Id2.16.840.1.113883.2.51.10.13Effective Date2021‑09‑10 14:50:49
Statusactive ActiveVersion Label1.0
NameXeHRDPatientSummaryDisplay NameXeH RD Patient Summary
Description

The International Patient Summary is a "Minimal and non-exhaustive Patient Summary, specialty-agnostic, condition-independent, but readily usable by all clinicians for the unscheduled (cross-border) care of a patient."

The IPS templates aim to:

  • Serve for both cross-jurisdictional (through adaptation/extension for multi-language and realm scenarios, including translation) and national (through localization) patient summaries.
  • Support emergency care and unplanned care in any country (home and foreign), regardless of language
  • Define value sets based on international vocabularies that are usable and understandable in any country  
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 25 templates
Uses as NameVersion
2.16.840.1.113883.2.51.10.5Includeactive XeH CDA author (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.6Includeactive XeH CDA custodian (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.8Includeactive XeH CDA legalAuthenticator (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.9Includeactive XeH CDA recordTarget (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.15Containmentactive XeH Patient History Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.16Containmentactive XeH Family History Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.17Containmentactive XeH Alerts Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.23Containmentactive XeH Problems Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.39Containmentactive XeH Care Team Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.41Containmentactive XeH Medication Summary Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.57Containmentactive XeH History of Past Illness Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.65Containmentactive XeH Immunizations Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.82Containmentactive XeH Vital Signs Section (1.0)DYNAMIC
2.16.840.1.113883.10.22.2.5Includepending IPS Patient Contacts (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.6Includepending IPS CDA documentationOf (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.7Includepending IPS CDA relatedDocument (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.2Containmentpending IPS Allergies and Intolerances Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.4Containmentpending IPS History of Procedures Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.6Containmentdraft IPS Medical Devices Section (2021)DYNAMIC
2.16.840.1.113883.10.22.3.8Containmentpending IPS Functional Status Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.9Containmentpending IPS Plan of Care Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.10Containmentpending IPS Social History Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.11Containmentpending IPS History of Pregnancy Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.12Containmentpending IPS Advance Directives Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.14Containmentpending IPS Results Section (STU1)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2020‑05‑08 12:30:59)
ref
hl7ips-

Version: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2017‑04‑11)
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
Example
<hl7:ClinicalDocument>
  <hl7:realmCode/>  <hl7:typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <hl7:templateId root="2.16.840.1.113883.10.22.1.1"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code displayName="--TODO--" code="60591-5" codeSystem="2.16.840.1.113883.6.1">
    <hl7:translation/>  </hl7:code>
  <hl7:title>title</hl7:title>  <hl7:effectiveTime value="20220218092735+01:00"/>  <hl7:confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/>  <hl7:languageCode code="en-US"/>  <hl7:setId root="1.2.3.999" extension="--example only--"/>  <hl7:versionNumber/>  <!-- include template 2.16.840.1.113883.2.51.10.9 'XeH CDA recordTarget' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.2.51.10.5 'XeH CDA author' (dynamic) 1..* M -->
  <!-- include template 2.16.840.1.113883.2.51.10.6 'XeH CDA custodian' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.2.51.10.8 'XeH CDA legalAuthenticator' (dynamic) 0..1 R -->
  <!-- include template 2.16.840.1.113883.10.22.2.5 'IPS Patient Contacts' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.10.22.2.6 'IPS CDA documentationOf ' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.10.22.2.7 'IPS CDA relatedDocument' (dynamic) 0..2 R -->
  <hl7:component>
    <hl7:structuredBody classCode="DOCBODY">
      <hl7:component>
        <!-- template 2.16.840.1.113883.2.51.10.15 'XeH Patient History Section' (2021-09-10T15:17:23) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.2.51.10.16 'XeH Family History Section' (2021-09-10T15:22:07) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.2.51.10.17 'XeH Alerts Section' (2021-09-10T15:24:33) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.2.51.10.41 'XeH Medication Summary Section' (2021-10-19T11:12:56) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.2 'IPS Allergies and Intolerances Section' (2016-11-11T00:00:00) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.2.51.10.23 'XeH Problems Section' (2021-09-22T17:29:31) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.4 'IPS History of Procedures Section' (2017-03-27T00:00:00) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.5 'IPS Immunizations Section' (2017-04-05T00:00:00) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.6 'IPS Medical Devices Section' (2021-10-20T17:11:42) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.14 'IPS Results Section' (2017-04-30T00:00:00) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.16 'IPS Vital Signs Section' (2020-05-08T19:22:15) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.2.51.10.57 'XeH History of Past Illness Section' (2022-02-18T09:12:34) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.8 'IPS Functional Status Section' (2020-05-08T19:17:37) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.9 'IPS Plan of Care Section' (2020-05-08T18:28:38) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.10 'IPS Social History Section' (2020-05-10T18:52:32) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.11 'IPS History of Pregnancy Section' (2020-05-07T18:46:08) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.10.22.3.12 'IPS Advance Directives Section' (2020-05-08T16:38:49) -->
      </hl7:component>
      <hl7:component>
        <!-- template 2.16.840.1.113883.2.51.10.39 'XeH Care Team Section' (2021-10-19T09:35:03) -->
      </hl7:component>
    </hl7:structuredBody>
  </hl7:component>
</hl7:ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
RCDA headerXeHRdotsmary
hl7:realmCode
CS0 … 1RXeHRdotsmary
hl7:typeId
II1 … 1M The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

