Difference between revisions of "IPS implementationguide 1"

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__NOTOC__
 
__NOTOC__
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<div class="online-document-information">
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<div class="panel-heading"> <span class="panel-title"><i class="fa fa-cogs"></i> Continuous Build </span> </div>
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<div class="panel-body"> <p class="bs">
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This is the '''Continuous Build''' of the HL7 CDA® R2 Implementation Guide '''International Patient Summary''' (will be incorrect/inconsistent at times).<p/>
 +
See the [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=483 Directory of the published standard].
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</div></div></div></div></div>
 
{{Infobox_Document
 
{{Infobox_Document
|Title    = HL7 International Patient Summary<br/>based on Clinical Document Architecture Release 2
+
|Title    = HL7 CDA® R2 Implementation Guide<br/>International Patient Summary<br/>STU Release 1 (Universal Realm)
 
|Short    = International Patient Summary
 
|Short    = International Patient Summary
|Namespace = cdaips  
+
|Namespace = cdaips
|Type      = Implementation Guide
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|Type      = Standard for Trial Use
|Version  = 0.10
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|Version  = 1.86
|Submitted = HL7 International
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|Sponsored = <!--Structured Documents Workgroup :: unset this to let appear the STU comment on the front page if period is STU -->
|Date      = 21. March 2017
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|Date      = October 25, 2018
|Status    = Draft
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|Status    = Final
|Period    = Draft
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|Period    = STU
 
|OID      = n.n.
 
|OID      = n.n.
 
|Realm    = Universal
 
|Realm    = Universal
 
|Custodian = HL7
 
|Custodian = HL7
|Copyrighttext = © 2016-2017 Health Level Seven International ® ALL RIGHTS RESERVED.<br/>The reproduction of this material in any form is strictly forbidden without the written permission of the publisher.  HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. Pat & TM Off.
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|Copyrighttext = © 2018 Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction of this material in any form is strictly forbidden without the written permission of the publisher.  HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. Pat & TM Off.<br>Use of this material is governed by HL7's IP Compliance Policy.
 +
|Topright  = CDAR2_INTLPATSUMMARY_STU_R1_2018OCT
 
}}
 
}}
  
 
{{:HL7_Important_Note}}
 
{{:HL7_Important_Note}}
  
{{:Authors_and_Contributors}}
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{{:IPS_Authors_and_Contributors}}
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__TOC__
 
__TOC__
=Introduction=
 
==Purpose==
 
The goal of this Implementation Guide is to identify the required clinical data with associated vocabulary bindings and value sets for patient summary, in the context of specific use cases, and to build an international document and associated templates based on HL7 CDA R2 (or a future CDA release) and potentially the FHIR standards, with value sets to support data elements within those templates. The initial use cases will be the patient summary, providing support for emergency care and unplanned care.
 
  
These templates/profiles aim to:
+
{{:IPS_Introduction_1}}
*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
+
{{:IPS_Technical_Background_1}}
*Define value sets based on international vocabularies that are usable and understandable in any country
+
 
 +
{{:IPS_Functional_requirements_1}}
 +
 
 +
{{:IPS_Design_conventions_and_principles_1}}
 +
 
 +
=Conformance clause=
 +
 
 +
This section references the requirements, criteria, or conditions to be satisfied in order that a product (tangible) or a service may claim conformance to this guide, and how other artifacts may claim compliance with it. (Note: The concept of conformance and compliance are used coherently with the HL7 Service-Aware Interoperability Framework: Canonical Definition Specification, Release 2<ref>HL7 Service-Aware Interoperability Framework: Canonical Definition Specification, Release 2 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=3</ref>. The fulfilment of these clauses indirectly assures that a product that is the subject of a “conformity assessment” satisfies the business or the design requirements this specification complies to. It should, however, be clear that compliance with the specified business or design requirements, for example in the future with the CEN prEN 17269 IPS, does not imply that the compliant implementations are technically interoperable. A “conformity assessment” is a process that assesses that any proposition that is true in a given specification is also true in the service or product that implements it. In most real-world cases conformance testing objects are used to technically validate the products. These objects provide a great help in the validation of the instances, even if they are most often not sufficient to guarantee the functional/ semantic conformity: many real-life examples can be made about instances that are technically valid, but not clinically meaningful or correct.
  
The deliverable(s) will address the requirements of an international patient summary:
+
<ref group="Figure" name="ipsworld"></ref> below depicts how this concept applies to the business requirements, the current and hopefully future IPS projects standards (CEN/TC 251 and HL7) and other related artifacts involved in this assessment chain. (see section [[#Relationships with other projects and guidelines | Relationships with other projects and guidelines]] for a description of the standards developed by the CEN/TC 251 IPS project )
*For the exchange of structured and coded information (section headings, entries)
+
*For administrative data in order to support content commitment, audit/logging/provenance
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{{IncludeImage|IPS_world.png|700px|80%}}
  
The Implementation Guide will receive input from the EHR WG regarding the specification of functional requirements on patient summaries.
+
<ref group="Figure" name="ipsworld">The IPS World</ref> The IPS World
  
This includes a compilation of the required clinical data, based on results of multiple previous projects on patient summaries (including but not limited to epSOS, ONC, Trillium Bridge, eHealth Exchange), rules and recommendations for the use and maintenance of associated vocabulary bindings and value sets (in multilingual settings), and templates for the implementation of international patient summary documents.  
+
The "rules" and processes for refining the standard through constraint and extension, including which standard artifacts are subject to constraint or extension; the definition of constraint and localization profiles; the criteria for establishing a conformance statement; and the principles guiding who may define extensions to the standards and under what circumstances they apply to the CDA standards are defined in §1.3 CDA Conformance of the CDA and detailed in the HL7 V3 Refinement, Constraint and Localization section (see the CDA R2 Standard<ref>CDA R2 Standard http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7</ref>).
  
Therefore this Implementation Guide has its primary focus on provisions for semantic interoperability.  
+
This guide does not provide additional requirements regarding the Recipient and the Originator Responsibilities.
  
Templates/profiles should take in consideration, where applicable, legal, organizational, security and infrastructure requirements based on experiences of pilot implementations (Trillium Bridge).
+
The formal representation used in this implementation guide for expressing the conformance statement is described in chapter "How to read the table view for templates" of this guide and makes use of a tabular representation that may include also computable or textual constraints. The template rules are formalized using the computable format defined by the HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1<ref name="teits">HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=377</ref> in order to facilitate also the automatic generation of consistent testing and validation capabilities.
  
The white paper on Comparative Analysis Between HL7 C-CDA R1.1 CCD and epSoS PS v1.4 will inform the development of the harmonized template and associated value sets.
+
The HL7 Templates Standard: "Specification and Use of Reusable Information Constraint Templates, Release 1" defines also how derived templates may relate to the templates defined in this guide for example:
 +
*Specialization: “A specialized template is a narrower, more explicit, more constrained template based on a “parent” template.
 +
* Adaptation: “The adapted template is “based on” the original template which means it can be an extension or a specialization (restriction) of the original template design.”
 +
* Equivalency: “two templates have the same purpose and the same design; however, their governance and/or metadata and/or details of their design may be different.
  
=== Background ===
+
Based on this the following way to use this guide may be considered :
 +
* IPS as a document: the conformance is asserted at the document level. All the rules defined  by this guide, or by a specialized IPS document level template, are fulfilled. Implementers may take advantage of the template openness to better support specific cases - “extended” parts, however, may not be interoperable among them.
 +
* IPS as a library: the conformance is asserted at the section or the entry level. The templates are used as a library to build, for example, new cross-border documents. For example the immunization section may be used to build an electronic implementation of the WHO yellow card for vaccinations; or the IPS section templates are used to communicate to the country of affiliation minimal and non-exhaustive information about the encounter in which the Patient Summary has been used (cross-border encounter report ). Implementers may take advantage of the template openness to better support specific cases - "extended” parts, however, may not be interoperable among them.
 +
* IPS as a reference: the implementation is conformant with templates that are an adaptation of or equivalent to those defined by this guide. In this case some of the rules defined by this guide are not fulfilled and the conformance cannot be asserted. However, differences may be limited and the effort required to achieve the harmonization may not be not large. Typical examples are templates in which alternatives vocabularies are used.
  
In 2010 a MoU was signed between EU and US to strengthen global cooperation in eHealth/Health. As a result, the ONC S&I “Interoperability of EHR” work group was launched in US in 2013 (http://wiki.siframework.org/EU-US+eHealth+Cooperation+Initiative) and the Trillium Bridge Project (www.trilliumbridge.eu) in Europe to compare the CDA templates specified at that time in Europe (epSOS PS V1.4) and in US (MU – C-CDA CCD v1.1) for Patient Summaries (PSs) and to build a Trans-Atlantic exchange proof of concept. Both initiatives resulted identifying the need for a common template and vocabularies for the Patient Summary, in particular the following recommendation was offered and endorsed by all members of the Joint Initiative Council and by the HL7 International Council: “to advance an International Patient Summary (IPS) standard and enable people to access and share their health information for emergency or unplanned care anywhere and as needed. At minimum the IPS should include immunizations, allergies, medications, clinical problems, past operations and implants.
+
Jurisdictions may also decide to impose the closure of the template in order to limit the implementation optionality. This should be carefully evaluated in terms of the flexibility of the solution.
  
Meanwhile
+
{{:IPS_Alltemplates}}
*A new version of the EU/US MOU Transatlantic eHealth/health IT Cooperation Roadmap entered consultation in November 2015 , ;
 
*(US) a Shared Nationwide interoperability roadmap was published in November 2015 ;
 
*The Joint Initiative Council (JIC) on SDO Global Health Informatics Standardization, initiated the standard sets project with patient summary as its pilot ;
 
*A maintenance process for the European Patient Summary Guidelines  is in progress (expected release on Nov 2016);
 
*The European eHealth Digital Service Infrastructure (project for the operational deployment of the EU cross-borders services) has been launched (2016-2018)
 
*ART-DECOR® and the HL7 DSTU (now STU) template exchange format are being more and more used by European countries, including for the European Patient Summary templates (aka epSOS PS template). ART DECOR is also connected to the IHE
 
  
==Scope==
+
{{:IPS_Appendix_1}}
==Ballot Status of the Document==
 
This Implementation Guide is a draft.
 
  
==Audience==
+
=List of all artifacts used in this guide=
==Relationships with other projects and guides==
+
==CDA Templates==
*Connection with CEN IPS ?
+
*[[2.16.840.1.113883.10.22.1.1]] International Patient Summary
*epSOS/eHDSI; C-CDA; IHE-PCC
+
*[[2.16.840.1.113883.10.22.2.1]] IPS CDA recordTarget
===Prerequisite Knowledge===
+
*[[2.16.840.1.113883.10.22.2.2]] IPS CDA author
==How to read this document==
+
*[[2.16.840.1.113883.10.22.2.3]] IPS CDA custodian
==Conventions==
+
*[[2.16.840.1.113883.10.22.2.4]] IPS CDA legalAuthenticator
==Contributions==
+
*[[2.16.840.1.113883.10.22.2.5]] IPS Patient Contacts
 +
*[[2.16.840.1.113883.10.22.2.6]] IPS CDA documentationOf
 +
*[[2.16.840.1.113883.10.22.2.7]] IPS CDA relatedDocument
 +
*[[2.16.840.1.113883.10.22.3.1]] IPS Medication Summary Section
 +
*[[2.16.840.1.113883.10.22.3.2]] IPS Allergies and Intolerances Section
 +
*[[2.16.840.1.113883.10.22.3.3]] IPS Problems Section
 +
*[[2.16.840.1.113883.10.22.3.4]] IPS History of Procedures Section
 +
*[[2.16.840.1.113883.10.22.3.5]] IPS Immunizations Section
 +
*[[2.16.840.1.113883.10.22.3.6]] IPS Medical Devices Section
 +
*[[2.16.840.1.113883.10.22.3.7]] IPS History of Past Illness Section
 +
*[[2.16.840.1.113883.10.22.3.8]] IPS Functional Status Section
 +
*[[2.16.840.1.113883.10.22.3.9]] IPS Plan of Care Section
 +
*[[2.16.840.1.113883.10.22.3.10]] IPS Social History Section
 +
*[[2.16.840.1.113883.10.22.3.11]] IPS History of Pregnancy Section
 +
*[[2.16.840.1.113883.10.22.3.12]] IPS Advance Directives Section
 +
*[[2.16.840.1.113883.10.22.3.14]] IPS Results Section
 +
*[[2.16.840.1.113883.10.22.3.15]] IPS Translation Section
 +
*[[2.16.840.1.113883.10.22.4.1]] IPS Allergy or Intolerance
 +
*[[2.16.840.1.113883.10.22.4.2]] IPS ManufacturedProduct
 +
*[[2.16.840.1.113883.10.22.4.3]] IPS Manufactured Material
 +
*[[2.16.840.1.113883.10.22.4.4]] IPS Medication Entry
 +
*[[2.16.840.1.113883.10.22.4.5]] IPS Allergy and Intolerance Concern
 +
*[[2.16.840.1.113883.10.22.4.6]] IPS Reaction Manifestation
 +
*[[2.16.840.1.113883.10.22.4.7]] IPS Problem Concern Entry
 +
*[[2.16.840.1.113883.10.22.4.8]] IPS Problem Entry
 +
*[[2.16.840.1.113883.10.22.4.9]] IPS Result Organizer
 +
*[[2.16.840.1.113883.10.22.4.10]] IPS Result Observation
 +
*[[2.16.840.1.113883.10.22.4.11]] IPS Pathology Result Observation
 +
*[[2.16.840.1.113883.10.22.4.12]] IPS Radiology Result Observation
 +
*[[2.16.840.1.113883.10.22.4.13]] IPS Laboratory Result Observation
 +
*[[2.16.840.1.113883.10.22.4.14]] IPS Body Author
 +
*[[2.16.840.1.113883.10.22.4.15]] IPS Immunization
 +
*[[2.16.840.1.113883.10.22.4.16]] IPS Immunization Medication Information
 +
*[[2.16.840.1.113883.10.22.4.17]] IPS Procedure Entry
 +
*[[2.16.840.1.113883.10.22.4.18]] IPS Criticality Observation
 +
*[[2.16.840.1.113883.10.22.4.19]] IPS Certainty Observation
 +
*[[2.16.840.1.113883.10.22.4.20]] IPS Problem Status Observation
 +
*[[2.16.840.1.113883.10.22.4.21]] IPS Allergy Status Observation
 +
*[[2.16.840.1.113883.10.22.4.22]] IPS Comment Activity
 +
*[[2.16.840.1.113883.10.22.4.23]] IPS ObservationMedia
 +
*[[2.16.840.1.113883.10.22.4.25]] IPS Severity Observation
 +
*[[2.16.840.1.113883.10.22.4.26]] IPS Medical Device
 +
*[[2.16.840.1.113883.10.22.4.27]] IPS Pregnancy Status Observation
 +
*[[2.16.840.1.113883.10.22.4.28]] IPS Pregnancy Outcome Observation
 +
*[[2.16.840.1.113883.10.22.4.29]] IPS Pregnancy Expected Delivery Date Observation
 +
*[[2.16.840.1.113883.10.22.4.30]] IPS Specimen Collection
 +
*[[2.16.840.1.113883.10.22.4.31]] IPS Internal Reference
 +
*[[2.16.840.1.113883.10.22.4.33]] IPS Subordinate SubstanceAdministration
 +
*[[2.16.840.1.113883.10.22.4.34]] IPS Social History Tobacco Use
 +
*[[2.16.840.1.113883.10.22.4.35]] IPS Social History Alcohol Use
 +
*[[2.16.840.1.113883.10.22.9.1]] IPS CDA Organization
 +
*[[2.16.840.1.113883.10.22.9.2]] IPS CDA Device
 +
*[[2.16.840.1.113883.10.22.9.3]] IPS CDA Person
 +
*[[2.16.840.1.113883.10.22.11]] IPS Address
  
=Principles and background=
+
==CDA Template References ==
==What is a CDA==
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* [[2.16.840.1.113883.10.21.9.1]] UV Use Period
==Templated CDA==
 
==Open and Closed Templates==
 
==Template versioning==
 
==Identifiers==
 
*(OID,...)
 
==Terminologies==
 
*Focus on Value Sets
 
===How to extend Value Sets===
 
==Datatypes used in this guide==
 
==Design conventions and principles==
 
===How to use terminology (preferred binding)===
 
===Notion of "Primary Code"===
 
===Usage of translations===
 
===Principle on negations and data known absent===
 
*Usage of negations
 
*The choice for negation it is not that of using negation indicator @negationInd but rely on the terminologies to do this
 
*To do: add a description in the introduction
 
*@negationInd in CDA has been superseded in V3 later by two other negation indicators: actNegationInd valueNegationInd
 
*Alignment with FHIR
 
  
==General implementation guidance==
+
==Unconstrained Templates from the original CDA specification ==
How to populates IDs, where I can get IDs
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* [[2.16.840.1.113883.10.12.151]] CDA Organization
==Standards used==
+
* [[2.16.840.1.113883.10.12.152]] CDA Person
SNOMED-CT, ...
+
* [[2.16.840.1.113883.10.12.153]] CDA AssignedEntity
==Legend==
+
* [[2.16.840.1.113883.10.12.318]] CDA Author (Body)
Description of formalisms used, symbols, icons, how to read ART-DECOR tables
+
* [[2.16.840.1.113883.10.12.315]] CDA Device
=Conformance clause=
+
* [[2.16.840.1.113883.10.12.319]] CDA Informant (Body)
Different conformance levels (to be explored)
+
* [[2.16.840.1.113883.10.12.323]] CDA Performer (Body)
=Functional requirements and high-level use cases=
+
* [[2.16.840.1.113883.10.12.313]] CDA PlayingEntity
*Add a reference to the CEN prEN. (to be analyzed)
+
* [[2.16.840.1.113883.10.12.316]] CDA RelatedEntity
*PSS
+
 
