14907). | CONF4907 |
cda:structuredBody
| | 1 … 1 | M | This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30695). | CONF0695 |
hl7:component
| | 0 … 1 | | Contains 2.16.840.1.113883.2.51.10.61 XeH Clinical Information (DYNAMIC) | CONF0695 |
hl7:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.2.51.10.63 XeH Imaging Procedure Description (DYNAMIC) | CONF0695 |
hl7:component
| | 0 … 1 | | Contains 2.16.840.1.113883.2.51.10.86 XeH Comparison Study (DYNAMIC) | CONF0695 |
hl7:component
| | 0 … 1 | | Contains 2.16.840.1.113883.2.51.10.79 XeH Findings (DYNAMIC) | CONF0695 |
hl7:component
| | 1 … 1 | R | Contains 2.16.840.1.113883.2.51.10.85 XeH Impression (DYNAMIC) | CONF0695 |
hl7:component
| | 0 … * | | Contains 2.16.840.1.113883.2.51.10.87 XeH Addendum (DYNAMIC) | CONF0695 |