XeHRdotsmary
@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
II1 … 1MXeHRdotsmary
@root
uid1 … 1F2.16.840.1.113883.2.51.10.13
hl7:templateId
II1 … 1MXeHRdotsmary
@root
uid1 … 1F2.16.840.1.113883.10.22.1.1
hl7:id
II1 … 1MUnique identifier of this instance of the Patient Summary.XeHRdotsmary
hl7:code
CE.IPS1 … 1MDetermines the document type that is the "Patient Summary" documentXeHRdotsmary
@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"/>
hl7:translation
CD.IPS0 … *This element can be here used either to provide the originally used document code if this IPS is the result of a transformation.XeHRdotsmary
hl7:title
ST1 … 1MClinicalDocument/title is used for display purposes.XeHRdotsmary
 Example<title>Patient Summary</title>
 Example<title>Profilo Sanitario Sintetico</title>
hl7:effectiveTime
TS.IPS.TZ1 … 1MTime of creation of the Patient SummaryXeHRdotsmary
 Example<effectiveTime value="20111113125600+0200"/>
hl7:confidentialityCode
CE.IPS1 … 1R

ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.

XeHRdotsmary
 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
CS1 … 1MDocument Language CodeXeHRdotsmary
 ConstraintThe 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 assertrolered error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe 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
II1 … 1R

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

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

Implementers are recommended to use this attribute.

XeHRdotsmary
hl7:versionNumber
1 … 1RXeHRdotsmary
Included1 … 1M from 2.16.840.1.113883.2.51.10.9 XeH CDA recordTarget (DYNAMIC)
hl7:recordTarget
1 … 1MXeHCdotsrget
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
 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 … 1MXeHCdotsrget
@classCode
cs0 … 1FPAT
hl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)XeHCdotsrget
hl7:addr
AD.IPS1 … *RThe patient address.XeHCdotsrget
 ConstraintWhen 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_cs0 … 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
cs0 … 1FNI
 ConstraintSHALL 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 assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe 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
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. XeHCdotsrget
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf 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 … 1MXeHCdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
 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
PN1 … *MPatient NameXeHCdotsrget
 ConstraintThe Alphabetic representation of the name SHALL be always provided
hl7:family
1 … *RPatient's Family Name/SurnameXeHCdotsrget
hl7:given
1 … *RPatient's Given NameXeHCdotsrget
hl7:administrativeGenderCode
CE.IPS1 … 1RPatient's GenderXeHCdotsrget
@nullFlavor
cs0 … 1FUNK
 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
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.XeHCdotsrget
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.

XeHCdotsrget
@classCode
cs1 … 1FGUARD
 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.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. XeHCdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr
AD.IPS1 … *RXeHCdotsrget
 ConstraintIf 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_cs0 … 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
cs0 … 1FNI
 ConstraintSHALL 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 assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe 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
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. XeHCdotsrget
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf 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 … 1RXeHCdotsrget
hl7:name
PN1 … *RPatient Guardian's NameXeHCdotsrget
hl7:family
ENXP1 … *RPatient Guardian's Family Name/SurnameXeHCdotsrget
hl7:given
ENXP1 … *RPatient Guardian's Given NameXeHCdotsrget
hl7:languageCommunication
0 … *RXeHCdotsrget
hl7:languageCode
CS1 … 1RPatient’s languageXeHCdotsrget
 ConstraintThe 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
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertrolered error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe 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) 
Included1 … *M from 2.16.840.1.113883.2.51.10.5 XeH CDA author (DYNAMIC)
hl7:author
1 … *MXeHCdotsthor
@typeCode
cs0 … 1FAUT
@contextControlCode
cs0 … 1FOP
 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.IPS0 … 1RFunction of the author (e.g. "Physician on duty", ...). Binding of this element is left open and needs to be set according to project policies.XeHCdotsthor
hl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. XeHCdotsthor
 Example<time value="201212290600+0100"/>
hl7:assignedAuthor
1 … 1RXeHCdotsthor
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *RAuthor Identifier(s)