*Add a reference to the data set included in the html package
+
==Value Sets ==
*Include in the functional area that no assumption on transport has been made…
+
*[[2.16.840.1.113883.11.22.2]] Allergy or Intolerance Type
*PS comes from one source, and covers different cases.
+
*[[2.16.840.1.113883.11.22.3]] Allergy Reaction
*Specify, how the provenance could be managed without going into details) to be included in next versions.
+
*[[2.16.840.1.113883.11.22.5]] CORE Problem List Disorders
*To be further discussed, in any case add a paragraph in which explain the problem and how it might be faced.
+
*[[2.16.840.1.113883.11.22.8]] IPS Condition Verification Status
 +
*[[2.16.840.1.113883.11.22.9]] Absent or Unknown Allergies
 +
*[[2.16.840.1.113883.11.22.10]] Allergies to substances
 +
*[[2.16.840.1.113883.11.22.11]] Adverse Reaction Agents
 +
*[[2.16.840.1.113883.11.22.12]] ActStatusActiveCompletedAbortedSuspended
 +
*[[2.16.840.1.113883.11.22.13]] Time units (UCUM)
 +
*[[2.16.840.1.113883.11.22.14]] DRUGActCode
 +
*[[2.16.840.1.113883.11.22.15]] Absent or Unknown Medication
 +
*[[2.16.840.1.113883.11.22.16]] Problem Type
 +
*[[2.16.840.1.113883.11.22.17]] Absent or Unknown Problems
 +
*[[2.16.840.1.113883.11.22.18]] Problem Severity
 +
*[[2.16.840.1.113883.11.22.19]] Language Code
 +
*[[2.16.840.1.113883.11.22.20]] IPS Expected Delivery Date Method
 +
*[[2.16.840.1.113883.11.22.21]] IPS Pregnancies Summary
 +
*[[2.16.840.1.113883.11.22.22]] ActStatusActiveCompletedAbortedCancelled
 +
*[[2.16.840.1.113883.11.22.23]] IPS Medical Devices
 +
*[[2.16.840.1.113883.11.22.24]] IPS Condition Status Code
 +
*[[2.16.840.1.113883.11.22.25]] Medicine Doseform
 +
*[[2.16.840.1.113883.11.22.27]] Medicine Package
 +
*[[2.16.840.1.113883.11.22.28]] Quantity Units
 +
*[[2.16.840.1.113883.11.22.29]] WHO ATC
 +
*[[2.16.840.1.113883.11.22.30]] Medicine Strength Numerator
 +
*[[2.16.840.1.113883.11.22.31]] Medicine Strength Denominator
 +
*[[2.16.840.1.113883.11.22.32]] Medicine Active Substances
 +
*[[2.16.840.1.113883.11.22.33]] Medicine Route of Administration
 +
*[[2.16.840.1.113883.11.22.34]] IPS No Drug Substances
 +
*[[2.16.840.1.113883.11.22.35]] IPS Procedures
 +
*[[2.16.840.1.113883.11.22.36]] Absent or Unknown Procedures
 +
*[[2.16.840.1.113883.11.22.37]] IPS Results Organizer
 +
*[[2.16.840.1.113883.11.22.38]] IPS Results Observation
 +
*[[2.16.840.1.113883.11.22.39]] IPS Results Observation Laboratory
 +
*[[2.16.840.1.113883.11.22.40]] IPS Results Observation Radiology
 +
*[[2.16.840.1.113883.11.22.41]] IPS Results Observation Pathology
 +
*[[2.16.840.1.113883.11.22.42]] IPS Allergy Status Code
 +
*[[2.16.840.1.113883.11.22.43]] Absent or Unknown Immunization
 +
*[[2.16.840.1.113883.11.22.44]] IPS Vaccines
 +
*[[2.16.840.1.113883.11.22.45]] IPS Multingredients Products
 +
*[[2.16.840.1.113883.11.22.46]] IPS Results Coded Values Laboratory
 +
*[[2.16.840.1.113883.11.22.47]] IPS Results Coded Values Pathology
 +
*[[2.16.840.1.113883.11.22.48]] IPS Results Coded Values Radiology
 +
*[[2.16.840.1.113883.11.22.49]] IPS Results Microorganism
 +
*[[2.16.840.1.113883.11.22.50]] IPS Results Blood Group phenotypes
 +
*[[2.16.840.1.113883.11.22.51]] IPS Results ABO+RH GROUP
 +
*[[2.16.840.1.113883.11.22.52]] IPS Results Presence/Absence
 +
*[[2.16.840.1.113883.11.22.53]] IPS Healthcare Professional Roles
 +
*[[2.16.840.1.113883.11.22.54]] IPS Personal Relationship
 +
*[[2.16.840.1.113883.11.22.55]] IPS Target Site
 +
*[[2.16.840.1.113883.11.22.56]] IPS Specimen Type
 +
*[[2.16.840.1.113883.11.22.57]] Laterality (qualifier)
 +
*[[2.16.840.1.113883.11.22.58]] Topographical modifier (qualifier)
 +
*[[2.16.840.1.113883.11.22.59]] IPS Current Smoking Status
 +
*[[2.16.840.1.113883.11.22.60]] Allergy-intolerance Criticality
 +
 
 +
==Value Sets References==
 +
*[[2.16.840.1.113883.1.11.1]] AdministrativeGender
 +
*[[2.16.840.1.113883.1.11.10706]] Timing Event
 +
*[[2.16.840.1.113883.1.11.11610]] x_ActRelationshipDocument
 +
*[[2.16.840.1.113883.1.11.15933]] ActStatus
 +
*[[2.16.840.1.113883.1.11.16926]] HL7 BasicConfidentialityKind
 +
*[[2.16.840.1.113883.1.11.19446]] x_ActRelationshipEntry
 +
*[[2.16.840.1.113883.1.11.19563]] PersonalRelationshipRoleType
 +
*[[2.16.840.1.113883.1.11.19601]] x_ServiceEventPerformer
 +
*[[2.16.840.1.113883.1.11.19709]] ActSubstanceAdministrationImmunizationCode
 +
*[[2.16.840.1.113883.1.11.19890]] x_ActStatusActiveComplete
 +
*[[2.16.840.1.113883.1.11.201]] TelecommunicationAddressUse
 +
*[[2.16.840.1.113883.1.11.20386]] SeverityObservationCode
 +
*[[2.16.840.1.113883.1.11.78]] Observation Interpretation
 +
*[[2.16.840.1.113883.11.20.9.18]] MoodCodeEvnInt
 +
*[[2.16.840.1.113883.11.20.9.33]] INDRoleclassCodes
 +
*[[2.16.840.1.113883.3.88.12.80.60]] Social History Type
 +
 
 +
==Data Types ==
 +
Data types for element definitions used
 +
*AD – Address
 +
*AD.IPS – IPS Address (see [https://docs.art-decor.org/documentation/datatypes/DTr1_AD.IPS/])
 +
*ANY – ANY
 +
*BL – Boolean
 +
*CD – Concept Descriptor
 +
*CD.IPS – IPS CD (see [https://docs.art-decor.org/documentation/datatypes/DTr1_CD.IPS])
 +
*CE – Coded with Equivalents
 +
*CE.IPS – IPS CE (see [https://docs.art-decor.org/documentation/datatypes/DTr1_CE.IPS])
 +
*CR – Concept Role
 +
*CS – Coded Simple Value
 +
*CV – Coded Value
 +
*CV.IPS – IPS CV (see [https://docs.art-decor.org/documentation/datatypes/DTr1_CV.IPS])
 +
*ED – Encapsulated Data
 +
*EIVL.event – Event-Related Interval of Time
 +
*EIVL_TS – Event-related time interval
 +
*EN – Entity Name
 +
*ENXP – Entity Name Part
 +
*II – Instance Identifier
 +
*INT – Integer
 +
*IVL_PQ – Interval of Physical Quantity
 +
*IVL_TS – Interval of Time Stamp
 +
*IVL_TS.IPS.TZ – IPS IVL Time Stamp TZ (see [https://docs.art-decor.org/documentation/datatypes/DTr1_IVL_TS.IPS.TZ])
 +
*IVL_TS.IPS.TZ.OPT
 +
*IVXB_TS – Interval Boundary of Time Stamp
 +
*ON – Organization Name
 +
*PIVL_TS – Periodic Interval of Timezone
 +
*PN – Person Name
 +
*PQ – Physical Quantity
 +
*SC – String with Codes
 +
*SD.TEXT – Structured Document Text
 +
*ST – Character String
 +
*SXPR_TS – Parenthetic Set Expression of Time Stamp
 +
*TEL – Telecommunication Address
 +
*TEL.IPS – IPS TEL (see [https://docs.art-decor.org/documentation/datatypes/DTr1_IVL_TS.IPS.TZ.OPT])
 +
*TS – Time Stamp
 +
*TS.IPS.TZ – IPS Time Stamp TZ (see [https://docs.art-decor.org/documentation/datatypes/DTr1_TS.IPS.TZ])
  
<div class="landscape">
+
Data types for attributes used
=Document Level Templates=
+
*bl – boolean code
=Header Level Templates =
+
*cs – code
=Section Level Templates =
+
*oid – identifier
==Allergies and/or Intolerances==
+
*set_cs – code
{{:2.16.840.1.113883.3.1937.777.13.10.5/dynamic}}
+
*st – string
 +
*uid – identifier
  
== History of Procedures ==
+
==Extensions==
{{:2.16.840.1.113883.3.1937.777.13.10.19/dynamic}}
+
=== Detailed medications information ===
 +
This specification uses CDA extensions in order to provide details about medications, as further described in the section on the design conventions for [[ IPS_implementationguide_1#Medicinal_Product_Identification|Medicinal Product Identification]] and as used in template 2.16.840.1.113883.10.22.4.3 ''IPS Manufactured Material''. The extension uses the namespace <code>urn:hl7-org:pharm</code>.  
  
== Medication Summary ==
+
This is the list of elements defined for that template.  
{{:2.16.840.1.113883.3.1937.777.13.10.3/dynamic}}
 
== Problems==
 
{{:2.16.840.1.113883.3.1937.777.13.10.8/dynamic}}
 
  
=Entry Level Templates =
+
*pharm:formCode (Administrable Pharmaceutical Dose Form)
== Allergy and Intolerance Concern ==
+
*pharm:asContent (Packaging of the medication)
{{:2.16.840.1.113883.3.1937.777.13.10.6/dynamic}}
+
**pharm:quantity
== Allergies and Intolerances ==
+
**pharm:containerPackagedMedicine (Most inner Package Item or the Packaged Medicinal Product)
{{:2.16.840.1.113883.3.1937.777.13.10.24/dynamic}}
+
***pharm:code
 +
***pharm:name (Name of the Package Item or of the Packaged Medicinal Product)
 +
***pharm:formCode (type of the most inner package item or of the or the Packaged Medicinal Product)
 +
***pharm:capacityQuantity (the functional capacity of the container)
 +
***pharm:asContent (Containing package)
 +
****pharm:quantity
 +
****pharm:containerPackagedMedicine (Intermediate Package Item or the Packaged Medicinal Product)
 +
*****pharm:code
 +
*****pharm:name (Name of the Package Item or of the Packaged Medicinal Product)
 +
*****pharm:formCode (type of the intermediate package item or of the or the Packaged Medicinal Product)
 +
*****pharm:capacityQuantity (the functional capacity of the container)
 +
*****pharm:asContent (Containing package)
 +
******pharm:quantity
 +
******pharm:containerPackagedMedicine (Packaged Medicinal Product)
 +
*******pharm:code
 +
*******pharm:name (Name of the Packaged Medicinal Product)
 +
*******pharm:formCode (type of the Packaged Medicinal Product)
 +
*******pharm:capacityQuantity (the functional capacity of the container)
 +
*pharm:asSpecializedKind (used to represent any classification of the product (ATC code, future PhPIDs,..) )
 +
**pharm:generalizedMaterialKind
 +
***pharm:code
 +
***pharm:name
 +
*pharm:ingredient (list of active substances used for this product)
 +
**pharm:quantity (strength)
 +
**pharm:ingredientSubstance (active substance)
 +
***pharm:code
 +
***pharm:name
  
== ManufacturedProduct==
+
===Translation of designations===
{{:2.16.840.1.113883.3.1937.777.13.10.1/dynamic}}
+
This specification recommends the introduction of an optional extension for properly recording multilingual designations, that is further described in the [[IPS_implementationguide_1#Translation_of_designations_2|section on the translation of designations]]
 +
*ips:designation
  
== Material==
+
{{:Reading_Guide_for_Publication_Artefacts}}
{{:2.16.840.1.113883.3.1937.777.13.10.2/dynamic}}
 
== Medication Entry==
 
{{:2.16.840.1.113883.3.1937.777.13.10.4/dynamic}}
 
== Reaction Manifestation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.7/dynamic}}
 
== Problem Concern Entry ==
 
{{:2.16.840.1.113883.3.1937.777.13.10.9/dynamic}}
 
== Problem Entry==
 
{{:2.16.840.1.113883.3.1937.777.13.10.10/dynamic}}
 
==Result Organizer==
 
{{:2.16.840.1.113883.3.1937.777.13.10.11/dynamic}}
 
== Result Observation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.12/dynamic}}
 
== Body Author==
 
{{:2.16.840.1.113883.3.1937.777.13.10.13/dynamic}}
 
== Immunization==
 
{{:2.16.840.1.113883.3.1937.777.13.10.14/dynamic}}
 
== Immunization Medication Information==
 
{{:2.16.840.1.113883.3.1937.777.13.10.15/dynamic}}
 
== Laboratory Result Observation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.16/dynamic}}
 
== Radiology Result Observation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.17/dynamic}}
 
== Pathology Result Observation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.18/dynamic}}
 
== Procedure Entry==
 
{{:2.16.840.1.113883.3.1937.777.13.10.20/dynamic}}
 
== Criticality Observation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.21/dynamic}}
 
== Certainty Observation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.22/dynamic}}
 
== Problem Status Observation==
 
{{:2.16.840.1.113883.3.1937.777.13.10.23/dynamic}}
 
  
</div>
+
=References=
 +
==Literature==
 +
* Whiting-O'Keefe QE, Simborg DW, Epstein WV, Warger A: A computerized summary medical record system can provide more information than the standard medical record. JAMA. 1985 Sep 6;254(9):1185-92.
 +
* Boone KW: The CDA Book. Springer 2011, ISBN 978-0-85729-336-7
  
=Appendix=
+
==Links==
==Acronyms and abbreviations ==
+
<references/>
==Glossary ==
 
==Licenses (for the artifacts used, for the code systems, etc.) ==
 
==Integrated examples, links to instances ==
 
==Validation artifacts (xsd, schematrons) ==
 
==Links to platforms, binaries, software libraries ==
 
==Operational information (helpdesk, actual server endpoints for testing/production/validation) ==
 
==FAQ’s ==
 
==References / Literature ==
 
==How to reuse this template==
 
  
=List of all artifacts used in this guide=
+
==Figures==
==System OIDs / IDs ==
+
<references group="Figure"/>
==Code systems ==
 
==CDA Templates (list of)==
 
==Value Sets ==
 
==Summary tables ==
 
  
=Examples (in progress)=
+
[[Category:IG]]

Latest revision as of 15:36, 19 July 2023

Continuous Build

This is the Continuous Build of the HL7 CDA® R2 Implementation Guide International Patient Summary (will be incorrect/inconsistent at times).

See the Directory of the published standard.

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This document contains: Standard for Trial Use International Patient Summary (1.86). The text materials belong to category cdaips.



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Primary Editor Giorgio Cangioli, PhD
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Primary Editor Rob Hausam
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Primary Editor Dr Kai U. Heitmann
Heitmann Consulting and Services, HL7 Germany, ART-DECOR Open Tools GmbH
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Phast
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Contributor Dr Philip Scott
HL7 UK
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Contributor Dr Christof Geßner
Gematik
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ELGA, HL7 Austria
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Contributor Catherine Chronaki
HL7 International Foundation
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Contributor Dr Stephen Chu
HL7 Australia
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Contributor Didi Davis
The Sequoia Project
ddavis@sequoiaproject.org
Other Contributors Alexander Berler (a.berler@gnomon.com.gr) ; Carina Seerainer (carina.seerainer@elga.gv.at); John Roberts (John.A.Roberts@tn.gov); Julie James (julie_james@bluewaveinformatics.co.uk); Mark Shafarman (mark.shafarman@earthlink.net); Fernando Portilla (fportila@gmail.com); Ed Hammond (william.hammond@duke.edu); Steve Kay (s.kay@histandards.net)


Contents

Introduction

An International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information intended for use in the unscheduled, cross-border care scenario, comprising at least the required elements of the IPS dataset. The IPS dataset is a minimal and non-exhaustive patient summary dataset, specialty-agnostic, condition-independent, but readily usable by clinicians for the cross-border unscheduled care of a patient.

Purpose

The goal of this Implementation Guide is to identify the required clinical data, vocabulary and value sets for an international patient summary. The international patient summary is specified as a templated document using HL7 CDA R2. The primary use case is to provide support for cross-border or cross-juridictional emergency and unplanned care.

This specification aims to support:

  • Cross-jurisdictional patient summaries (through adaptation/extension for multi-language and realm scenarios, including translation).
  • Emergency and unplanned care in any country, regardless of language.
  • Value sets based on international vocabularies that are usable and understandable in any country.
  • Data and metadata for document-level provenance.

Project Background

This Implementation Guide has drawn upon the results of multiple previous projects on patient summaries (including but not limited to epSOS [1], ONC S&I, Trillium Bridge[2], Sequoia eHealth Exchange [3]), rules and recommendations for vocabularies and value sets (in multilingual settings) and templates for the implementation of international patient summary documents.

The idea of the International Patient Summary has been one of the main results of the 2010 EU/US Memorandum of Understanding through its two operational arms: the European project Trillium Bridge and the Interoperability of EHR work group formed under the ONC Standards and Interoperability Framework (ONC S&I) EU/US eHealth Cooperation Initiative[4]. These initiatives identified the need for common templates and vocabularies for the patient summary.

The Joint Initiative Council (JIC) on SDO Global Health Informatics Standardization has initiated the standard sets project with patient summary as its pilot [5]; and the IPS became one of the main subjects of the new EU / US roadmap , having as a declared goal “to enable a standardized international patient summary (IPS) to be in use by 2020”[6].

The first standardization activity concerning the IPS was initially promoted in April 2014 by ONC within HL7 International. The project was called “INTernational PAtient Summary (INTERPAS)”. In May 2016, the European Commission granted an Agreement with CEN/ TC 251, recognizing the need to effectively support the leadership and active participation in IPS standardization activities. Thanks to the new boost from the European Commission (EC) and ONC a revision of the HL7 project was started in May 2016, as well as the standardization activities in CEN/TC 251 for the European standards on Patient Summaries. Since the beginning of this new phase, the initiatives were envisaged as a single common IPS project supported by different organizations; where the CEN/TC 251 and the HL7 teams worked together, taking in account the inputs of the JIC Standard Sets initiative on Patient Summary, with the common intent of developing coherent set of standards to support the International Patient Summary concept.

To expedite progress it was also agreed to set up an informal collaboration, promoting a continuous alignment process between the two SDO-specific projects, thanks also to a cross-participation in the project teams. Overlaps have thus been minimized: the CEN/TC 251 activities have been focused on the IPS dataset, formalized by the CEN/TC 251 Draft European standard (prEN) 17269:2018: The Patient Summary for Unscheduled, Cross-border Care" (the CEN/TC 251 prEN 17269:2018 PS in [Figure 1]); the HL7 ones initially on its implementation based on HL7 CDA R2 - this guide - and next on FHIR (the HL7 IPS IGs in [Figure 1]). The figure shows how the products of these standardization activities are placed in the HL7 SAIF Interoperability Matrix.

IPS SAIF.png

IPS SAIF.png

[Figure 1] IPS Standards in the HL7 SAIF Interoperability Matrix

A formal agreement between HL7 International and CEN/TC 251 has been finally signed in April 2017 in which these organizations established “in order to further the care for citizens across the globe <…> to collaborate on a single, common International Patient Summary (IPS) specification”; and that “the IPS specification shall focus on a minimal and non-exhaustive Patient Summary dataset, which is specialty-agnostic and condition-independent, but still clinically relevant.”.

Scope

As expressed in the introduction, the International Patient Summary is

  • a minimal and non-exhaustive patient summary,
  • specialty-agnostic,
  • condition-independent,
  • but readily usable by clinicians for cross-border unscheduled care of a patient.

In this context, minimal and non-exhaustive means that an IPS is not intended to reproduce (the entire) content of an Electronic Health Record (EHR).

Specialty-agnostic means that an IPS is not filtered for a specialty. As an example, allergies are not filtered to the specialty of internal medicine, thus may also include food allergies, if considered to be relevant for, e.g. unplanned care.

Condition-independent means that an IPS is not specific to particular conditions, and focuses on the patient current condition(s).

Furthermore the scope of the IPS is global. Although this is a major challenge, this implementation guide takes various experiences and newer developments into account to address global feasibility as far as possible.

