| Item | DT | Card | Conf | Description | Label |
|---|
hl7:recordTarget
| | 1 … 1 | R | A human patient for whom this CDA document instance was created.
- Target patient
The HL7 CDA R2 (2005) standard allows multiple patients.
In order to ensure that the information in a CDA document is unambiguously assigned to one and only patient, a CDA-CH V2 based document MUST contain exactly one patient.
Special cases: In exceptional cases (e.g., new-born twins, both having jaundice), multiple documents MUST be created (all of the same content, but each with a unique patient).
- Patient identifiers
Multiple ids (patient identification number) MAY be declared.
If multiple ids are known, it is highly recommended to declare all known ids. Especially in cases where the CDA document instance is kind of an answer to a preceding order (independent of its data format), all ids specified by the ordering system SHALL be declared in the CDA document instance. This allows the receiver to assign its internal patient identification.
The patient identification number MUST be grouped with the OID of its assigning system. The patient identification number MUST be unique within the system identified by the OID.
The declared OID MUST be found in one of the public OID registries, such as oid.refdata.ch (preferred), oid-info.com, hl7.org/oid, www.dimdi.de/static/de/klassi/oid/, gesundheit.gv.at/OID_Frontend/ etc.
OIDs that can't be found in a public OID registry are NOT ALLOWED.
- Pseudonymizing
In special cases, the demographic data of the patient are not allowed to be transmitted or they have to be pseudonymized.
While HL7 CDA or its derivatives like CDA-CH or Swiss exchange formats nevertheless require these elements in the XML structure, the affected values MUST be replaced by a nullFlavor of type "MSK" (masked), in order to support the required data format structure and simultaneously to shield the real data.
| cdac ient |
hl7:patientRole
| | 1 … 1 | R | | cdacient |
hl7:id
| II | 1 … * | R | The patient's id. | cdacient |
@extension
| st | 1 … 1 | R | The id itself. It MUST be unique within the issuing system. |
@root
| uid | 1 … 1 | R | The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED. |
hl7:addr
| AD | 0 … * | | The patient's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | cdacient |
hl7:telecom
| TEL | 0 … * | | The patient's means of communication (phone, eMail, ...). | cdacient |
hl7:patient
| | 1 … 1 | R | Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | cdacient |
hl7:administrativeGenderCode
| CE | 1 … 1 | R | The patient's gender according to the Swiss EPR XDS.b metadata. | cdacient |
@displayName
| st | 1 … 1 | R | |
@code
| cs | 1 … 1 | R | |
@codeSystemName
| st | 1 … 1 | F | HL7 AdministrativeGender |
@codeSystem
| oid | 1 … 1 | F | 2.16.840.1.113883.5.1 |
| | CONF | |
hl7:birthTime
| TS.CH.TZ | 1 … 1 | | The patient's birthdate. | cdacient |
hl7:maritalStatusCode
| CE | 0 … 1 | | The patient's marital status. | cdacient |
@displayName
| st | 1 … 1 | R | |
@code
| cs | 1 … 1 | R | |
@codeSystemName
| st | 1 … 1 | F | HL7 MaritalStatus |
@codeSystem
| oid | 1 … 1 | F | 2.16.840.1.113883.1.11.12212 |
| | CONF | |
hl7:translation
| | 0 … * | | A translation of the code to another coding system | cdacient |
@displayName
| st | 1 … 1 | R | |
@code
| cs | 1 … 1 | R | |
@codeSystemName
| st | 1 … 1 | R | |
@codeSystem
| oid | 1 … 1 | R | |
hl7:religiousAffiliationCode
| CE | 0 … 1 | | The patient's religion. | cdacient |
@nullFlavor
| cs | 0 … 1 | F | NAV |
@displayName
| st | 0 … 1 | | |
@code
| cs | 0 … 1 | | |
@codeSystemName
| st | 0 … 1 | | |
@codeSystem
| oid | 0 … 1 | | |
hl7:originalText
| ED | 0 … 1 | C | The patient's religion as plain text. | cdacient |
| | Schematron assert | role |  error | |
| | test | (@nullFlavor='NAV' and originalText and not(@codeSystem or @codeSystemName or @code or @displayName)) or (@codeSystem and @codeSystemName and @code and @displayName) | |
| | Message | Either a code described by code, codeSystem, codeSystemName and displayName or originalText and nullFlavor="NAV" is REQUIRED. | |
hl7:guardian
| | 0 … * | | The patient's guardian. | cdacient |
hl7:id
| II | 0 … * | | The guardian's id. | cdacient |
hl7:code
| CE | 0 … 1 | | The guardian's role. | cdacient |
@nullFlavor
| cs | 0 … 1 | | |
@displayName
| st | 0 … 1 | | |
@codeSystemName
| st | 0 … 1 | F | HL7RoleCode |
@codeSystem
| oid | 0 … 1 | F | 2.16.840.1.113883.5.111 |
@code
| cs | 0 … 1 | | |
| | Schematron assert | role | error | |
| | test | (not(@nullFlavor) and @displayName and @code and @codeSystem and @codeSystemName) or (@nullFlavor and not(@displayName or @code or @codeSystem or @codeSystemName)) | |
| | Message | Either nullFlavor or a valid code is required. | |
hl7:addr
| AD | 0 … * | | The guardian's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | cdacient |
hl7:telecom
| TEL | 0 … * | | The guardian's means of communication (phone, eMail, ...). | cdacient |
| Choice | 1 … 1 | | Elements to choose from: |
hl7:guardianPerson
| | | | The guardian's as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) | cdacient |
hl7:guardianOrganization
| | | | The guardian's as an organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC) | cdacient |
hl7:birthplace
| | 0 … 1 | | The patient's birthplace. | cdacient |
hl7:place
| | 1 … 1 | | | cdacient |
hl7:name
| EN | 0 … 1 | | The patient's birthplace name. | cdacient |
hl7:addr
| AD | 1 … 1 | R | The patient's birthplace address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) | cdacient |
hl7:languageCommunication
| | 0 … * | R | The patient's language skills. | cdacient |
hl7:languageCode
| CS | 1 … 1 | | | cdacient |
| | CONF | |
hl7:modeCode
| CE | 0 … 1 | | | cdacient |
| | CONF | |
hl7:proficiencyLevelCode
| CE | 0 … 1 | | | cdacient |
| | CONF | |
hl7:preferenceInd
| BL | 0 … 1 | | In case of @value=true it is the patient's correspondence language. | cdacient |
hl7:providerOrganization
| | 0 … 1 | | The organization who took care of the patient in the same context with the current CDA document. E.g. entry of the Medreg, FMH Index or the Health Organisation Index (HOI) of the Swiss EPR.
Contains 2.16.756.5.30.1.1.10.9.30 Organization Compilation with GLN and name (DYNAMIC) | cdacient |
Draft