in case the author is a device, the UDI Device Identifier MAY be specified as a second id element.
XeHCdotsthor
@nullFlavor
cs0 … 1 
hl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.XeHCdotsthor
 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.IPS1 … *RXeHCdotsthor
 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.IPS1 … *RXeHCdotsthor
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@value
st0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
hl7:assignedPerson
0 … 1CXeHCdotsthor
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this documentXeHCdotsthor
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … *RXeHCdotsthor
hl7:given
1 … *RXeHCdotsthor
hl7:assignedAuthoringDevice
0 … 1CContains 2.16.840.1.113883.2.51.10.90 XeH CDA Device (DYNAMIC)XeHCdotsthor
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
hl7:representedOrganization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHCdotsthor
Included1 … 1M from 2.16.840.1.113883.2.51.10.6 XeH CDA custodian (DYNAMIC)
hl7:custodian
1 … 1MXeHCdotsdian
@typeCode
cs0 … 1FCST
 Example<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
hl7:assignedCustodian
1 … 1RXeHCdotsdian
@classCode
cs0 … 1FASSIGNED
hl7:representedCustodianOrganization
1 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHCdotsdian
Included0 … 1R from 2.16.840.1.113883.2.51.10.8 XeH CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1RXeHCdotsator
 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.TZ1 … 1MTime of signing the documentXeHCdotsator
hl7:signatureCode
CS1 … 1RSignature codeXeHCdotsator
@code
CONF0 … 1FS
hl7:assignedEntity
0 … 1RThe entity that is responsible for the legal authentication of the CDA documentXeHCdotsator
hl7:id
1 … *RUnique identification of legal authenticatorXeHCdotsator
hl7:code
CE.IPS (preferred)A code, which identifies the profession/competence/specialty of the author when it is a person.
XeHCdotsator
 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.IPS1 … *RXeHCdotsator
hl7:telecom
TEL.IPS1 … *RXeHCdotsator
hl7:assignedPerson
1 … 1RContains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)XeHCdotsator
hl7:representedOrganization
1 … 1MOrganization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
XeHCdotsator
Included0 … * from 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (DYNAMIC)
hl7:participant
0 … *RPatient contacts or the Preferred Health Professional to contact in case of emergency.IPSCdotsacts
where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']
@typeCode
cs1 … 1FIND
 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
II1 … 1MIPSCdotsacts
@root
uid1 … 1F2.16.840.1.113883.10.22.2.5
hl7:functionCode
0 … 1CThe   element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.IPSCdotsacts
@code
CONF0 … 1FPCP
@codeSystem
0 … 1F2.16.840.1.113883.5.88
hl7:associatedEntity
RThe element identifies the type of contact. IPSCdotsacts
@classCode
cs1 … 1R
 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.IPS0 … 1RThis element indicates the relationship between the patient and this participant.IPSCdotsacts
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.54 IPS Personal Relationship (DYNAMIC)
or
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.IPS1 … *RPatient Contact's / Preferred HP's AddressIPSCdotsacts
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf 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_cs0 … 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
cs0 … 1FNI
 ConstraintSHALL 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 assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe 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
TEL1 … *RPatient Contact's / Preferred HP's/Legal Organization telephone or e-mail element is required.IPSCdotsacts
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf 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="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
Choice1 … 2Elements to choose from:
  • hl7:associatedPerson
  • hl7:scopingOrganization
hl7:associatedPerson
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be providedIPSCdotsacts
hl7:name
PN1 … *RPatient Contact's Name / Preferred HP's NameIPSCdotsacts
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … *RPatient Contact's Family Name/Surname / Preferred HP's Family Name/SurnameIPSCdotsacts
hl7:given
1 … *RPatient Contact's Given Name / Preferred HP's Given NameIPSCdotsacts
hl7:scopingOrganization
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be providedIPSCdotsacts
hl7:name
ON1 … *ROrganization's NameIPSCdotsacts
Included1 … 1M from 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (DYNAMIC)
hl7:documentationOf
1 … 1MThe documentationOf relationship in an International Patient Summary contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.IPSddotsPCPR
@typeCode
cs0 … 1FDOC
 Example<documentationOf>
  <serviceEvent classCode="PCPR">
    <effectiveTime>
      <low nullFlavor="NI"/>      <high value="20110308"/>    </effectiveTime>
    <performer typeCode="PRF">
      <!-- See example below -->
    </performer>
  </serviceEvent>
</documentationOf>
hl7:serviceEvent
1 … 1RThe main activity being described by a IPS is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).