General Principles for this Specification

With the formal agreement signed on April 2017, HL7 International and CEN/TC 251 expressed their intent to collaborate under the following principles for the IPS:

IPS principles.png

IPS principles.png

[Figure 2] The IPS Principles

  1. The standards specification for the IPS will be implementable
    • Promote (the evolution and convergence of) existing standards
    • Rely on solutions that are already implemented or ready for implementation
    • Consider new or additional solutions as they become available
  2. The standards specification for the IPS will be applicable for global use
    • Strive for global accessibility of standards for use at no cost
    • Strive for a core set of globally accessible and usable terminologies and value sets
    • Include free text in addition to the structured codes as needed
    • Do not include local solutions in the core specification that are not available in other jurisdictions
  3. The standards specification will be extensible and open to future use cases and solutions
    • The IPS provides common content that can be extended and specialized for other use cases, or localized for specific jurisdictional needs
    • The IPS is open to emerging solutions for unresolved issues or improvements
  4. The standards specification and their implementation must be sustainable through:
    • A robust maintenance and update process for the IPS
    • A process to ensure clinical validity of the IPS, meeting:
      • clinical requirements (including workflow)
      • clinical documentation requirements
      • information quality requirements

Moreover HL7 International and CEN/TC 251 will manage the expectations of the IPS standards specification among stakeholders, by

  • stipulating the role of the IPS as a foundation for others to extend
  • justifying the inclusion of items in the IPS within the limited context of cross-border or cross-jurisdiction unscheduled care.

The more relevant consequences of these principles in the template design are:

  • The adoption of a meet in the middle approach in the templates design to balance the need of maximizing the reuse of existing implemented templates (epSOS, C-CDA CCD; IHE PCC…) and facilitate implementation with the need of optimizing the fitness for purpose within the IPS scope. This approach aims to avoid a pure technical exercise of templates harmonization or an academic exercise that does not take in account what is already implemented.

IPS-meet-in-the-middle.png

IPS-meet-in-the-middle.png

[Figure 3] The IPS meet-in-the-middle approach

  • Cooperate with the HL7 Terminology Authority and the organizations that own the used code systems (e.g. SNOMED International) to make the IPS value sets available for global use at no cost for implementation of the IPS.
  • When global identifiers are not (or not yet) available, as in the case of the medicinal products, enhance the model proposed for that element with relevant identifying and descriptive attributes that could help with the global identification of that element.
  • Select a set of global reference terminologies, with provision for the inclusion of locally used terminologies.
  • Avoid solutions (e.g. identifiers, terminologies, standards) that are not yet available for actual global use (even those that are otherwise promising for resolution of well-known issues, such as medicinal product identification). However, the IPS has been already designed, where possible, to be ready to adopt these solutions when they are made available for real use (e.g. the IDMP identifiers) and to already support parts of those solutions that can be used today.
  • Within the scope of the IPS and of the “implementable” principle, attempt to be sufficiently generic in the design of the templates so that the IPS templates are extensible for supporting new scenarios, specific specialties or conditions through template specialization or adaptation mechanisms.

Structuring Choices

The International Patient Summary is specified as a templated document using HL7 CDA R2. The expressiveness of SNOMED CT and other primary terminologies enables this specification to represent the two general categories “condition/activity unknown” and “condition/activity known absent” in a style which is more independent of the underlying syntax (CDA R2 or FHIR), as explained in detail in section 4.2.

To be universally exchangeable and understood, a patient summary must rely as much as possible on structured data and multilingual international reference terminologies that are licensed at no cost for global use in the International Patient Summary. In the case of SNOMED CT, it is envisioned that SNOMED International could embrace the idea of a globally accessible open and free specification for the International Patient Summary that references a core set of globally accessible and usable value sets licensed at no-cost with the aim to serve the public good. In this spirit, this version of the International Patient Summary defines SNOMED CT as a primary terminology (the meaning of "primary terminology" is explained in section 4.1) and it is used in many of the value sets. To allow, however, a global and free implementation of the IPS this guide does not impose the usage of these SNOMED CT-based value sets. This choice may be revised in future versions. Other primary terminologies used in this specification are LOINC for observations (e.g., laboratory tests) and document sections, UCUM for units of measure, and EDQM Standard Terms for dose forms and routes. Looking at the availability of other globally usable reference terminologies and toward alignment with a future FHIR version of the IPS, in some selected cases FHIR-defined terminologies are recommended.

This specification adopts ART-DECOR®[7] as the specification platform for this Implementation Guide and uses the HL7 template exchange format[8]. This tool and format are increasingly used by several regions, including European countries, and have been adopted by the EU eHealth Digital Service Infrastructure (eHDSI) project for the operational deployment of the EU cross-borders patient summary and ePrescription services. Users of the specification can visit the IPS project page in ART-DECOR® to browse the specifications and review examples. Users may also use the tool to validate their IPS instances.

Ballot Status of the Document

This Implementation Guide is STU with the intention to go normative.

Audience

The audience for this Implementation Guide includes:

Public

  • Citizens who want to carry or access their healthcare data for emergency or unplanned care purposes.

Regulatory

  • Policy makers such as healthcare payers or government agencies.
  • Healthcare information governance authorities and regulatory bodies.

Clinical

  • Healthcare providers that offer unscheduled and emergency care.
  • Healthcare providers that populate regional and national patient summaries.

Technical

  • Vendors of EHR systems for unplanned care management, personal health records and mobile health data applications.
  • System integrators.
  • Organizations that manage regional and national patient summaries.

Relationships with other projects and guidelines

This guide is one of the products of the International Patient Summary project (see the Project Background section for details). This project relates to other projects and products as:

  • The European Commission CEN/TC 251 Grant Agreement “The International Patient Summary Standards Project” (SA/CEN/GROW/EFTA/000/2015-16).
    This project has as one of its goal “to participate in the creation of an International Patient Summary specification, at a global level, and turn this into a European standard, in line with the Guidelines on Minimum/Nonexhaustive Patient Summary Dataset for Electronic Exchange as adopted by the European eHealth Network"
    Under this project two other standard work items have been promoted under CEN/TC 251:
    • The CEN/TC 251 “prEN 17269: The Patient Summary for Unscheduled, Cross-border Care”.
      Its goal is to “formalise the dataset required to share information about the medical background and history of a patient …. It uses the European guidelines (version 2, November 2016) as an official source for the requirements….”
      Even if it is a European standard it is designed to be applicable in a wider global context.
    • The CEN/TC 251 “prTS 17288: The International Patient Summary: Guidance for European Implementation Technical Specification.
      Its goal is to “provide implementation guidance to support the use of the International Patient Summary dataset in a European context”
      This document is focused on the European cross-country services.
CEN IPS Grant.png
CEN IPS Grant.png

[Figure 4] The European Commission CEN/TC 251 Grant Agreement

  • The European eHealth Network Guideline on the electronic exchange of health data under Cross-Border Directive 2011/24/EU. Release 2. [9] This Guideline, together with the general guidelines for the electronic exchange of health data under Cross-Border Directive 2011/24/EU, documents the clauses agreed among the European Countries to support the exchange of Patient Summary data for unscheduled care.

The relationships among these standards are shown in Figure 14 included in the section Conformance clause.

Listed below are other related initiatives:

  • The HL7 Consolidated CDA (C-CDA) [10] implementation guide was developed and produced through the joint efforts of HL7, two Sub-Work Groups of the Office of the National Coordinator (ONC) Standards and Interoperability (S&I) Framework — Longitudinal Care Plan (LCP) and Long-Term Post-Acute Care (LTPAC) Transition) — and through the SMART C-CDA Collaborative hosted by ONC and Harvard Medical School. It provides a library of CDA templates for implementing a set of CDA documents.
    This is one of the primary sources for this Implementation Guide.
  • The IHE Patient Care Coordination (PCC) Cross-Enterprise Sharing of Medical Summaries (XDS-MS) [11] – “defines a mechanisms to automate the sharing process between care providers of Medical Summaries, a class of clinical documents that contain the most relevant portions of information about the patient intended for a specific provider or a broad range of potential providers in different settings.” .
    This is one of the primary sources for this Implementation Guide.
  • eHealth Digital Service Infrastructure (eHDSI) Patient Summary Service [12].This European initiative operationalizes the work done by the epSOS and EXPAND projects for the implementation of European Cross-border services for the exchange of patient summaries and ePrescriptions. This is one of the primary sources for this Implementation Guide.
  • The Joint Initiative on SDO Global Health Informatics Standardization (JIC) Patient Summary Standards Set is a set of health informatics standards and related artifacts that can be used to support the implementation of a Patient Summary [13]. The definition of the Patient Summary given by this initiative is a little broader than that adopted by the HL7 and CEN/TC 251 projects, being ““the minimum set of information needed to assure healthcare coordination and the continuity of care” .
  • The Data Provenance is an ONC S&I initiative addressing the “source data” challenge so that trust in the authenticity of the data can help inform decision making. The HL7 CDA® Release 2 Implementation Guide: Data Provenance, Release 1[14] is one of the products resulting from the joint efforts of Health Level Seven (HL7) and the Office of the National Coordinator (ONC) Standards and Interoperability Standards and Interoperability Framework-Data Provenance Initiative.

Reading Publication Artifacts

A reading guide is available that explains the formalism used to express the publication artifacts, i.e. template meta data and template design. For convenience the guide is included in the appendix. (see section 12 How to read the table view for templates)

Technical Background

What is a CDA

CDA R2 is "… a document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange” [CDA R2, Section 1.1]. Clinical documents, according to CDA, have the following characteristics:

  • Persistence
  • Stewardship
  • Potential for authentication
  • Context
  • Wholeness
  • Human readability

CDA defines a header for classification and management and a document body that carries the clinical record. While the header metadata are prescriptive and designed for consistency across all instances, the body is highly generic, leaving the designation of semantic requirements to implementation.

Templated CDA

CDA R2 can be constrained by mechanisms defined in the “Refinement and Localization” section of the HL7 Version 3 Interoperability Standards. The mechanism most commonly used to constrain CDA is referred to as “templated CDA”. This specification created a set of artifacts containing modular CDA templates (and associated value sets) for the purpose of the International Patient Summary, and the templates can be reused across any number of CDA document types.

There are different kinds of templates that might be created. Among them, the most common ones are:

  • CDA Document Level Templates constrain fields in the Clinical Document Architecture (CDA) header, and define containment relationships to CDA sections.
    For example, a History-and-Physical document-level template might require that the patient’s name be present, and that the document contain a Physical Exam section.
  • CDA Header Level Templates constrain fields for parts of the CDA header, like the patient (record target), the author, participations or the service event.
  • CDA Section Level Templates constrain fields in the CDA section, and define containment relationships to CDA entries.
    For example, a Physical-exam section-level template might require that the section/code be fixed to a particular LOINC code, and that the section contain a Systolic Blood Pressure observation.
  • CDA Entry Level Templates constrain the CDA clinical statement model in accordance with real world observations and acts.
    For example, a Systolic-blood-pressure entry-level template defines how the CDA Observation class is constrained (how to populate observation/code, how to populate observation/value, etc.) to represent the notion of a systolic blood pressure.

Open and Closed Templates

Open templates permit anything to be done in the underlying standard that is not explicitly prohibited. This allows templates to be built up over time that extend and go beyond the original use cases for which they were originally designed.

Closed templates only permit what has been defined in the template, and do not permit anything beyond that. There are good reasons to use closed templates, sometimes having to do with local policy. For example, in communicating information from a healthcare provider to an insurance company, some information may need to be omitted to ensure patient privacy laws are followed. Most templates developed for CDA are of the open sort.

Template versioning

Template versioning is needed to enable template designs to evolve over time.

Template versioning enables template designers to control and shape the conformance statements that make up a template’s design over time tailoring the design to fit the template’s intended purpose.

Each template version is associated with a particular template. The template – as a whole – has a mandatory globally unique, non-semantic, identifier. The identifier serves as the identifier of the original intent of the template and as the identifier of the set of versions that represent the template over time.

Template versions have a mandatory timestamp (date and optional time), called the “effective date”. The date can be seen as the point in time when the template version “came into being”, i.e. was recognized as existent by the governance group. Use of the template prior to this date would be considered an invalid use of the template.

For further information on Templates, Template Versions and related topics refer to the HL7 Templates Standard[8].

Conformance Verbs

The conformance verb keywords SHALL, SHOULD, MAY and SHALL NOT in this document are to be interpreted as described in the HL7 Version 3 Publishing Facilitator's Guide[15].

  • SHALL: an absolute requirement
  • SHALL NOT: an absolute prohibition against inclusion
  • SHOULD: best practice or recommendation. There may be valid reasons to ignore an item, but the full implications must be understood and carefully weighed before choosing a different course
  • MAY: truly optional; can be included or omitted as the author decides with no implications

Identifiers for Templates and Value Sets

This specification uses the following OIDs for the artifacts that are registered at the HL7 OID registry.

  • The root OID for templates is 2.16.840.1.113883.10.22
    • Document Level Templates are sub branch .1, e.g. 2.16.840.1.113883.10.22.1.1 International Patient Summary
    • Header Level Templates are summarized under 2.16.840.1.113883.10.22.2, e.g. 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget
    • Section Level Templates are summarized under 2.16.840.1.113883.10.22.3, e.g. 2.16.840.1.113883.10.22.3.1 IPS Medication Summary Section
    • Entry Level templates are summarized under 2.16.840.1.113883.10.22.4, e.g. 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation
    • “other” assistance templates are summarized under 2.16.840.1.113883.10.22.9, e.g. 2.16.840.1.113883.10.22.9.2 IPS CDA Device
  • The root OID for Value Sets is 2.16.840.1.113883.11

The sub branches for templates follow the recommendations of HL7 International and ISO 13582[16]

Terminologies

Note: Much of the description provided in this section is copied and adapted from the §4.2.8 Vocabulary Conformance section of the C-CDA DSTU R2.1 Implementation Guide Volume 1.[17]

The templates in this document use terms from several code systems. These vocabularies are defined in various supporting specifications and may be maintained by other bodies, as is the case for the LOINC® and SNOMED CT® vocabularies. The primary terminologies identified for this specification are listed in section 4.1.

Note that value set identifiers (e.g., ValueSet 2.16.840.1.113883.1.11.78 Observation Interpretation (DYNAMIC)) used in the binding definitions of template conformance statements do not appear in the XML instance of a CDA document. The definition of the template must be referenced to determine or validate the vocabulary conformance requirements of the template.

Value set bindings adhere to HL7 Vocabulary Working Group best practices, and include both an indication of stability and of coding strength for the binding. Value set bindings can be STATIC, meaning that they bind to a specified version of a value set, or DYNAMIC, meaning that they bind to the most current version of the value set. If a STATIC binding is specified, a date SHALL be included to indicate the value set version. If a DYNAMIC binding is specified, the value set authority and link to the base definition of the value set SHALL be included, if available, so implementers can access the current version of the value set. When a vocabulary binding binds to a single code, the stability of the binding is implicitly STATIC.

For example, to convey @code=11450-4, the code’s displayName 'Problem List', the OID of the codeSystem from which the code is drawn '2.16.840.1.113883.6.1', and the codeSystemName 'LOINC', the tabular view used in this guide is presented as shown below.

hl7:code 1 … 1M
@codeCONF1 … 1F11450-4
@codeSystem1 … 1F2.16.840.1.113883.6.1 (LOINC)
@displayName1 … 1FProblem List

[Figure 5] Binding to a Single Code (tabular view)

HL7 Data Types Release 1 requires the codeSystem attribute unless the underlying data type is “Coded Simple” or “CS”, in which case it is prohibited. The displayName and the codeSystemName are optional, but recommended, in all cases.

The above example would be properly expressed as follows.

<code code="11450-4" codeSystem="2.16.840.1.113883.6.1"/>

<!-- or -->

<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" 
  displayName="Problem List" codeSystemName=”LOINC”/>

[Figure 6] XML Expression of a Single-Code Binding

A full discussion of the representation of vocabulary is outside the scope of this document; for more information, see the HL7 V3 Normative Edition 2010[18] sections on Abstract Data Types and XML Data Types R1.

There is a discrepancy between the HL7 R1 Data Types and this guide in the implementation of translation code versus the original code. The R1 data type requires the original code in the root. The convention agreed upon for this implementation guide is that a code from the required value set is used in the element and other codes not included in the value set are to be represented in a translation for the element. Note: This discrepancy is resolved in HL7 Data Types R2, but that is not available for use in CDA R2.

In the next example, the conformant code is SNOMED CT code 206525008.

<code code="206525008" codeSystem="2.16.840.1.113883.6.96"
  displayName="neonatal necrotizing enterocolitis" codeSystemName="SNOMED CT">
  <translation code="NEC-1" codeSystem="2.16.840.1.113883.19"
    displayName="necrotizing enterocolitis"/>
</code>

[Figure 7] Translation Code Example

Value set tables are present below a template, or are referenced if they occur elsewhere in the specification, when there are value set bindings in the template. The value set table provides the value set identifier, a description, and a link to the source of the value set when possible. Ellipses in the last row indicate the value set members shown are examples and the true source must be accessed to see all members.

If a value set binding has a DYNAMIC stability, implementers creating a CDA document must go to the location in the URL to check for the most current version of the value set expansion.

Note: Much of the description provided in the following three sections on value set definitions and expansions and extending value sets is adapted from Core Principles and Properties of HL7 Version 3 Models.[19]

Value Set Definitions

Two approaches can be used to define the contents of a Value Set:

  • Extensional Definition: Explicitly enumerating each of the Value Set concepts.
    • An Extensional Definition is an enumeration of all of the concepts within the Value Set. A Value Set defined by extension is composed of explicitly enumerated sets of concept representations (with the Code System in which they are valid). The simplest case is when the Value Set consists of only one concept.
  • Intensional Definition: Defining an algorithm that, when executed by a machine (or interpreted by a human being), yields an enumeration of all of the concepts within the Value Set, which is called a Value Set Expansion.
    • An Intensional Definition is a set of rules that can be expanded (ideally computationally) to an exact set of concept representations at a particular point in time.

Many of the value sets used in the IPS specification are defined intensionally. The source of truth for these value sets and their definitions for IPS is ART-DECOR®[20].

IPS intensionalvs.png

IPS intensionalvs.png

[Figure 8] Intensional value set definition.

Value Set Expansions

To obtain a list of enumerated concepts, Value Sets must be expanded. This means that the Value Set Definition must be converted to a list of concept representations at a point in time. This normally is a list of codes that may be used in populating or validating communicated model instances (but it may alternatively be a list of designations). While this is straightforward for extensional Value Set Definitions, an intensional Value Set Definition must be resolved to a Value Set Expansion by processing the rules contained in the Value Set Definition. Value Set Expansion can be done as early as the point of Value Set definition or as late as run time. For intensional Value Sets, the set of concepts contained in the expansion will generally change when the definition is changed (a new version of the Value Set Definition), but also may change with the identical version of the definition if the underlying code systems change, and the changes are part of the Value Set Expansion. This can be controlled if the definition statement refers to specific code system versions, thereby prohibiting the expansion from changing when the code system changes with a new version release. See Core Principles and Properties of HL7 Version 3 Models for additional details.[19]

In order to implement the IPS specification, the intensionally defined value sets must be expanded (as noted above). ART-DECOR® is expected to provide capabilities for generating the required value set expansions. Other terminology servers are also expected to provide this service.

How to extend Value Sets

For elements with a binding to a value set that allows extensibility (Extensible/CWE), it may at times be necessary to extend the value set in order to support implementation needs. Coded With Extensibility (Extensible/CWE) means that the set of codes resulting from processing the Value Set Definition is not necessarily complete for its intended use-case. There may be some concepts that need to be communicated that cannot be represented within the expansion of the specified value set. In these cases, implementers therefore have permission to send local codes or original text within the coded element if an appropriate code cannot be found within the value set and its current expansion. When this does occur, however, there is an expectation that implementers should feed back these "missing concepts" to the maintainers of the Value Sets or referenced Code System(s) to have the necessary concept added, and then to transition to the new "official" code when one is subsequently added to the value set.

Functional requirements and high-level use cases

Several use cases may be identified for the International Patient Summary within its scope (“specialty-agnostic, condition-independent, but readily usable by clinicians for the cross-border unscheduled care”). Section Examples provide a subset of some real world user stories for the cross-border care developed by the Trillium Bridge Project and by the S&I EU-US eHealth Cooperation Initiative in the scope of the EU/US Roadmap initiative.

The cross-border care is not however the only expected usage scenario for the IPS. Some European countries have already manifested their interest on the IPS work for their future national Patient Summary for unscheduled care. Patient summary initiatives are currently in various stages of development in other parts of the world.

As shown by the user stories there are several possible options in terms of creation, sharing and usage of an IPS. For example:

  1. An IPS can be created when requested and used before, during, or after a care episode; or can be asynchronously generated and made available for future usage (e.g. store and retrieve).
  2. The IPS can be retrieved using a document exchange infrastructure; transported by the patient; or shared using cloud-services.
  3. The IPS may be subject of a transformation process that may include syntactical conversions, coded concept mappings and coded concept designation or free text translations. This transformation process may be performed in the creation phase, during the transmission, or after the IPS has been received, possibly using an external service.
  4. Finally, the received CDA may be used in different ways. For example, displayed using a common CDA stylesheet; display the extracted relevant information; incorporated into the receiver’s EHR. Alternatively, a specialized viewer may be adopted to enable the display of the translated content.


Moreover for cross-jurisdiction exchange, the IPS could be used as:

  1. shared format among jurisdictions (case A), where jurisdictions originate and use IPS conforming documents unaltered.
  2. pivot document among existing summaries / data formats (case B). For example, the IPS is used as intermediate format between the US C-CDA CCD (please note that the CCD scope differs from that of the IPS) and the European eHDSI Patient Summary for a Transatlantic Patient Summary exchange.
  3. mixed mode (Case C), where either the originator or the consumer is expected to use an IPS conforming document.
IPS cases.png

[Figure 9] Examples of IPS usage

Considering all those possible combinations and additional business requirements agreed by jurisdictions, there are several technical infrastructures and services that may be designed to support these requirements.

It is out of scope of this standard to provide any indication about solutions and strategies for the IPS creation, sharing, syntactical and semantic mapping, translation, and use.

That said, an International Patient Summary may:

  1. be the result of automatic assembly (assembled IPS) or of a human summarization act (human curated IPS)
  2. have one or more EHR sources
  3. document information from a single or multiple jurisdictions/organizations
  4. aggregate input from a single or multiple encounters.


A clear determination of such contextual information raises the trustworthiness of the received IPS and helps the appropriate usage of its content by the receiver . Most of these aspects are related to data provenance introduced in section 1.8 and further detailed in section 4.11.

Even if many jurisdictions require that only one active Patient Summary for unscheduled care be made available, this guide does not impose such constraints and leaves them to jurisdictional implementations.

Moreover it is also out of scope of this guide to:

  • provide guidance on how to determine the relevance of data for their inclusion in a IPS;
  • define selection or composition rules for facing potential inconsistencies from multiple sources in case of automatic collection.

Code mappings and multilingual support

The capability of managing locally used coded concepts and reference terminologies, and that of providing receiving providers with human readable information in a language that can be understood by them, are critical aspects to be taken in account in the cross-border sharing of documents. This section summarizes some of the requirements related to these aspects, including also additional needs derived from the European cross-border services and some lessons learned by the EU/US Trillium Bridge Project.

The European cross-border services (eHDSI) use a business to business exchange infrastructure based on a network of country gateways that mediate access to the national infrastructures. The eHDSI Patient Summary (eHDSI PS) is used as a “pivot” document for the cross-border exchange. Local PS using data/document formats are in fact remapped into the eHDSI PS. The document exchanged is processed each time it passes through one of these gateway applying the needed syntactical transformation, code mappings. and translation of the code designations. Finally, in the current practice the received PSs are displayed using specialized display tools that build a human readable representation of the PS in the target language using the translated designations reported in the coded entries.

The adoption of translated narratives in the received document has been one of the indications received by the Trillium Bridge Project. This in fact allows extending multilingual support for the cross-border patient summaries to a wider set of potential consumers (EHR-or PHR systems), without requiring specialized viewers as applied in the eHDSI services.

Concept code mapping

In several real world use cases the records used as source for the Patient Summaries may use locally adopted terminologies, which are mapped to the reference value sets when possible, or otherwise used directly to provide uncoded information. This leads to a series of requirements listed below and detailed further in section 4 Design conventions and principles.

  • When the original coded concept is mapped to one of the coded concepts included in the reference value sets (called hereafter reference code/coded concept), both the original and the reference codes SHALL be reported in the IPS instance.
  • When the original coded concept is not mapped to one of the coded concepts included in the reference value sets, the original code SHALL be reported in the IPS instance as well as the indication that mapping was not successful.
  • When the original record, for a specific coded element, is not able to provide coded but only textual information, this information SHALL be reported in the IPS instance.

This guide also accommodates these situations:

  • The original record may support multi-coding. The IPS instance should make clear whether the additional codes belong to the original content or are the result of post hoc concept code mapping.
  • The original record may include references to the pieces of text the coding was derived from. If present, the IPS instance should preserve this link between the original code and the referred text.
  • Distinct original and reference coded concepts may belong to the same code system. This may be the result of a different level of granularity between the original and the reference value sets, or the result of format transformation - e.g. CCD document is used as input for generating an IPS. The requirement of recording both coded concepts applies also to these cases.

Multilingual support

Multilingual support by IPS can be split in two categories of action:

  1. The translation of coded concept designations (displayName)
  2. The translation of the narrative.

These actions may deal with various choices:

  • Translation to the language of the receiving care provider: a foreign provider retrieves a translated copy of the IPS from the patient's country of affiliation…
  • Translation to a commonly agreed language: an English version of the IPS is prepared.
  • Predefined set of translations included in the shared IPS.

This guide does not favor any of these solutions. All of them are supported.

Translation of Designations

The European Cross-border services requires that for “safety and liability reasons” all of the original coded terms (designations, displayName) shall be recorded in the exchanged documents together with at least the English and the receiving country language terms (designations, displayName) associated with the reference codes. The designations translated in the receiving country language are used to generate the human readable content shown to the receiving provider. No free text translation is applied in this case. In order to accomplish this objective, the IPS should have the capability to record one or more designations, possibly indicating the language used. The solution chosen to fulfill this requirement is specified in section 4.6.

Narrative Translation

Narrative translation covers two kinds of operations:

  • Translation of the original narrative text, which can be automated (e.g. using translation services) and/or human curated.
  • Creation of new narrative for the target language, based on the coded entries.

The level of quality and liability obtained depends on the solution adopted and on the quality of the translation service used. It is out of the scope of this guide to suggest any of these solutions. In all cases, however:

  • the language of the narrative should be identifiable
  • the original and the translated narrative should be clearly distinguished
  • the translation methodology applied (e.g. derived from the coded entries; translated by a generic service;..) should be noted

Design conventions and principles

How to use terminologies (preferred binding)

As stated in section 1.5, to be universally exchangeable the International Patient Summary must rely on international multilingual reference terminologies. To that effect, each codeable element of the international patient summary template is bound to a Value Set built upon an international reference terminology, such as SNOMED CT, LOINC, UCUM or EDQM Standard Terms. In some selected cases, in consideration of the availability of other globally usable reference terminologies and for alignment with a future FHIR version of the IPS, FHIR-defined terminologies have been specified. These terminologies have been selected to provide the preferred bindings for the codeable elements of the patient summary. They are the primary terminologies of this specification.

Nevertheless, it is anticipated that in some situations a system producing an instance of patient summary might not support one or the other of these primary terminologies, supporting only a local interface terminology instead. Similarly, it is also anticipated that the receiving system might in some cases not be able to use a code in a patient summary, either because this code belongs to a primary terminology that the receiving system does not support or because this code belongs to an interface terminology specific to the country of the producing system.

In order to maximize the international scope and usability of patient summaries, and also to accommodate the exceptional situations listed above, this specification makes these requirements:

  • The Primary Code of a codeable element SHOULD be populated.
  • If populated, the Primary Code of a codeable element SHALL be chosen from the primary terminology assigned to the value set bound to this element; unless exceptions have been agreed.
  • The 'displayName' of the Primary Code SHALL be populated with a term representing this same code in the terminology used, in the language chosen for the current instance of the patient summary.
  • When the primary 'code' element is not populated, an appropriate 'nullFlavor' value SHALL be used along with the 'originalText' element (referencing a textual expression in the narrative representing the meaning for the producer) and/or one or more coded 'translation' elements.
  • One or more Alternate Codes from a local interface terminology MAY be provided, each with its associated 'displayName'.
  • In case the primary code is derived from an alternate terminology the alternate code SHOULD be provided in the translation element.

Primary Code

In the data type for codeable elements (CD constrained by the CD.IPS template), the Primary Code is represented by the attributes @code, @displayName, @codeSystem, @codeSystemName, @codeSystemVersion.

Alternate Code

In the data type for codeable elements (CD constrained by the CD.IPS template), an Alternate Code is carried in a 'translation' sub-element.

Original Text

In the data type for codeable elements (CD constrained by the CD.IPS template), the Original Text is provided in the 'originalText' sub-element.

Representing "known absent" and "not known"

In line with the properties of minimalism and non-exhaustiveness for the IPS (see the IPS definition above), and benefiting from the experience acquired with the European cross-border services, this guide explicitly addresses two general situations:

  1. condition or activity unknown
  2. condition or activity known absent.


Other kinds of negations such as: (a) the negation of an allergy to a specific agent; (b) the absence of a particular disease; or (c) the fact that a specific vaccination has not been performed, have been considered beyond the set of essential data for an IPS.

This specification represents this core set of negations (“general condition/activity unknown” and “general condition/activity/known absent” ) using explicit coded elements rather than relying on specific mechanisms of HL7 CDA such as nullFlavor and negationInd attributes or human readable text (possibly not understood by the foreign country receiver).

In contrast to the practice to use negationInd or nullFlavor attributes on a section itself, we prohibit the use of these attributes on section level to express “unknown” or “no information” situations. A section holds the categorized (coded) narrative part of the documented activity and will never carry negationInd or nullFlavor attributes. Instead, we enforce by design, that “unknown” or “no information” expressions always go to the coded entry with a corresponding act code.

The main reasons for this choice are:

  • @negationInd in CDA has been superseded in V3 later by two other negation indicators: @actNegationInd and @valueNegationInd.
  • To make clinical content representation less dependent on a particular format or syntax, enabling a more practical path to transforming and exchanging data from one standard format (e.g. CDA R2) to another (e.g. FHIR).
  • to provide one single method to express the presence or absence of a particular condition (e.g. an allergy) or activity (e.g. an immunization), or the lack of knowledge regarding this kind of condition or activity, resulting in a more robust and easily implementable specification.

For the other kinds of negations, not explicitly mentioned in this guide, it is suggested to apply – where possible – the same approach. Future versions of this guide may extend the number of cases covered and include new coded concepts for supporting them.

When needed, more specific statements such as the absence of a specific condition or activity, although considered as beyond the set of essential data for IPS, can still be expressed by using the native negationInd attribute of CDA R2.

Uncoded information

An IPS originator may not be able to value a coded element with an appropriate coded concept, but only with textual information. This may happen for two reasons:

  1. the originator is not able to express the concept in the reference value sets
  2. the originator is not able to express the concept in any known terminology.


The first case, assuming that the coding strength is Required (aka CNE, coded, no extensions), is represented in this guide with the following assertion:

<code codeSystem="2.16.840.1.113883.6.96" nullFlavor="OTH">
  <originalText>
    <reference value="#ref1"/>
  </originalText>
</code>

That is expressing that there are no codes applicable in the referred code system (in the example, SNOMED CT). Please note that according to this guide the text is documented in the section narrative and only referenced by the coded element.

Note: Data Types R1 doesn't allow specifying that there are no codes applicable in the referred value set, as instead is possible with Data Types R2. Future versions of this guide may consider extending the data type to better support this situation.

The second case, that applies both to Required (aka CNE, coded no extensions) and Extensible (CWE, coded with extensions) coding strengths, is instead here represented valuing the coded element with the most generic nullFlavor “NI” (No Information) and pointing the text in the section narrative:

<value xsi:type="CD" nullFlavor="NI">
  <originalText>
    <reference value="#ref1"/>
  </originalText>
</value>

Note: The most proper NullFlavor code to be used here would be "UNC" (Uncoded). This code is available in the current and other recent versions of the HL7 RIM, but it is not present in version 2.07 of the RIM on which the CDA R2 standard is based. In the absence of "UNC", the most appropriate NullFlavor code to use for representing that the data is unable to be coded is "NI".

Unmapped Coded Concepts

In several real world situations the records used as source for the Patient Summaries may use locally adopted terminologies mapped into the reference value sets. When the original coded concept cannot be mapped in one of the coded concepts included in the reference value sets, it is recommended to populate the original code in the IPS instance (in a 'translation' sub-element), with a nullFlavor indicating that the mapping didn’t occur. (See also the Concept code mapping in the functional requirements section.). The nullFlavor value depends upon the coding strength of the binding.

Two circumstances are considered here: the case in which the coding strength is Required (CNE) and when it is Extensible (CWE).

In the case of coding strength Required (CNE), use nullFlavor "OTH":

<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" nullFlavor="OTH"> 
  [
    <originalText>
      <reference value="#ref1"/>
    </originalText>
  ] 
  <translation code="A02.9" codeSystem="2.16.840.1.113883.6.3"
    displayName="Infezioni da Salmonella non specificate"/>
</value>

The square brackets [ ] are used to indicate that the originalText element may or may not be present

Note: It may happen that a mapping would be possible in the target code system, but not in the target value set; Data Types R1 does not allow the specification of this difference, that there are no codes applicable in the reference value set, which is possible with Data Types R2.

Future versions of this guide may consider extending the data type to better support this situation.

In the case of Extensible (CWE) coding strength, this guide recommends representing the original code in the <translation> sub-element and using a nullFlavor for the primary code. This highlights the fact that a mapping to the reference value set was attempted, but no suitable target codes were identified.

<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" nullFlavor="NI"> 
  [
    <originalText>
      <reference value="#ref1"/>
    </originalText>
  ] 
  <translation code="A02.9" codeSystem="2.16.840.1.113883.6.3" 
    displayName="Infezioni da Salmonella non specificate"/>
</value>

The square brackets [ ] are used to indicate that the originalText element may or may not be present.

Mapped coded concepts

As mentioned above, in several circumstances an original coded concept is mapped into the reference value set. When this occurs, both the original and the reference codes should be reported in the IPS instance.

Functional requirements exposed in section 3.1 (multi-coding, link to original text, mapping between codes of the same code system) are also detailed below.

Case 1: Single local code mapped to primary code from the reference value set.

<value xsi:type="CD" code="42338000" codeSystem="2.16.840.1.113883.6.96"
  displayName="Salmonella gastroenteritis">
  [
    <originalText>
      <reference value="#ref1"/>
    </originalText>
  ] 
  <translation code="003.0" codeSystem="2.16.840.1.113883.6.103"
    displayName="Gastroenterite da Salmonella"/>
</value>

The square brackets [ ] are used to indicate that the originalText element may or may not be present

Case 2: Multiple local codes mapped together using nested 'translation' elements, and mapped to the primary code from the reference value set.

<value xsi:type="CD" code="422479008" codeSystem="2.16.840.1.113883.6.96"
  codeSystemName="SNOMED CT"
  displayName="FEMALE BREAST INFILTRATING DUCTAL CARCINOMA, STAGE 2">
  [
    <originalText>
       <reference value="#problem4name"/>
    </originalText>
  ]
  <translation code="code-example" codeSystem="1.999.999"
    codeSystemName="this is only an example"
    displayName="FEMALE BREAST INFILTRATING DUCTAL CARCINOMA, STAGE 2">
    <translation code="174.9" codeSystem="2.16.840.1.113883.6.103"
      codeSystemName="ICD-9CM"
      displayName="Malignant neoplasm of breast (female), unspecified"/>
    <translation code="C50.919" codeSystem="2.16.840.1.113883.6.90"
      codeSystemName="ICD-10-CM"
      displayName="Malignant neoplasm of unspecified site of unspecified female breast"/>
 </translation>
</value>

Case 3: Original and the reference coded concepts belong to the same code system (distinct codes). This may be the result of a different level of granularity between the original term and the reference value sets.

<code code="60591-5" codeSystem="2.16.840.1.113883.6.1"
  codeSystemName="LOINC" displayName="Patient Summary">
  <translation code="60592-3" codeSystem="2.16.840.1.113883.6.1"
    displayName="Patient summary unexpected contact"/>
</code>

Note: The R1 data type definition identifies the <translation> as “a set of other concept descriptors that translate this concept descriptor into other code systems." There is however a common understanding that it may be more than one representation in a single code system where code systems allow multiple representations, such as SNOMED CT. Data Types R2 extended the possibility to provide translations also in the same code system.

Translation of designations

The capability of recording one or more designations, in different languages, for the exchanged Patent Summary is one of the functional requirements requested for “safety and liability reasons” by the European Cross-border services (see Designations’ Translation under the Functional requirements and high-level use cases for more details).

Given that the base CDA R2 standard which uses datatypes R1 does not offer a native way to convey the language translation of 'displayName', this guide introduces an optional 'ips:designation' extension to the CD datatype for that purpose.

Below are examples of usage of this extension.

No code mapping

<code code="60591-5" codeSystem="2.16.840.1.113883.6.1"
  codeSystemName="LOINC" displayName="Patient Summary">
  <ips:designation language="it-IT">Profilo Sanitario Sintetico</ips:designation>
  <ips:designation language="fr-FR">Patient Summary</ips:designation>
  <ips:designation language="en">Patient Summary</ips:designation>
</code>

Including code mapping

<value xsi:type="CD" code="42338000" codeSystem="2.16.840.1.113883.6.96"
  displayName="Salmonella-gastroenterit">
  <ips:designation language="da-DK">Salmonella-gastroenterit</ips:designation>
  <ips:designation language="en">Salmonella gastroenteritis (disorder)</ips:designation> 
  [
    <originalText>
      <reference value="#ref1"/>
    </originalText>
  ]
  <translation code="003.0" codeSystem="2.16.840.1.113883.6.103"
    displayName="Gastroenterite da Salmonella"/>
</value>

Narrative Translations

“Narrative translation” means both the translation of the original narrative text, that can be human curated or automatically performed, and the generation of a translated narrative based on the coded entries.

The functional requirements associated with this process are described in the Designations’ Translation section under Functional requirements and high-level use cases, and can be summarized in two main points : (a) language identification and (b) distinguishable original and translated narratives. Moreover, the methodology applied for the narrative translation (e.g. derived from the coded entries; translated by a generic service;..) should be noted.

Regarding the translation of section narrative <text>, this guide recommends providing this translation on purely textual subordinate sections (one per translation) as specified in the IPS Translation Section (2.16.840.1.113883.10.22.3.15) template.