For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the low value should represent the date when the treatment relationship between the patient and the GP started; and the high value the date of the latest care event.
IPSddotsPCPR
@classCode
cs1 … 1FPCPR
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *RIPSddotsPCPR
hl7:effectiveTime
IVL_TS1 … 1RIPSddotsPCPR
hl7:low
TS1 … 1RIPSddotsPCPR
hl7:high
TS1 … 1RIPSddotsPCPR
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 counselorsIPSddotsPCPR
@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)
 Example<performer typeCode="PRF">
  <assignedEntity>
    <id assigningAuthorityName="MEF" displayable="false" extension="DVLMMG57R07F205G" root="2.16.840.1.113883.2.9.4.3.2"/>    <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors">
      <translation codeSystem="2.16.840.1.113883.2.9.5.1.111" code="MMG" displayName="Medico di Medicina Generale"/>    </code>
    <addr nullFlavor="NI"/>    <telecom nullFlavor="NI"/>    <assignedPerson>
      <name>
        <family>DVALUNO</family>        <given>MMG</given>      </name>
    </assignedPerson>
    <representedOrganization>
      <id assigningAuthorityName="A.S.L. DELLA PROVINCIA DI LECCO" extension="030305" root="2.16.840.1.113883.2.9.4.1.1"/>      <name>A.S.L. DELLA PROVINCIA
DI LECCO
</name>
      <telecom nullFlavor="NI"/>      <addr>
        <state>LECCO</state>        <city>LECCO</city>        <country>IT</country>        <postalCode>23900</postalCode>        <streetAddressLine>CORSO CARLO ALBERTO,120</streetAddressLine>      </addr>
    </representedOrganization>
  </assignedEntity>
</performer>
hl7:functionCode
CE.IPS0 … 1RIPSddotsPCPR
hl7:time
IVL_TS.IPS.TZ0 … 1RIPSddotsPCPR
hl7:assignedEntity
1 … 1MIPSddotsPCPR
hl7:id
II1 … *RHealthcare provider ID numberIPSddotsPCPR
hl7:code
CE.IPS (extensible)0 … 1RIt describes the professional role of the healthcare provider involved in the current or pertinent historical care of the patient.IPSddotsPCPR
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
hl7:addr
AD.IPS1 … *RIPSddotsPCPR
hl7:telecom
TEL.IPS1 … *RIPSddotsPCPR
hl7:assignedPerson
0 … 1Contains 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)IPSddotsPCPR
hl7:representedOrganization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)IPSddotsPCPR
Included0 … 2R from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)
 ConstraintA 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 … 2RIPSCdotsment
@typeCode
cs1 … 1R
 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 … 1RIPSCdotsment
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RIPSCdotsment
hl7:code
CD.IPS0 … 1RIPSCdotsment
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1RIPSCdotsment
hl7:setId
II0 … 1RIPSCdotsment
hl7:versionNumber
INT0 … 1RIPSCdotsment
hl7:component
1 … 1MXeHRdotsmary
hl7:structuredBody
1 … 1MNote: the proposed order of the sections hereafter indicated is not mandatoryXeHRdotsmary
@classCode
cs0 … 1FDOCBODY
hl7:component
0 … 1Contains 2.16.840.1.113883.2.51.10.15 XeH Patient History Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.2.51.10.16 XeH Family History Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.2.51.10.17 XeH Alerts Section (DYNAMIC)XeHRdotsmary
hl7:component
1 … 1MContains 2.16.840.1.113883.2.51.10.41 XeH Medication Summary Section (DYNAMIC)XeHRdotsmary
hl7:component
1 … 1MContains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC)XeHRdotsmary
hl7:component
1 … 1MContains 2.16.840.1.113883.2.51.10.23 XeH Problems Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1RContains 2.16.840.1.113883.2.51.10.65 XeH Immunizations Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1RContains 2.16.840.1.113883.2.51.10.82 XeH Vital Signs Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.2.51.10.57 XeH History of Past Illness Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC)XeHRdotsmary
hl7:component
0 … 1Contains 2.16.840.1.113883.2.51.10.39 XeH Care Team Section (DYNAMIC)XeHRdotsmary