An example of this is:

<section>
  <templateId root="2.16.840.1.113883.3.1937.777.13.10.5"/>
   <id root="..." extension="..."/>
   <code code="48765-2" codeSystem="2.16.840.1.113883.6.1"
      displayName="Allergies and adverse reactions"/>
   <title>Allergies and Intolerances</title>
   <text>No known Allergies</text>
   <!-- omissions -->
   <component>
      <section>
        <!--  subordinate section carrying a translation of the parent section -->
        <title>Allergie ed Intolleranze</title>
        <text>Nessuna Allergia Nota</text>
        <languageCode code="it-IT"/>
      </section>
    </component>
</section>

Determining the Status of Clinical Statement

Note: Most of the description provided in this section is copied from the § 3.3 Determining the Status of Clinical Statement of the C-CDA DSTU R2.1 Implementation Guide Volume 1.[17]

A recipient must be able to determine whether the status of an entry — which can include a problem, a medication administration, etc. — is active, completed, or in some other state. Determination of the exact status is dependent on the interplay between an act’s various components (such as statusCode and effectiveTime). The following principles apply when representing or interpreting the status of a clinical statement.

  • The Act.statusCode of the clinical statement specifies the state of the entry: Per the RIM, the statusCode “reflects the state of the activity. In the case of an Observation, this is the status of the activity of observing, not the status of what is being observed.”
  • Act.statusCode and Act.moodCode are inter-related: Generally, an act in EVN (event) mood is a discrete event (a user looks, listens, measures, and records what was done or observed), so generally an act in EVN mood will have a statusCode of “completed.” A prolonged period of observation is an exception, in which a user would potentially have an observation in EVN mood that is “active.” For an Observation in RQO (request) mood, the statusCode generally remains “active” until the request is complete, at which time the statusCode changes to “completed.” For an Observation in GOL (goal) mood, the statusCode generally remains “active” as long as the observation in question is still an active goal for the patient.
  • Act.statusCode and Act.effectiveTime are interrelated: Per the RIM, the effectiveTime, also referred to as the “biologically relevant time,” is the time at which the act holds for the patient. So, whereas the effectiveTime is the biologically relevant time, the statusCode is the state of the activity. For a provider seeing a patient in a clinic and observing a history of heart attack that occurred 5 years ago, the status of the observation is completed, and the effectiveTime is five years ago.

The IPS Problem Concern Entry and the IPS Allergy and Intolerance Concern templates reflect an ongoing concern on behalf of the provider that placed the concern (e.g. a disease, an allergy, or other conditions) on a patient’s problem or allergy list. The purpose of the concern act is that of supporting the tracking of a problem or a condition (e.g. an allergy). A concern act can contain one or more discrete observations related to this concern. Each of them reflects the change in the clinical understanding of a condition over time. For instance, a Concern may initially contain a symptom of “chest pain”, later identified as consequence of a gastroesophageal reflux. The later problem observation will have a more recent author time stamp.

There are different kinds of status that could be of clinical interest for a condition:

  • The status of the concern (active, inactive,..)
  • The status of the condition (e.g. active, inactive, resolved,..)
  • The confirmation status [verification status, certainty] (e.g. confirmed, provisional, refuted,…)

Not all of them can be represented in a CDA using the statusCode elements of the concern (ACT) and observation (condition).

Status of the concern and related times

The statusCode of the Problem Concern Act is the definitive indication of the status of the concern. So long as the provider has an ongoing concern — meaning that the provider is monitoring the condition, whether it includes problems that have been resolved or not — the statusCode of the Concern Act is “active.” When the underlying conditions are no longer an active concern, the statusCode of the Problem Concern Act is set to “completed.”

The Concern Act effectiveTime reflects the time that the underlying condition was considered a concern. It may or may not correspond to the effectiveTime of the condition (e.g., even five years later, the clinician may remain concerned about a prior heart attack). The effectiveTime/low of the Concern Act asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. (i.e. it should be equal to the earliest author time stamp) The effectiveTime/high asserts when the concern became inactive, and it is present if the statusCode of the concern act is "completed". If this date is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".

Status of the condition and related times

Each Observation contained by a Concern Act is a discrete observation of a condition. Its statusCode is always “completed” since it is the “status of the activity of observing, not the status of what is being observed”. The clinical status of a condition (e.g. a disease, an allergy,..) is instead recorded by specialized subordinated observations (IPS Allergy Status Observation; IPS Problem Status Observation), documenting whether it is active, in remission, resolved, et cetera. The effectiveTime, also referred to as the "biologically relevant time", is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed six months ago, the effectiveTime is six months ago. The effectiveTime of the Observation gives an indication of whether or not the underlying condition is resolved, but the current status is documented by a subordinated observation. The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance was biologically resolved. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".


IPS ProblemActConcern.png

IPS ProblemActConcern.png

[Figure 10] Problem Concern Act (from C-CDA IG DTSU R2.1)[17]

Confirmation status

The confirmation status, also noted as verification status or certainty, indicates the certainty associated with a condition (e.g. confirmed, provisional, refuted,…) providing information about the potential risk, for example, of a reaction to the identified substance. The confirmation status of a condition (e.g. a disease, an allergy,..) is recorded by a specialized subordinated observation (IPS certainty Observation), documenting whether the condition is confirmed, unconfirmed, provisional, refuted, et cetera.

The use of medication statements in the summary

A medication list may strongly vary depending on the context of use (e.g. support for prescription or dispensation, drug reconciliation, etc. ) and on the type of information reported (e.g. patient-reported medication, prescribed, dispensed or administered medications, active or past medications, etc.).

This is still true also for the medication summary in a Patient Summary. It could be, for instance, a list of "Relevant prescribed medicines whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not" (European guidelines on Patient Summary [21]); a list of actually dispensed medications; a list of relevant medications for the patient (IHE PCC [22]); or conversely, it could be a complete history including the full patient's prescription and dispensation history and information about intended drug monitoring (C-CDA [17]).

Moreover, for the scope of the International Patient Summary, it is important to know what medications are being taken by or have been given to a patient; without necessarily providing all the details about the medication order, supply, administration or monitoring. This information need, in line with the IPS principle of minimum non exhaustive data, is well expressed by the concept of Medication Statement (see https://www.hl7.org/fhir/medicationstatement.html).

The IPS medication summary is therefore a list of relevant medication statements, possibly built from either a prescription list or a dispensation list. In fact, in many practical cases data included in a Patient Summary are derived from the list of the medicines prescribed by a GP and recorded in its EHR-S; or extracted from a in regional/national prescribing and/or dispensation systems. In these cases, data obtained from actual dispensation and/or prescription records can be still recorded in the IPS as statements and the original request, supply or administration records referred by the statement if really needed.

Medicinal Product Identification

The identification of medicinal products is quite easily solved within a single jurisdiction relying on local drug databases. In contrast, it is one of the major open issues for eHealth services across jurisdictions.

The set of ISO standards called IDMP[23] - designed initially for the regulatory scope, but hopefully extensible to other domains - are the most promising solution for solving this known issue, as also highlighted by the European project OpenMedicine [24]. The completion of the IDMP implementation guides, the deployment of the needed supporting services, and the development of some companion standards that will allow the seamless flow of the IDMP identifiers and attributes from the regulatory space to the clinical world (and back) are however still in progress. Additional time is needed before these identifiers and attributes will be available in full for practical use.

Following therefore the IPS principles of “implementability”, “openness" and "extensibility”, the solution proposed here does not rely on IDMP identifiers. Nonetheless, it takes into account, however, relevant IDMP identifiers and attributes which are already usable in the IPS, namely the Pharmaceutical Product Identifiers (PhPIDs), the Medicinal Product Identifier (MPID), and the Medicinal Product Package Identifier (PCID).

Note: IDMP Medicinal Product (MPID) and Medicinal Product Package (PCID) identifiers depend on the market authorization. The “same” product might therefore have different IDs if different authorizations have been received in different countries, while the PhPID should be the same. For the purpose of the IPS, future standards and implementation guides should define global product identifiers that do not depend on the drug registration process (as the Virtual Medicinal Product in SNOMED CT) and relate to IDMP identifiers.

Thus, in the absence of a global identification system for medicinal products, the solution proposed here is based on the approach initially adopted by the European cross-border services (epSOS and currently by the eHDSI project), reused by the IHE Pharmacy templates and more recently adopted (for specific cases) by the HL7 Pharmacy Medication statement templates. The main idea is to integrate local drug identifiers (e.g. product codes) with all the relevant identifying and descriptive attributes that may help the receiver to understand the type of product the sender is referring to, e.g.: active ingredients, administrative dose forms, strength, route of administration and package description.

Medication data is usually represented in the CDA Templates using the manufacturedMaterial class, which includes a code and a name to describe any level of the product: packaged product, medicinal product, classes or clusters or products, and so on. This information is not however sufficient for covering the requirements of the IPS.

IPS CDA SBDAM.png

IPS CDA SBDAM.png

[Figure 11] Representation of medicines in CDA

Hence, in order to describe these attributes the CDA model has been extended enhancing the Manufactured Material class with attributes and relationships derived from the latest published version of the R_Medication CMET (see HL7 V3 Normative Edition 2017) based on the HL7 Common Product Model (“The common product model is used to improve the alignment between the different representations of products used within the body of HL7 Version 3 models. One goal of this effort is to make it possible to have a single representation, which could then be used as a common message element type (CMET) across those models.”) .

[Figure 12] shows how the CDA model has been enhanced with the R_Medication CMET.

IPS extensions.png

IPS extensions.png

[Figure 12]Extension of the CDA model from the content of the R_Medication CMET.

Provenance

In the development of this Implementation Guide, consideration was given to the HL7 CDA® Release 2 Implementation Guide: Data Provenance, Release 1 - US Realm Draft Standard for Trial Use (December 2015). That guide provides a matrix offering a thorough and systematic analysis of provenance characteristics of electronic health records. Given the agreed scope principle that the IPS be minimal and implementable, and the variable maturity and operational methods of existing national patient summaries, the proposal is that this first version should not attempt to require the full detail of that provenance specification.

The approach proposed for this version of the IPS is to:

  • Allow optional documentation of section-level provenance.
  • Require document-level provenance.
  • Define IPS document provenance as one of two types: human-curated or software-assembled, based on the authors recorded in the header.
    • The classification is based on whether the IPS document is constructed by a human or an automated process, regardless of whether the IPS contains some content of both kinds.
  • Require the IPS source system to identify the IPS provenance type and author.
    • The author shall be a human, if the IPS provenance type is "human-curated", or a device or system if the IPS provenance type is "software-assembled".
    • In the case of a software-assembled IPS that is then verified by a human, the document provenance type shall be "software-assembled" and the author shall be the device or system that constructed the IPS document, but an additional verifier identity shall name the human who performed this check. For the avoidance of doubt, verifier is not the same as legalAuthenticator (the verifier is represented as a participant with typeCode "VRF"). However, in cases where the verifying person intentionally wishes to sign the document, this shall be recorded as a legalAuthenticator.
  • Allow optional section level author, provenance type, verifier, and informant identification, for IPS source systems that can support this.
  • Not attempt to implement the US Realm CDA data provenance templates.

Note: Discussions with the EHR work group suggest that a possible future project should be an IPS functional profile, once there is greater clarity and operational experience of using the IPS.

Representation of Names

This specification requires that any Person Name is represented including at least the given and family components and therefore is never documented as a single string.

Even though it is recognized that there is not in all cultures the same concept of “family name”, no evidence has been collected in analyzing the international context (e.g. Japan, Korea; China) that justifies the retirement of this requirement.

Moreover, due to the global scope of the International Patient Summary, the case of non-alphabetic representations of the names has also been considered.

In this case, to facilitate the global use of the IPS, at least one alphabetic representation of the name SHALL be provided.

Conformance clause

This section references the requirements, criteria, or conditions to be satisfied in order that a product (tangible) or a service may claim conformance to this guide, and how other artifacts may claim compliance with it. (Note: The concept of conformance and compliance are used coherently with the HL7 Service-Aware Interoperability Framework: Canonical Definition Specification, Release 2[25]. The fulfilment of these clauses indirectly assures that a product that is the subject of a “conformity assessment” satisfies the business or the design requirements this specification complies to. It should, however, be clear that compliance with the specified business or design requirements, for example in the future with the CEN prEN 17269 IPS, does not imply that the compliant implementations are technically interoperable. A “conformity assessment” is a process that assesses that any proposition that is true in a given specification is also true in the service or product that implements it. In most real-world cases conformance testing objects are used to technically validate the products. These objects provide a great help in the validation of the instances, even if they are most often not sufficient to guarantee the functional/ semantic conformity: many real-life examples can be made about instances that are technically valid, but not clinically meaningful or correct.

[Figure 13] below depicts how this concept applies to the business requirements, the current and hopefully future IPS projects standards (CEN/TC 251 and HL7) and other related artifacts involved in this assessment chain. (see section Relationships with other projects and guidelines for a description of the standards developed by the CEN/TC 251 IPS project )

IPS world.png

IPS world.png

[Figure 13] The IPS World

The "rules" and processes for refining the standard through constraint and extension, including which standard artifacts are subject to constraint or extension; the definition of constraint and localization profiles; the criteria for establishing a conformance statement; and the principles guiding who may define extensions to the standards and under what circumstances they apply to the CDA standards are defined in §1.3 CDA Conformance of the CDA and detailed in the HL7 V3 Refinement, Constraint and Localization section (see the CDA R2 Standard[26]).

This guide does not provide additional requirements regarding the Recipient and the Originator Responsibilities.

The formal representation used in this implementation guide for expressing the conformance statement is described in chapter "How to read the table view for templates" of this guide and makes use of a tabular representation that may include also computable or textual constraints. The template rules are formalized using the computable format defined by the HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1[8] in order to facilitate also the automatic generation of consistent testing and validation capabilities.

The HL7 Templates Standard: "Specification and Use of Reusable Information Constraint Templates, Release 1" defines also how derived templates may relate to the templates defined in this guide for example:

  • Specialization: “A specialized template is a narrower, more explicit, more constrained template based on a “parent” template.
  • Adaptation: “The adapted template is “based on” the original template which means it can be an extension or a specialization (restriction) of the original template design.”
  • Equivalency: “two templates have the same purpose and the same design; however, their governance and/or metadata and/or details of their design may be different.”

Based on this the following way to use this guide may be considered :

  • IPS as a document: the conformance is asserted at the document level. All the rules defined by this guide, or by a specialized IPS document level template, are fulfilled. Implementers may take advantage of the template openness to better support specific cases - “extended” parts, however, may not be interoperable among them.
  • IPS as a library: the conformance is asserted at the section or the entry level. The templates are used as a library to build, for example, new cross-border documents. For example the immunization section may be used to build an electronic implementation of the WHO yellow card for vaccinations; or the IPS section templates are used to communicate to the country of affiliation minimal and non-exhaustive information about the encounter in which the Patient Summary has been used (cross-border encounter report ). Implementers may take advantage of the template openness to better support specific cases - "extended” parts, however, may not be interoperable among them.
  • IPS as a reference: the implementation is conformant with templates that are an adaptation of or equivalent to those defined by this guide. In this case some of the rules defined by this guide are not fulfilled and the conformance cannot be asserted. However, differences may be limited and the effort required to achieve the harmonization may not be not large. Typical examples are templates in which alternatives vocabularies are used.

Jurisdictions may also decide to impose the closure of the template in order to limit the implementation optionality. This should be carefully evaluated in terms of the flexibility of the solution.

CDA Document Level Templates

International Patient Summary

Id2.16.840.1.113883.10.22.1.1Effective Date2020‑07‑14 16:08:21
Other versions this id:
  • Kblank.png HL7-IPS as of 2024‑08‑02 13:02:39
  • Kblank.png HL7-IPS as of 2020‑05‑08 12:30:59
  • Kblank.png HL7-IPS as of 2017‑04‑11
StatusKyellow.png DraftVersion Label2021
NameHL7-IPSDisplay NameInternational 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)
Uses
Uses 21 templates
Used by as NameVersion
hl7ips-transaction-2TransactionKyellow.png IPS Created (2020)2017‑04‑07 11:10:54
Uses as NameVersion
2.16.840.1.113883.10.22.2.1IncludeKyellow.png IPS CDA recordTarget (2021)DYNAMIC
2.16.840.1.113883.10.22.2.2IncludeKorange.png IPS CDA author (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.3IncludeKyellow.png IPS CDA custodian (2021)DYNAMIC
2.16.840.1.113883.10.22.2.4IncludeKorange.png IPS CDA legalAuthenticator (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.5IncludeKorange.png IPS Patient Contacts (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.6IncludeKorange.png IPS CDA documentationOf (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.7IncludeKorange.png IPS CDA relatedDocument (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.1ContainmentKorange.png IPS Medication Summary Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.2ContainmentKyellow.png IPS Allergies and Intolerances Section (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.3ContainmentKorange.png IPS Problems Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.4ContainmentKorange.png IPS History of Procedures Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.5ContainmentKorange.png IPS Immunizations Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.6ContainmentKyellow.png IPS Medical Devices Section (2021)DYNAMIC
2.16.840.1.113883.10.22.3.14ContainmentKorange.png IPS Results Section (STU1)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2ContainmentKgreen.png IHE Coded Vital Signs Section (2014)DYNAMIC
2.16.840.1.113883.10.22.3.7ContainmentKorange.png IPS History of Past Illness Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.8ContainmentKorange.png IPS Functional Status Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.9ContainmentKorange.png IPS Plan of Care Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.10ContainmentKorange.png IPS Social History Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.11ContainmentKorange.png IPS History of Pregnancy Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.12ContainmentKorange.png IPS Advance Directives Section (TI-2020)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2020‑05‑08 12:30:59)
Version: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2017‑04‑11)
Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 epSOS-Patient Summary (2013‑12‑20)
ref
epsos-

Adaptation: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
Example
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"/>  <!-- include template 2.16.840.1.113883.10.22.2.1 'IPS CDA recordTarget' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.10.22.2.2 'IPS CDA author' (dynamic) 1..* M -->
  <!-- include template 2.16.840.1.113883.10.22.2.3 'IPS CDA custodian' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.10.22.2.4 'IPS 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..* R -->
  <component>
    <structuredBody classCode="DOCBODY">
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.1 'IPS Medication Summary Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.2 'IPS Allergies and Intolerances Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.3 'IPS Problems Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.4 'IPS History of Procedures Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.5 'IPS Immunizations Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.6 'IPS Medical Devices Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.7 'IPS History of Past Illness Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.14 'IPS Results Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.8 'IPS Functional Status Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.9 'IPS Plan of Treatment Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.10 'IPS Social History Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.11 'IPS History of Pregnancy Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.12 'IPS Advance Directives Section' (dynamic) -->
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
RCDA header(HL7-IPS)
Treetree.pnghl7:realmCode
CS0 … 1R(HL7-IPS)
Treetree.pnghl7:typeId
II1 … 1M The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

(HL7-IPS)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
 Example<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
Treetree.pnghl7:templateId
II1 … 1M(HL7-IPS)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.1.1
Treetree.pnghl7:id
II1 … 1MUnique identifier of this instance of the Patient Summary.(HL7-IPS)
Treetree.pnghl7:code
CE.IPS1 … 1MDetermines the document type that is the "Patient Summary" document(HL7-IPS)
Treeblank.pngTreetree.png@displayName
1 … 1R
Treeblank.pngTreetree.png@code
CONF1 … 1F60591-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
 Example<code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/>
Treeblank.pngTreetree.pnghl7:translation
CD.IPS0 … *RThis element can be here used either to provide the originally used document code if this IPS is the result of a transformation.(HL7-IPS)
Treetree.pnghl7:title
ST1 … 1MClinicalDocument/title is used for display purposes.(HL7-IPS)
 Example<title>Patient Summary</title>
 Example<title>Profilo Sanitario Sintetico</title>
Treetree.pnghl7:effectiveTime
TS.IPS.TZ1 … 1MTime of creation of the Patient Summary(HL7-IPS)
 Example<effectiveTime value="20111113125600+0200"/>
Treetree.pnghl7:confidentialityCode
CE.IPS1 … 1R(HL7-IPS)
 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"/>
Treetree.pnghl7:language​Code
CS1 … 1MDocument Language Code(HL7-IPS)
 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 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)
 Example<languageCode code="en-GB"/>
 Example<languageCode code="fil-PH"/>
 Schematron assertrole 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) 
Treetree.pnghl7:setId
II0 … 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.

(HL7-IPS)
Treetree.pnghl7:versionNumber
0 … 1R(HL7-IPS)
Included1 … 1M from 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget (DYNAMIC)
Treetree.pnghl7:recordTarget
1 … 1M(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs0 … 1FRCT
Treeblank.pngTreetree.png@context​Control​Code
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>
Treeblank.pngTreetree.pnghl7:patientRole
1 … 1M(HL7-IPS)
 
Target.png
hl7ips-data​element-2.1Kyellow.png Patient Attributes Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPAT
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)(HL7-IPS)
 
Target.png
hl7ips-data​element-202Kyellow.png Healthcare related Identifiers Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-7Kyellow.png Insurance identifier Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RThe patient address.(HL7-IPS)
 
Target.png
hl7ips-data​element-162Kyellow.png Address Kyellow.png CEN/TC 251 prEN 17269
 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 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.
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. (HL7-IPS)
 
Target.png
hl7ips-data​element-100Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
1 … 1M(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
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>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *MPatient Name(HL7-IPS)
 
Target.png
hl7ips-data​element-3Kyellow.png Patient's name Kyellow.png CEN/TC 251 prEN 17269
 ConstraintThe Alphabetic representation of the name SHALL be always provided
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient's Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient's Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE.IPS1 … 1RPatient's Gender(HL7-IPS)
 
Target.png
hl7ips-data​element-4Kyellow.png Administrative gender Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.(HL7-IPS)
 
Target.png
hl7ips-data​element-5Kyellow.png Date of birth Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7: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.

(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. (HL7-IPS)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 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.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. (HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian​Person
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Guardian's Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
ENXP1 … *RPatient Guardian's Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
ENXP1 … *RPatient Guardian's Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Communication
0 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Code
CS1 … 1RPatient’s language(HL7-IPS)
 
Target.png
hl7ips-data​element-135Kyellow.png Patient’s preferred language Kyellow.png CEN/TC 251 prEN 17269
 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 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)
 Example
British English
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertrole 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 2.16.840.1.113883.10.22.2.2 IPS CDA author (DYNAMIC)
Treetree.pnghl7:author
1 … *M(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs0 … 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
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>
Treeblank.pngTreetree.pnghl7:functionCode
CE.IPS0 … 1R(HL7-IPS)
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. (HL7-IPS)
 Example<time value="201212290600+0100"/>
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RAuthor Identifier(s)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.(HL7-IPS)
 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"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
 Example<addr use="WP">
  <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr>
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
url0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(HL7-IPS)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(HL7-IPS)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1R(HL7-IPS)
Included from 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs1 … 1R
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
 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.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … 1R(HL7-IPS)
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 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.
Included1 … 1M from 2.16.840.1.113883.10.22.2.3 IPS CDA custodian (DYNAMIC)
Treetree.pnghl7:custodian
1 … 1M(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCST
 Example<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
Treeblank.pngTreetree.pnghl7:assignedCustodian
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs1 … 1R
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
 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.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … 1R(HL7-IPS)
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 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.
Included0 … 1R from 2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator (DYNAMIC)
Treetree.pnghl7:legalAuthenticator
0 … 1R(HL7-IPS)
 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>
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1MTime of signing the document(HL7-IPS)
Treeblank.pngTreetree.pnghl7:signatureCode
CS0 … 1RSignature code(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FS
Treeblank.pngTreetree.pnghl7:assignedEntity
0 … 1RThe entity that is responsible for the legal authentication of the CDA document(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
1 … *RUnique identification of legal authenticator(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the legal authenticator(HL7-IPS)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RHP Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RHP Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MOrganization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
(HL7-IPS)
Included0 … * from 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (DYNAMIC)
Treetree.pnghl7:participant
0 … *RPatient contacts or the Preferred Health Professional to contact in case of emergency.(HL7-IPS)
where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']
 
Target.png
hl7ips-data​element-154Kyellow.png Patient’s Address Book Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-163Kyellow.png Preferred Healthcare providers Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@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>
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.2.5
Treeblank.pngTreetree.pnghl7:functionCode
0 … 1CThe  <functionCode> element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.</functionCode>(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FPCP
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.88 (Participation Function)
Treeblank.pngTreetree.pnghl7:associated​Entity
RThe <associatedEntity> element identifies the type of contact. </associatedEntity>(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CV.IPS0 … 1RThis element indicates the relationship between the patient and this participant.(HL7-IPS)
 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"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RPatient Contact's / Preferred HP's Address(HL7-IPS)
 Schematron assertrole 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 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.
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required.</telecom>(HL7-IPS)
 
Target.png
hl7ips-data​element-169Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-174Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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:associated​Person
  • hl7:scoping​Organization
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(HL7-IPS)
 
Target.png
hl7ips-data​element-165Kyellow.png Healthcare Provider (person) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Contact's Name / Preferred HP's Name(HL7-IPS)
 
Target.png
hl7ips-data​element-121Kyellow.png Name Kyellow.png CEN/TC 251 prEN 17269
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient Contact's Family Name/Surname / Preferred HP's Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient Contact's Given Name / Preferred HP's Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(HL7-IPS)
 
Target.png
hl7ips-data​element-166Kyellow.png Healthcare Provider (organisation) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … *ROrganization's Name(HL7-IPS)
 
Target.png
hl7ips-data​element-172Kyellow.png Organisation’s Name Kyellow.png CEN/TC 251 prEN 17269
Included1 … 1M from 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (DYNAMIC)
Treetree.pnghl7: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.(HL7-IPS)
Treeblank.pngTreetree.png@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>
Treeblank.pngTreetree.pnghl7: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.
(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPCPR
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:low
TS1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:high
TS1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7: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 counselors(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:functionCode
CE.IPS0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
IVL_TS.IPS.TZ0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1M(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RHealthcare provider ID number(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7: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.(HL7-IPS)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1(HL7-IPS)
Included from 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(HL7-IPS)
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. 
Treetree.pnghl7:relatedDocument
0 … 2R(HL7-IPS)
Treeblank.pngTreetree.png@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)
Treeblank.pngTreetree.pnghl7:parentDocument
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDOCCLIN
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs0 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:setId
II0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:versionNumber
INT0 … 1R(HL7-IPS)
Treetree.pnghl7:component
1 … 1M(HL7-IPS)
Treeblank.pngTreetree.pnghl7:structuredBody
1 … 1MNote: the proposed order of the sections hereafter indicated is not mandatory(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDOCBODY
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1MContains 2.16.840.1.113883.10.22.3.1 IPS Medication Summary Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1MContains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1MContains 2.16.840.1.113883.10.22.3.3 IPS Problems Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.5 IPS Immunizations Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 IHE Coded Vital Signs Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC)(HL7-IPS)

CDA Header Level Templates

IPS CDA author

Id2.16.840.1.113883.10.22.2.2Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAauthorDisplay NameIPS CDA author
Description

A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).

For definition “The author element represents the creator of the clinical document. If the role of the actor is the entry of information from his or her own knowledge or application of skills, that actor is the author. If one actor provides information to another actor who filters, reasons, or algorithmically creates new information, then that second actor is also an author, having created information from his or her own knowledge or skills. [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March 2009].

According to this definition, not any device that generates the electronic document has to be considered as an author:

  • a spider collecting and filtering information from different repositories, according to defined rules and policies, for the scope of creating a Patient Summary is definitely a document author (and in some cases the only one );
  • an application that transforms a Patient Summary record into this CDA format may not be an author;
  • For cross-border exchange purposes, a device, which modifies the concepts conveyed (e.g. applying code system mappings), should appear as one of the authors. In this case (document generated through a transformation process) the authors of the parent (original) patient summary should appear as authors as well.

Further to this, authorship can give information about the nature of Patient Summary :

  • if there is a person author only, then the Patient Summary is the result of a practitioner clinical act;
  • if there are device authors only, the summary was automatically generated according to well defined rules defined by the responsible organization.
The CDA standard allows to provide detailed information about what was authored by whom in the Patient Summary, allowing the specification of authorship at the whole document level, at the section level and also at the entry level. In any case it is not required to repeat this information for each of the mentioned levels, taking advantage of the context conduction propriety.
In fact “context that is specified on an outer tag holds true for all nested tags, unless overridden on a nested tag. Context specified on a tag within the CDA body always overrides context propagated from an outer tag. For instance, the specification of authorship at a document section level overrides all authorship propagated from outer tags.” (HL7 CDA R2 Standard).
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.9.2IncludeKorange.png IPS CDA Device (STU1)DYNAMIC
2.16.840.1.113883.10.22.9.1IncludeKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.102 CDA author (2005‑09‑07)
ref
ad1bbr-
Example
Human Author
<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"/>    <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medico"/>    <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>
    <representedOrganization>
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedOrganization>
  </assignedAuthor>
</author>
Example
Device Author
<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="1.2.3.999" extension="__example only__"/>    <addr use="WP">
      <state>Castilla-La Mancha</state>      <city>Toledo</city>      <precinct>Toledo</precinct>      <country>ES</country>      <postalCode>45071</postalCode>      <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>    </addr>
    <telecom nullFlavor="NI"/>    <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
      <softwareName displayName="Turriano"/>    </assignedAuthoringDevice>
    <representedOrganization classCode="ORG" determinerCode="INSTANCE">
      <id root="1.2.3.999" extension="__example only__"/>      <name>SESCAM</name>      <telecom use="WP" value="tel:+34925274100"/>      <addr use="WP">
        <state>Castilla-La Mancha</state>        <city>Toledo</city>        <precinct>Toledo</precinct>        <country>ES</country>        <postalCode>45071</postalCode>        <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>      </addr>
    </representedOrganization>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
1 … *R(IPS...hor)
Treetree.png@typeCode
cs0 … 1FAUT
Treetree.png@context​Control​Code
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>
Treetree.pnghl7:functionCode
CE.IPS0 … 1R(IPS...hor)
Treetree.pnghl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. (IPS...hor)
 Example<time value="201212290600+0100"/>
Treetree.pnghl7:assignedAuthor
1 … 1R(IPS...hor)
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreetree.pnghl7:id
II1 … *RAuthor Identifier(s)(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreetree.pnghl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.(IPS...hor)
 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"/>
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...hor)
 Example<addr use="WP">
  <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr>
Treeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreetree.png@value
url0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...hor)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...hor)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...hor)
Treeblank.pngTreetree.pnghl7:represented​Organization
0 … 1R(IPS...hor)
Included from 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FORG
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs1 … 1R
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
 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.
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … 1R(IPS...hor)
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...hor)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...hor)
 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.

IPS CDA custodian

Id2.16.840.1.113883.10.22.2.3Effective Date2021‑08‑04 12:13:07
Other versions this id:
  • Kblank.png IPSCDAcustodian as of 2017‑04‑11
StatusKyellow.png DraftVersion Label2021
NameIPSCDAcustodianDisplay NameIPS CDA custodian
Description

The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.

This information is required by the CDA R2 standard and shall be recorded in the ClinicalDocument/custodian/assignedCustodian/ representedCustodianOrganization element.

There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.

ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.11IncludeKorange.png IPS Address (STU1)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.2.3 IPS CDA custodian (2017‑04‑11)
Adaptation: template 2.16.840.1.113883.10.12.104 CDA custodian (2005‑09‑07)
ref
ad1bbr-
Example
Example
<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
ItemDTCardConfDescriptionLabel
hl7:custodian
1 … 1R(IPS...ian)
Treetree.png@typeCode
cs0 … 1FCST
 Example<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
Treetree.pnghl7:assignedCustodian
1 … 1R(IPS...ian)
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreetree.pnghl7:represented​Custodian​Organization
1 … 1R(IPS...ian)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FORG
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ian)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1R(IPS...ian)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … 1R(IPS...ian)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs1 … 1R
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
 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.
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … 1R(IPS...ian)
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...ian)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...ian)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...ian)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...ian)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...ian)
 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.

IPS CDA documentationOf

Id2.16.840.1.113883.10.22.2.6Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSdocumentationOfPCPRDisplay NameIPS CDA documentationOf
Description
The 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.

The 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.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.9.3IncludeKorange.png IPS CDA Person (STU1)DYNAMIC
2.16.840.1.113883.10.22.9.1ContainmentKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.110 CDA documentationOf (2005‑09‑07)
ref
ad1bbr-
Example
Example
<documentationOf typeCode="DOC">
  <serviceEvent classCode="PCPR" moodCode="EVN">
    <id root="1.2.3.999" extension="__example only__"/>    <effectiveTime>
      <low nullFlavor="UNK"/>      <high value="20170613124706"/>    </effectiveTime>
    <performer typeCode="PRF">
      <assignedEntity>
        <id root="1.2.3.999" extension="__example only__"/>        <code code="22" displayName="Health professionals" codeSystem="2.16.840.1.113883.2.9.6.2.7"/>        <addr nullFlavor="NI"/>        <telecom nullFlavor="NI"/>        <assignedPerson>
          <!-- template 'IPS CDA Person' (dynamic) -->
        </assignedPerson>
        <representedOrganization>
          <!-- template 'IPS CDA Organization' (dynamic) -->
        </representedOrganization>
      </assignedEntity>
    </performer>
  </serviceEvent>
</documentationOf>
ItemDTCardConfDescriptionLabel
hl7:documentationOf
0 … *RThe 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.(IPS...CPR)
Treetree.png@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>
Treetree.pnghl7: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.
(IPS...CPR)
Treeblank.pngTreetree.png@classCode
cs1 … 1FPCPR
Treeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreetree.pnghl7:id
II0 … *R(IPS...CPR)
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
TS1 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
TS1 … 1R(IPS...CPR)
Treeblank.pngTreetree.pnghl7: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 counselors(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.png@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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:functionCode
CE.IPS0 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
IVL_TS.IPS.TZ0 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1M(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RHealthcare provider ID number(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7: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.(IPS...CPR)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1(IPS...CPR)
Included from 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *R(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(IPS...CPR)

IPS CDA legalAuthenticator

Id2.16.840.1.113883.10.22.2.4Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAlegalAuthenticatorDisplay NameIPS CDA legalAuthenticator
Description
The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated.
The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication.
All clinical documents have the potential for legal authentication, given the appropriate credentials.

Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system.
Note that the legal authenticator, if present, must be a person.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.9.1ContainmentKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (2005‑09‑07)
ref
ad1bbr-
Example
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>
ItemDTCardConfDescriptionLabel
hl7:legalAuthenticator
R(IPS...tor)
 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>
Treetree.pnghl7:time
TS.IPS.TZ1 … 1MTime of signing the document(IPS...tor)
Treetree.pnghl7:signatureCode
CS0 … 1RSignature code(IPS...tor)
Treeblank.pngTreetree.png@code
CONF0 … 1FS
Treetree.pnghl7:assignedEntity
0 … 1RThe entity that is responsible for the legal authentication of the CDA document(IPS...tor)
Treeblank.pngTreetree.pnghl7:id
1 … *RUnique identification of legal authenticator(IPS...tor)
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...tor)
Treeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(IPS...tor)
Treeblank.pngTreetree.pnghl7:assigned​Person
1 … 1R(IPS...tor)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the legal authenticator(IPS...tor)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RHP Family Name/Surname(IPS...tor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RHP Given Name(IPS...tor)
Treeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MOrganization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
(IPS...tor)

IPS CDA Organization

Id2.16.840.1.113883.10.22.9.1Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAOrganizationDisplay NameIPS CDA Organization
DescriptionThis is a reusable template providing essential information for describing / identifying an organization.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.11IncludeKorange.png IPS Address (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (2013‑12‑20)
ref
epsos-
Example
Example
<id root="1.2.3.999" extension="__example only__"/><name>name</name><name>SESCAM</name><telecom use="WP" value="tel:+34925274100"/><telecom use="WP" value="mailto:best.organization@foo.too.es"/><addr use="WP">
  <state>Castilla-La Mancha</state>  <city>Toledo</city>  <precinct>Toledo</precinct>  <country>ES</country>  <postalCode>45071</postalCode>  <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine></addr>
ItemDTCardConfDescriptionLabel
@classCode
cs1 … 1FORG
@determiner​Code
cs1 … 1FINSTANCE
hl7:id
II1 … *R(IPS...ion)
Treetree.png@nullFlavor
cs0 … 1 
hl7:name
ON1 … 1R(IPS...ion)
Treetree.png@nullFlavor
cs0 … 1 
hl7:telecom
TEL1 … *R(IPS...ion)
Treetree.png@use
set_cs1 … 1R
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treetree.png@nullFlavor
cs0 … 1 
 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:addr
AD.IPS1 … 1R(IPS...ion)
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treetree.png@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)
Treetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...ion)
 Schematron assertrole 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 
Treetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...ion)
Treetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...ion)
Treetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...ion)
Treetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...ion)
 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.

IPS CDA Person

Id2.16.840.1.113883.10.22.9.3Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAPersonDisplay NameIPS CDA Person
DescriptionPerson name
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
@classCode
cs0 … 1FPSN
@determiner​Code
cs0 … 1FINSTANCE
hl7:name
PN1 … *R(IPS...son)

IPS CDA recordTarget

Id2.16.840.1.113883.10.22.2.1Effective Date2021‑09‑02 12:10:24
Other versions this id:
  • Kblank.png IPSCDArecordTarget as of 2020‑07‑14 16:56:08
  • Kblank.png IPSCDArecordTarget as of 2017‑04‑11
StatusKyellow.png DraftVersion Label2021
NameIPSCDArecordTargetDisplay NameIPS CDA recordTarget
Description
The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 9 concepts
IdNameData Set
hl7ips-data​element-100Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-135Kyellow.png Patient’s preferred language Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-162Kyellow.png Address Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-2.1Kyellow.png Patient Attributes Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-202Kyellow.png Healthcare related Identifiers Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-3Kyellow.png Patient's name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-4Kyellow.png Administrative gender Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-5Kyellow.png Date of birth Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-7Kyellow.png Insurance identifier Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.11IncludeKorange.png IPS Address (STU1)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget (2020‑07‑14 16:56:08)
Adaptation: template 2.16.840.1.113883.3.1937.777.11.10.100 epSOS CDA recordTarget (2013‑12‑20)
ref
epsos-

Adaptation: template 2.16.840.1.113883.10.12.101 CDA recordTarget (2005‑09‑07)
ref
ad1bbr-
Example
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>
ItemDTCardConfDescriptionLabel
hl7:recordTarget
1 … *R(IPS...get)
Treetree.png@typeCode
cs0 … 1FRCT
Treetree.png@context​Control​Code
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>
Treetree.pnghl7:patientRole
1 … 1M(IPS...get)
 
Target.png
hl7ips-data​element-2.1Kyellow.png Patient Attributes Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@classCode
cs0 … 1FPAT
Treeblank.pngTreetree.pnghl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)(IPS...get)
 
Target.png
hl7ips-data​element-202Kyellow.png Healthcare related Identifiers Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-7Kyellow.png Insurance identifier Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RThe patient address.(IPS...get)
 
Target.png
hl7ips-data​element-162Kyellow.png Address Kyellow.png CEN/TC 251 prEN 17269
 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)
Treeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...get)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...get)
 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.
Treeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. (IPS...get)
 
Target.png
hl7ips-data​element-100Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreetree.png@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"/>
Treeblank.pngTreetree.pnghl7:patient
1 … 1M(IPS...get)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *MPatient Name(IPS...get)
 
Target.png
hl7ips-data​element-3Kyellow.png Patient's name Kyellow.png CEN/TC 251 prEN 17269
 ConstraintThe Alphabetic representation of the name SHALL be always provided
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient's Family Name/Surname(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient's Given Name(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE.IPS1 … 1RPatient's Gender(IPS...get)
 
Target.png
hl7ips-data​element-4Kyellow.png Administrative gender Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.(IPS...get)
 
Target.png
hl7ips-data​element-5Kyellow.png Date of birth Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.pnghl7: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.

(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. (IPS...get)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...get)
 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...get)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...get)
 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.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. (IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@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.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian​Person
1 … 1R(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Guardian's Name(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
ENXP1 … *RPatient Guardian's Family Name/Surname(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
ENXP1 … *RPatient Guardian's Given Name(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:language​Communication
0 … *R(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Code
CS1 … 1RPatient’s language(IPS...get)
 
Target.png
hl7ips-data​element-135Kyellow.png Patient’s preferred language Kyellow.png CEN/TC 251 prEN 17269
 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 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)
 Example
British English
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertrole 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) 

IPS CDA relatedDocument

Id2.16.840.1.113883.10.22.2.7Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDArelatedDocumentDisplay NameIPS CDA relatedDocument
Description

An IPS may have three types of parent document:

  • A superseded version that the present instance of the document wholly replaces (typeCode = RPLC). 
  • A source document from which the present document is transformed (typeCode = XFRM). An IPS may be created by transformation from an already existing local Patient Summary or an IPS document. An example of this case is the creation of a derived instance in which translations are appended in order to facilitate the cross-border usage of this document; or the case in which a local patient summary is transformed to originate a new IPS instance.
  • An original version that the present document integrates (typeCode = APND). Some cross-border legal agreements (e.g.  the European Digital Service Infrastructure for eHealth) require the patient summary to be accompanied by  a printable representation of the original national data / document this IPS comes from. The relationship between the IPS and this content may be tracked using this relationship. 

Note 1: even for countries not dealing with real documents in their National Infrastructures (e.g. data collected from local databases), this mechanism could be useful to identify the collection of data used for generating the epSOS CDAs, facilitating the information backtracking. In that case the ID might be that of the epSOS friendly document or of any other kind of intermediate document used for generating the NCP document input.
Note 2: even if none of the allowable relationships defined by the CDA standard (XFRM, RPLC, APND) fits perfectly with the described case; the APND relationship seems to be the one that fits the better. In fact “An addendum is a separate document that references the parent document, and may extend or alter the observations in the prior document. The parent document remains a current component of the patient record, and the addendum and its parent are both read by report recipients.”

ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.12.111 CDA relatedDocument (2005‑09‑07)
ref
ad1bbr-
Example
Example of national document identified by its ID
<relatedDocument typeCode="XFRM">
  <!-- the IPS is obtained as trasformation of the "aa-bb-cc" document -->
  <parentDocument>
    <id root="aa-bb-cc"/>  </parentDocument>
</relatedDocument>
Example
Reference to the local PS and to supporting documentation
<!-- the example starts here -->
<relatedDocument typeCode="XFRM">
  <!-- the IPS is obtained as trasformation of the "aa-bb-cc" Local Patient Summary -->
  <parentDocument>
    <id root="aa-bb-cc"/>  </parentDocument>
</relatedDocument>
<relatedDocument typeCode="APND">
  <!-- the IPS is integrated by the information provided by the "aa1-bb1-cc1" document -->
  <parentDocument>
    <id root="aa1-bb1-cc1"/>  </parentDocument>
</relatedDocument>
<!-- the example ends here -->
ItemDTCardConfDescriptionLabel
hl7:relatedDocument
0 … *R(IPS...ent)
Treetree.png@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)
Treetree.pnghl7:parentDocument
1 … 1R(IPS...ent)
Treeblank.pngTreetree.png@classCode
cs0 … 1FDOCCLIN
Treeblank.pngTreetree.png@moodCode
cs0 … 1FEVN
Treeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ent)
Treeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.pnghl7:text
ED0 … 1R(IPS...ent)
Treeblank.pngTreetree.pnghl7:setId
II0 … 1R(IPS...ent)
Treeblank.pngTreetree.pnghl7:versionNumber
INT0 … 1R(IPS...ent)

IPS Patient Contacts

Id2.16.840.1.113883.10.22.2.5Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAContactsDisplay NameIPS Patient Contacts
Description
The IPS may record several kinds of patient contacts, including parents, relatives, caregivers, and others related in some way to the patient.
A patient contact may be an individual or an organization with a relationship to the patient, including health provider (person or organization) to be contacted in case of emergency. 
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 8 concepts
IdNameData Set
hl7ips-data​element-121Kyellow.png Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-154Kyellow.png Patient’s Address Book Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-163Kyellow.png Preferred Healthcare providers Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-165Kyellow.png Healthcare Provider (person) Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-166Kyellow.png Healthcare Provider (organisation) Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-169Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-172Kyellow.png Organisation’s Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-174Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.11IncludeKorange.png IPS Address (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.108 CDA participant (DYNAMIC)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.2.4 IHE Patient Contacts (DYNAMIC)
ref
IHE-PCC-
Example
Contact person
<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>
Example
Preferred Health Professional for emergency contact
<participant typeCode="IND">
  <templateId root="2.16.840.1.113883.10.22.2.5"/>  <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>  <time value="20070213"/>  <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>
</participant>
ItemDTCardConfDescriptionLabel
hl7:participant
RPatient contacts or the Preferred Health Professional to contact in case of emergency.(IPS...cts)
where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']
 
Target.png
hl7ips-data​element-154Kyellow.png Patient’s Address Book Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-163Kyellow.png Preferred Healthcare providers Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@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>
Treetree.pnghl7:templateId
II1 … 1M(IPS...cts)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.2.5
Treetree.pnghl7:functionCode
0 … 1CThe  <functionCode> element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.</functionCode>(IPS...cts)
Treeblank.pngTreetree.png@code
CONF0 … 1FPCP
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.88 (Participation Function)
Treetree.pnghl7:associated​Entity
RThe <associatedEntity> element identifies the type of contact. </associatedEntity>(IPS...cts)
Treeblank.pngTreetree.png@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>
Treeblank.pngTreetree.pnghl7:code
CV.IPS0 … 1RThis element indicates the relationship between the patient and this participant.(IPS...cts)
 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"/>
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RPatient Contact's / Preferred HP's Address(IPS...cts)
 Schematron assertrole 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)
Treeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreetree.png@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 assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...cts)
 Schematron assertrole 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 
Treeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...cts)
 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.
Treeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required.</telecom>(IPS...cts)
 
Target.png
hl7ips-data​element-169Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-174Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@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)
Treeblank.pngTreeblank.pngTreetree.png@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:associated​Person
  • hl7:scoping​Organization
Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(IPS...cts)
 
Target.png
hl7ips-data​element-165Kyellow.png Healthcare Provider (person) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Contact's Name / Preferred HP's Name(IPS...cts)
 
Target.png
hl7ips-data​element-121Kyellow.png Name Kyellow.png CEN/TC 251 prEN 17269
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient Contact's Family Name/Surname / Preferred HP's Family Name/Surname(IPS...cts)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient Contact's Given Name / Preferred HP's Given Name(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(IPS...cts)
 
Target.png
hl7ips-data​element-166Kyellow.png Healthcare Provider (organisation) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … *ROrganization's Name(IPS...cts)
 
Target.png
hl7ips-data​element-172Kyellow.png Organisation’s Name Kyellow.png CEN/TC 251 prEN 17269


CDA Section Level Templates

IPS Advance Directives Section

Id2.16.840.1.113883.10.22.3.12Effective Date2020‑05‑08 16:38:49
Other versions this id:
  • Kblank.png IPSAdvanceDirectivesSection as of 2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelTI-2020
NameIPSAdvanceDirectivesSectionDisplay NameIPS Advance Directives Section
Description
The advance directive section shall contain a narrative description of patient's advance directive.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
Entries for references to consent and advance directive documents when known will be specified by future versions of this template.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.12
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-26Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-8Kyellow.png Advance Directives Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.46ContainmentKorange.png IPS Advance Directive Organizer (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.35 IHE Coded Advance directives section (DYNAMIC)
ref
IHE-PCC-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.34 IHE Advance directives section (DYNAMIC)
ref
IHE-PCC-

Adaptation: template 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (DYNAMIC)
ref
bccdapilot-
Example
Example
<cda:section classCode="DOCSECT">
  <hl7:templateId root="2.16.840.1.113883.10.22.3.12"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="42348-3" codeSystem="2.16.840.1.113883.6.1"/>  <hl7:title>title</hl7:title>  <hl7:text/>  <hl7:author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (2017-03-02T00:00:00) -->
  </hl7:author>
  <hl7:informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (2005-09-07T00:00:00) -->
  </hl7:informant>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.46 'IPS Advance Directive Organizer' (2020-05-08T16:11:48) -->
  </hl7:entry>
  <hl7:component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (2017-07-12T00:00:00) -->
  </hl7:component>
</cda:section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-8Kyellow.png Advance Directives Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.12
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F42348-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MAdvance directives(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-26Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.46 IPS Advance Directive Organizer (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Allergies and Intolerances Section

Id2.16.840.1.113883.10.22.3.2Effective Date2024‑08‑04 10:07:36
Other versions this id:
  • Kblank.png IPSSectionAllergiesOrIntolerances as of 2016‑11‑11
StatusKyellow.png DraftVersion LabelSTU2
NameIPSSectionAllergiesOrIntolerancesDisplay NameIPS Allergies and Intolerances Section
Description
This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. 
At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.

The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.2
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-183Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-28Kyellow.png Allergy or Intolerance list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-9Kyellow.png Allergies and Intolerances Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.5ContainmentKyellow.png IPS Allergy and Intolerance Concern (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (2016‑11‑11)
Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.1.2 Alerts section (DYNAMIC)
ref
ccd1-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.2"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies and adverse reactions">
    <title>Allergies and Intolerances</title>    <text>
      <!-- Textual description of the Allergies and Intolerances -->
    </text>
    <author>
      <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
    </author>
    <informant>
      <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
    </informant>
    <entry typeCode="COMP" contextConductionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.5 'IPS Allergy and Intolerance Concern' (dynamic) -->
    </entry>
    <component>
      <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
    </component>
  </code>
</section>
Example
No information available
<hl7:section>
  <hl7:templateId root="2.16.840.1.113883.10.22.3.2"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies and adverse reactions"/>  <hl7:title>Allergies and Intolerances</hl7:title>  <hl7:text>
    <!-- Textual description of the Allergies and Intolerances -->
  </hl7:text>
  <hl7:entry>
    <hl7:act classCode="ACT" moodCode="EVN">
      <hl7:templateId root="2.16.840.1.113883.10.22.4.5"/>      <hl7:id root="1.2.3.999" extension="__example only__"/>      <hl7:code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <hl7:statusCode code="active"/>      <hl7:effectiveTime>
        <hl7:low nullFlavor="NA"/>      </hl7:effectiveTime>
      <hl7:entryRelationship typeCode="SUBJ" inversionInd="false">
        <hl7:observation classCode="OBS" moodCode="EVN">
          <hl7:templateId root="2.16.840.1.113883.10.22.4.1"/>          <hl7:code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4"/>          <hl7:statusCode code="completed"/>          <hl7:effectiveTime>
            <hl7:low nullFlavor="NA"/>          </hl7:effectiveTime>
          <hl7:value code="no-allergy-info" displayName="No information about allergies" codeSystem="2.16.840.1.113883.5.1150.1"/>        </hl7:observation>
      </hl7:entryRelationship>
    </hl7:act>
  </hl7:entry>
</hl7:section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1R(IPS...ces)
 
Target.png
hl7ips-data​element-9Kyellow.png Allergies and Intolerances Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ces)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.2
Treetree.pnghl7:id
II0 … *R(IPS...ces)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ces)
Treeblank.pngTreetree.png@code
CONF1 … 1F48765-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1M(IPS...ces)
Treetree.pnghl7:text
SD.TEXT1 … 1MSection text(IPS...ces)
 
Target.png
hl7ips-data​element-183Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ces)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ces)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ces)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ces)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ces)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ces)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ces)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ces)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ces)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ces)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ces)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ces)
Treetree.pnghl7:entry
1 … *MContains 2.16.840.1.113883.10.22.4.5 IPS Allergy and Intolerance Concern (DYNAMIC)(IPS...ces)
 
Target.png
hl7ips-data​element-28Kyellow.png Allergy or Intolerance list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ces)

IPS Functional Status Section

Id2.16.840.1.113883.10.22.3.8Effective Date2020‑05‑08 19:17:37
Other versions this id:
  • Kblank.png IPSFunctionalStatusSection as of 2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelTI-2020
NameIPSFunctionalStatusSectionDisplay NameIPS Functional Status Section
Description
The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.
Coded clinical statements will be specified by future versions of this template.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.8
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-10Kyellow.png Functional Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-137Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-197Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.42ContainmentKorange.png IPS Survey Panel (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.17 eHDSI Functional Status (DYNAMIC)
ref
epsos-

Adaptation: template 2.16.840.1.113883.10.20.1.5 Functional status section (DYNAMIC)
ref
ccd1-
Example
Example
<cda:section classCode="DOCSECT">
  <hl7:templateId root="2.16.840.1.113883.10.22.3.8"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="47420-5" codeSystem="2.16.840.1.113883.6.1"/>  <hl7:title>title</hl7:title>  <hl7:text/>  <hl7:author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (2017-03-02T00:00:00) -->
  </hl7:author>
  <hl7:informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (2005-09-07T00:00:00) -->
  </hl7:informant>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.42 'IPS Survey Panel' (2020-05-08T19:02:26) -->
  </hl7:entry>
  <hl7:component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (2017-07-12T00:00:00) -->
  </hl7:component>
</cda:section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-10Kyellow.png Functional Status Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.8
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F47420-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MFunctional Status Assessment(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-137Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-197Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.42 IPS Survey Panel (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS History of Past Illness Section

Id2.16.840.1.113883.10.22.3.7Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSHistoryOfPastIllnessSectionDisplay NameIPS History of Past Illness Section
Description
The History of Past Illness section contains a narrative description and coded entries of the conditions the patient suffered in the past. 
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.7
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-11Kyellow.png History of Past Illness Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-31Kyellow.png Past health conditions and problems list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-35Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.7ContainmentKyellow.png IPS Problem Concern Entry (2021)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.8 IHE History of Past Illness Section (2013‑12‑20)
ref
IHE-PCC-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5.1 IHE Concern Entry (DYNAMIC)
ref
IHE-PCC-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.7"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" displayName="History of Past illness"/>  <title>...</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.7 'IPS Problem Concern Entry' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-11Kyellow.png History of Past Illness Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.7
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F11348-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MHistory of Past Illness(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-35Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *RContains 2.16.840.1.113883.10.22.4.7 IPS Problem Concern Entry (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-31Kyellow.png Past health conditions and problems list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS History of Pregnancy Section

Id2.16.840.1.113883.10.22.3.11Effective Date2020‑05‑07 18:46:08
Other versions this id:
  • Kblank.png IPSHistoryofpregnancysection as of 2018‑09‑06 09:46:57
  • Kblank.png IPSHistoryofpregnancysection as of 2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelTI-2020
NameIPSHistoryofpregnancysectionDisplay NameIPS History of Pregnancy Section
Description
The history of pregnancy section shall contain information about whether the patient is currently pregnant (optional with the Expected Delivery Date) or not.
It may contain addition summarizing information about the outcome of earlier pregnancies.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.11
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 5 concepts
IdNameData Set
hl7ips-data​element-12Kyellow.png History of Pregnancy Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-225Kyellow.png Pregnancy Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-37Kyellow.png Status of pregnancy Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-38Kyellow.png Previous Pregnancies Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-39Kyellow.png Previous Pregnancies Description Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 6 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.27ContainmentKyellow.png IPS Pregnancy Status Observation (2021)DYNAMIC
2.16.840.1.113883.10.22.4.28ContainmentKorange.png IPS Pregnancy Outcome Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.36ContainmentKorange.png IPS Pregnancy Observation (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (2018‑09‑06 09:46:57)
Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 eHDSI Pregnancy History (DYNAMIC)
ref
epsos-
Example
Example
<cda:section classCode="DOCSECT">
  <hl7:templateId root="2.16.840.1.113883.10.22.3.11"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="10162-6" codeSystem="2.16.840.1.113883.6.1"/>  <hl7:title>title</hl7:title>  <hl7:text/>  <hl7:author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (2017-03-02T00:00:00) -->
  </hl7:author>
  <hl7:informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (2005-09-07T00:00:00) -->
  </hl7:informant>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.27 'IPS Pregnancy Status Observation' (2020-05-07T19:22:01) -->
  </hl7:entry>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.28 'IPS Pregnancy Outcome Observation' (2017-04-13T00:00:00) -->
  </hl7:entry>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.36 'IPS Pregnancy Observation' (2020-05-07T18:36:37) -->
  </hl7:entry>
  <hl7:component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (2017-07-12T00:00:00) -->
  </hl7:component>
</cda:section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-12Kyellow.png History of Pregnancy Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.11
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F10162-6
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MHistory of pregnancies(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-225Kyellow.png Pregnancy Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-39Kyellow.png Previous Pregnancies Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
0 … 1RContains 2.16.840.1.113883.10.22.4.27 IPS Pregnancy Status Observation (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-37Kyellow.png Status of pregnancy Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *RContains 2.16.840.1.113883.10.22.4.28 IPS Pregnancy Outcome Observation (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-38Kyellow.png Previous Pregnancies Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.36 IPS Pregnancy Observation (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS History of Procedures Section

Id2.16.840.1.113883.10.22.3.4Effective Date2017‑03‑27
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSHistoryofProceduresSectionDisplay NameIPS History of Procedures Section
Description
The History of Procedures Section contains a description of the  patient past procedures that are pertinent to the scope of this document.
Procedures may refer for example to:
  1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)
  2. Therapeutic procedure: e.g. dialysis; 
  3. Surgical procedure: e.g. appendectomy
All those are represented in this template as procedures.

The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.4
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-13Kyellow.png History of Procedures Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-43Kyellow.png Procedure list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-51Kyellow.png Procedure description Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.17ContainmentKyellow.png IPS Procedure Entry (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.2 IHE History of Surgical Procedures Section (2017‑03‑24 14:43:08)
ref
IHE-PCC-
Example
Example
<section>
  <templateId root="2.16.840.1.113883.10.22.3.4"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" displayName="History of procedures"/>  <title>History of procedures</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.17 'IPS Procedure Entry' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
(IPS...ion)
 
Target.png
hl7ips-data​element-13Kyellow.png History of Procedures Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.4
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F47519-4
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MHistory of procedures(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1R(IPS...ion)
 
Target.png
hl7ips-data​element-51Kyellow.png Procedure description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *RContains 2.16.840.1.113883.10.22.4.17 IPS Procedure Entry (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-43Kyellow.png Procedure list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Immunizations Section

Id2.16.840.1.113883.10.22.3.5Effective Date2017‑04‑05
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSImmunizationsSectionDisplay NameIPS Immunizations Section
Description
The Immunizations Section defines a patient's current immunization status and pertinent immunization history.
The primary use case for the Immunization Section is to enable communication of a patient's immunization status.
The section includes current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.5
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-14Kyellow.png Immunizations Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-50Kyellow.png Immunizations list Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.15ContainmentKyellow.png IPS Immunization (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.2.2.1 Immunizations Section (entries required) (V3) (2015‑08‑01)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.5"/>  <code code="11369-6" codeSystem="2.16.840.1.113883.6.1" disaplayName="History of Immunization"/>  <title>History of Immunization</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.15 'IPS Immunization' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
(IPS...ion)
 
Target.png
hl7ips-data​element-14Kyellow.png Immunizations Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.5
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F11369-6
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1M(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *MContains 2.16.840.1.113883.10.22.4.15 IPS Immunization (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-50Kyellow.png Immunizations list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Medical Devices Section

Id2.16.840.1.113883.10.22.3.6Effective Date2021‑10‑20 17:11:42
Other versions this id:
  • Kblank.png IPSMedicalDevicesSection as of 2017‑04‑11
StatusKyellow.png DraftVersion Label2021
NameIPSMedicalDevicesSectionDisplay NameIPS Medical Devices Section
Description
The medical devices section contains narrative text and coded entries describing the patient history of medical device use.
Medical devices include, but are not limited to, implanted devices and devices for nutrition. 
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.6
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-15Kyellow.png Medical Devices Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-219Kyellow.png Device List Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 5 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.26ContainmentKorange.png IPS Medical Device (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.17ContainmentKyellow.png IPS Procedure Entry (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (2017‑04‑11)
Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.2.4 Section Medical Devices Coded (2013‑12‑20)
ref
epsos-

Adaptation: template 2.16.840.1.113883.10.20.1.7 Medical equipment section (DYNAMIC)
ref
ccd1-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 IHE Medical Devices Section (DYNAMIC)
ref
IHE-PCC-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.6"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="46264-8" codeSystem="2.16.840.1.113883.6.1" displayName="History of medical device use"/>  <title>History of medical device use</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.26 'IPS Medical Device' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-15Kyellow.png Medical Devices Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.6
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F46264-8
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MMedical Devices(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *RContains 2.16.840.1.113883.10.22.4.26 IPS Medical Device (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-219Kyellow.png Device List Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.17 IPS Procedure Entry (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Medication Summary Section

Id2.16.840.1.113883.10.22.3.1Effective Date2016‑11‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSMedicationSummarySectionDisplay NameIPS Medication Summary Section
Description
The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary.
The actual content could depend on the jurisdiction, it could report:
  • the currently active medications; 
  • the current and past medications considered relevant by the authoring GP; 
  • the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.
In all those cases however medications are documented in the Patient Summary as medication statements.

This section requires either an entry indicating the subject is known not to be on any medications; either an entry indicating that no information is available about medications; or entries summarizing the subject's medications.

The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.1
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-16Kyellow.png Medication Summary Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-61Kyellow.png List of medication Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.4ContainmentKyellow.png IPS Medication Statement (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.1.8 Medication section (DYNAMIC)
ref
ccd1-

Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 Section Medication Summary (2013‑12‑20)
ref
epsos-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.1"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" displayName="Terapie farmacologiche"/>  <title>Terapie farmacologiche</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.4 'IPS Medication Entry' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-16Kyellow.png Medication Summary Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.1
Treetree.pnghl7:id
II0 … *(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1MHistory of medication use(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F10160-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MMedication Summary (IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1MSection text(IPS...ion)
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *RContains 2.16.840.1.113883.10.22.4.4 IPS Medication Statement (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-61Kyellow.png List of medication Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Plan of Care Section

Id2.16.840.1.113883.10.22.3.9Effective Date2020‑05‑08 18:28:38
Other versions this id:
  • Kblank.png IPSPlanofCareSection as of 2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelTI-2020
NameIPSPlanofCareSectionDisplay NameIPS Plan of Care Section
Description
The care plan section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.9
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-110Kyellow.png Plan Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-17Kyellow.png Plan Of Care Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 8 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.41ContainmentKorange.png IPS Planned Observation (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.4.38ContainmentKorange.png IPS Planned Procedure (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.4.40ContainmentKorange.png IPS Planned Encounter (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.4.47ContainmentKorange.png IPS Planned Immunization (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.4.39ContainmentKyellow.png IPS Planned Act (2022)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.31 IHE Care Plan Section (DYNAMIC)
ref
IHE-PCC-

Adaptation: template 2.16.840.1.113883.10.20.1.10 Plan of care section (DYNAMIC)
ref
ccd1-

Adaptation: template 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (DYNAMIC)
ref
bccdapilot-
Example
Example
<cda:section classCode="DOCSECT">
  <hl7:templateId root="2.16.840.1.113883.10.22.3.9"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="18776-5" codeSystem="2.16.840.1.113883.6.1"/>  <hl7:title>title</hl7:title>  <hl7:text/>  <hl7:author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (2017-03-02T00:00:00) -->
  </hl7:author>
  <hl7:informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (2005-09-07T00:00:00) -->
  </hl7:informant>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.41 'IPS Planned Observation' (2020-05-08T18:34:42) -->
  </hl7:entry>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.38 'IPS Planned Procedure' (2020-05-08T17:38:48) -->
  </hl7:entry>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.40 'IPS Planned Encounter' (2020-05-08T18:18:38) -->
  </hl7:entry>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.47 'IPS Planned Immunization' (2020-05-08T17:29:18) -->
  </hl7:entry>
  <hl7:entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.39 'IPS Planned Act' (2020-05-08T18:08:52) -->
  </hl7:entry>
  <hl7:component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (2017-07-12T00:00:00) -->
  </hl7:component>
</cda:section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-17Kyellow.png Plan Of Care Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.9
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F18776-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MPlan of Care(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-110Kyellow.png Plan Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.41 IPS Planned Observation (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.38 IPS Planned Procedure (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.40 IPS Planned Encounter (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.47 IPS Planned Immunization (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.39 IPS Planned Act (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Problems Section

Id2.16.840.1.113883.10.22.3.3Effective Date2017‑02‑15
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSProblemListDisplay NameIPS Problems Section
Description
The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient. This section can record different kinds of  problems as, but not limited to,  chronic diseases (e.g. COPD, diabetes, hypertension); contagious diseases; nutritional problems (e.g. metabolic diseases); and so on.The optional author and informant elements are used, when necessary, to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.3
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-130Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-139Kyellow.png Problem list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-18Kyellow.png Problems Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.7ContainmentKyellow.png IPS Problem Concern Entry (2021)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.1.11 Problem section (DYNAMIC)
ref
ccd1-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.6 Section Active Problems (2013‑12‑20)
ref
epsos-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.3"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>  <title>Active Problems</title>  <text>Narrative text of the Problem List sections</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.7 'IPS Problem Concern Entry' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ist)
 
Target.png
hl7ips-data​element-18Kyellow.png Problems Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ist)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.3
Treetree.pnghl7:id
II0 … *R(IPS...ist)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ist)
Treeblank.pngTreetree.png@code
CONF1 … 1F11450-4
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1M(IPS...ist)
Treetree.pnghl7:text
SD.TEXT1 … 1MSection text(IPS...ist)
 
Target.png
hl7ips-data​element-130Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ist)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ist)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ist)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ist)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ist)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ist)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ist)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ist)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ist)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ist)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ist)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ist)
Treetree.pnghl7:entry
1 … *RContains 2.16.840.1.113883.10.22.4.7 IPS Problem Concern Entry (DYNAMIC)(IPS...ist)
 
Target.png
hl7ips-data​element-139Kyellow.png Problem list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ist)

IPS Results Section

Id2.16.840.1.113883.10.22.3.14Effective Date2017‑04‑30
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSResultsSectionDisplay NameIPS Results Section
Description
This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
The structured, machine-processable content of this section is sorted out between as many Result Organizer entries as needed. One Result Organizer entry groups results, which have a common context of production:
  • common specialty (imaging, bacteriology, serology, chemistry,  surgical pathology, clinical, radiology ...), 
  • common overall interpretation, (which interprets the set of results of the Organizer),
  • common biologic specimen for in vitro diagnostic observations, 
  • common associated illustrative image.
The optional author and informant elements of the section are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
In case this section assembles results from multiple authors (e.g.; results authored by a clinical laboratory, and results produced by a radiology center), the authors are listed in the section, and each Result Organizer of the section indicates its own author(s).
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.14
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-126Kyellow.png Observations results list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-142Kyellow.png Result Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-19Kyellow.png Results Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.9ContainmentKorange.png IPS Result Organizer (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.3.14"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" displayName="Relevant diagnostic tests/laboratory data Narrative"/>  <title>MOST SIGNIFICANT RESULTS</title>  <text>
    <!-- some clinical laboratory results and some surgical pathology results presented to the human reader -->
  </text>
  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
  </author>
  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->
  </author>
  <entry typeCode="COMP" contextConductionInd="true">
    <!--- 1st Organizer: chemistry observations on blood serum specimen produced and interpreted by a clinical laboratory -->
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18719-5" displayName="Chemistry studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
      </author>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - common blood serum specimen -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of chemistry results -->
      </component>
    </organizer>
  </entry>
  <entry>
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18723-7" displayName="Hematology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
      </author>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - venous blood total specimen -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of hematology results -->
      </component>
    </organizer>
  </entry>
  <entry>
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="11529-5" displayName="Surgical pathology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->
      </author>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.11 'IPS Pathology Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - excised tissue specimen -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - pathologist's interpretation -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.23 'IPS ObservationMedia' - an illustrative slide image -->
      </component>
    </organizer>
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
(IPS...ion)
 
Target.png
hl7ips-data​element-19Kyellow.png Results Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1R(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.14
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F30954-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1M(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-142Kyellow.png Result Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *MContains 2.16.840.1.113883.10.22.4.9 IPS Result Organizer (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-126Kyellow.png Observations results list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Social History Section

Id2.16.840.1.113883.10.22.3.10Effective Date2020‑05‑10 18:52:32
Other versions this id:
  • Kblank.png IPSSocialHistorySection as of 2020‑05‑10 18:52:19
  • Kblank.png IPSSocialHistorySection as of 2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelTI-2020
NameIPSSocialHistorySectionDisplay NameIPS Social History Section
Description
The social history section contains a description of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.10
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-147Kyellow.png Life Style Factor list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-149Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-20Kyellow.png Social History Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 6 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.34ContainmentKorange.png IPS Social History Tobacco Use (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.35ContainmentKorange.png IPS Social History Alcohol Use (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.48ContainmentKorange.png IPS Social History Observation (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.3.10 IPS Social History Section (2017‑04‑13)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.16 IHE Social History Section (DYNAMIC)
ref
IHE-PCC-

Adaptation: template 2.16.840.1.113883.10.20.1.15 Social history section (DYNAMIC)
ref
ccd1-

Adaptation: template 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (DYNAMIC)
ref
bccdapilot-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.10"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social history Narrative"/>  <title>Social History</title>  <text> Social History text </text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.34 'IPS Social History Tobacco Use' (dynamic) -->
  </entry>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.35 'IPS Social History Alcohol Use' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-20Kyellow.png Social History Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.10
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F29762-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MSocial History(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-149Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
0 … 1Contains 2.16.840.1.113883.10.22.4.34 IPS Social History Tobacco Use (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-147Kyellow.png Life Style Factor list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … 1Contains 2.16.840.1.113883.10.22.4.35 IPS Social History Alcohol Use (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-147Kyellow.png Life Style Factor list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entry
0 … *Contains 2.16.840.1.113883.10.22.4.48 IPS Social History Observation (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)

IPS Translation Section

Id2.16.840.1.113883.10.22.3.15Effective Date2021‑09‑02 12:04:41
Other versions this id:
  • Kblank.png IPSTranslationSection as of 2017‑07‑12
StatusKyellow.png DraftVersion Label2021
NameIPSTranslationSectionDisplay NameIPS Translation Section
DescriptionTemplate CDA Section to carry the translations of a Parent Section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipVersion: template 2.16.840.1.113883.10.22.3.15 IPS Translation Section (2017‑07‑12)
Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
<section>
  <title>Translated title</title>  <!-- subordinate section carrying a translation of the parent section -->
  <text>This is an English text</text>  <languageCode code="en-US"/></section>
ItemDTCardConfDescriptionLabel
hl7:section
(IPS...ion)
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:title
ST1 … 1R(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1R(IPS...ion)
Treetree.pnghl7:language​Code
CS1 … 1R(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)


CDA Entry Level Templates

IPS Allergy and Intolerance Concern

Id2.16.840.1.113883.10.22.4.5Effective Date2024‑08‑04 10:09:24
Other versions this id:
  • Kblank.png IPSAllergyAndIntoleranceConcern as of 2016‑11‑11
StatusKyellow.png DraftVersion LabelSTU2
NameIPSAllergyAndIntoleranceConcernDisplay NameIPS Allergy and Intolerance Concern
Description
This template reflects an ongoing concern on behalf of the person that placed the allergy on a patient’s allergy list.
A concern may refer to one or more allergies or intolerances.
There are different kinds of status that could be related to an allergy, or more in general to a condition:
  • The status of the concern (active, inactive,..)
  • The status of the condition (e.g. active, inactive, resolved,..)
  • The confirmation status [clinical workflow status, certainty] (e.g. confirmed, likely, unlikely,…)
Not all of them can be represented in a CDA using the statusCode elements of the concern (ACT) and observation (condition).
As long as the underlying condition is of concern to the author (i.e., as long as the allergy, whether active or resolved, is of ongoing concern and interest to the author), the statusCode is “active”.
In case the clinician deems that there is no longer any need to track the underlying conditions then the concern is inactive and the statusCode is set to "completed".
The effectiveTime/low of the Allergy Concern Act asserts when the concern became active. This equates to the time the concern was authored in the patient's chart.
The effectiveTime/high asserts when the concern became inactive, and it is present if the statusCode of the concern act is "completed"
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.5
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.4.1ContainmentKyellow.png IPS Allergy or Intolerance (STU2)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.5 IPS Allergy and Intolerance Concern (2016‑11‑11)
Adaptation: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 IHE Allergy and Intolerance Concern Entry (2013‑12‑20)
ref
IHE-PCC-
Example
Example
<act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.5"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6">
    <statusCode code="active"/>    <effectiveTime>
      <low value="..."/>      <high value="..."/>    </effectiveTime>
    <entryRelationship typeCode="SUBJ" inversionInd="false">
      <!-- template 2.16.840.1.113883.10.22.4.1 'IPS Allergy or Intolerance' (dynamic) -->
    </entryRelationship>
  </code>
</act>
ItemDTCardConfDescriptionLabel
hl7:act
0 … *R(IPS...ern)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ern)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.5
Treetree.pnghl7:id
II0 … *R(IPS...ern)
Treetree.pnghl7:code
CD1 … 1M(IPS...ern)
Treeblank.pngTreetree.png@code
CONF1 … 1FCONC
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.5.6 (HL7ActClass)
Treetree.pnghl7:statusCode
CS1 … 1RAs long as the underlying conditions are of concern to the author (i.e., as long as allergies, whether active or resolved, is of ongoing concern and interest to the author), the statusCode is “ active ”. The concern is tracked by the author.

Only when the underlying allergies are no longer of concern then the statusCode is set to “ completed ”. The author is no more tracking this concern and no further actions are expected.
(IPS...ern)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...ern)
Treeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RThis element asserts when the concern became active. This equates to the time the concern was authored in the patient's chart and the author started tracking this concern.(IPS...ern)
Treeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1CThis element asserts when the clinician deemed there is no longer any need to track the underlying conditions.(IPS...ern)
 ConstraintIf statusCode/@code="completed" Completed, then effectiveTime *SHALL* contain [1..1] high
 Schematron assertrole error 
 testnot(../hl7:statusCode[@code='completed']) or hl7:high 
 MessageIf statusCode/@code="completed" Completed, then effectiveTime *SHALL* contain [1..1] high 
Treetree.pnghl7:entryRelationship
1 … *RContains 2.16.840.1.113883.10.22.4.1 IPS Allergy or Intolerance (DYNAMIC)(IPS...ern)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl0 … 1Ffalse

IPS Allergy Certainty Observation

{{: 2.16.840.1.113883.10.22.10/dynamic}}

IPS Allergy or Intolerance

Id2.16.840.1.113883.10.22.4.1Effective Date2024‑08‑04 09:48:50
Other versions this id:
  • Kblank.png IPSEntryAllergyOrIntolerance as of 2016‑11‑10
StatusKyellow.png DraftVersion LabelSTU2
NameIPSEntryAllergyOrIntoleranceDisplay NameIPS Allergy or Intolerance
Description
This template reflects a discrete observation about a patient's allergy or intolerance.
Because it is a discrete observation, it will have a statusCode of "completed".
The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient.
For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.
The effectiveTime of the Allergy - Intolerance Observation gives an indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. 
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". 
It is recommended that the agent responsible for an allergy or adverse reaction would be used for describing the allergy, however the possibility that pre-coordinate codes (e.g. "allergy to nuts") will be used has been here also considered.
The agent responsible for  an allergy or adverse reaction it is not always a manufactured material (for example, food allergies), nor is it necessarily consumed; however  the playingEntity classCode = "MMAT" for all agents, manufactured or not is expected to be used. This choice depends on thecharacteristics of the base CDA R2 specification.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.1
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 12 concepts
IdNameData Set
hl7ips-data​element-173Kyellow.png Agent Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-182Kyellow.png Allergies/Intolerances Content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-184Kyellow.png Allergy/Intolerance Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-185Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-186Kyellow.png Clinical Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-187Kyellow.png Onset date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-188Kyellow.png End Date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-189Kyellow.png Criticality Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-190Kyellow.png Certainty Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-191Kyellow.png Type of propensity Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-192Kyellow.png Reaction Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-196Kyellow.png Agent code Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.6ContainmentKyellow.png IPS Reaction Manifestation (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.18ContainmentKorange.png IPS Criticality Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.10ContainmentKorange.png IPS Allergy Certainty Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.21ContainmentKorange.png IPS Allergy Status Observation (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.1 IPS Allergy or Intolerance (2016‑11‑10)
Adaptation: template 2.16.840.1.113883.10.20.1.18 Alert observation (DYNAMIC)
ref
ccd1-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
ch-pcc-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 eHDSI Allergies And Intolerances (DYNAMIC)
ref
epsos-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <id root=" " extension=" "/>  <!-- This is the code that shows what kind of allergy or intolerance -->
  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
    <text>
      <reference value="#ref1"/>    </text>
    <statusCode code="completed"/>    <effectiveTime>
      <low value="20170701"/>    </effectiveTime>
    <!-- This is the allergen - the substance that caused the allergy -->
    <participant typeCode="CSM">
      <participantRole classCode="MANU">
        <playingEntity classCode="MMAT">
          <code code=" " codeSystem=" ">
            <originalText>
              <reference value="#substance"/>            </originalText>
          </code>
          <name>...</name>        </playingEntity>
      </participantRole>
    </participant>
    <!-- This is how the allergy manifests itself -->
    <entryRelationship typeCode="MFST" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.6 'IPS Reaction Manifestation' (dynamic) -->
    </entryRelationship>
    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.18 'IPS Criticality Observation' (dynamic) -->
    </entryRelationship>
    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
    </entryRelationship>
    <entryRelationship typeCode="REFR" inversionInd="false">
      <!-- template 2.16.840.1.113883.10.22.4.21 'IPS Allergy Status Observation' (dynamic) -->
    </entryRelationship>
  </code>
</observation>
Example
No Known Allergies
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="allergy" displayName="Allergy" codeSystem="2.16.840.1.113883.4.642.1.122">
    <statusCode code="completed"/>    <effectiveTime>
      <low nullFlavor="UNK"/>    </effectiveTime>
    <value code="X-NoKnownAllergy" displayName="No known allergy" codeSystem="2.16.840.1.113883.5.1150.2"/>  </code>
</observation>
Example
No Information available about allergies or intolerances
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
    <statusCode code="completed"/>    <effectiveTime>
      <low nullFlavor="NA"/>    </effectiveTime>
    <value code="no-allergy-info" displayName="No information about allergies" codeSystem="2.16.840.1.113883.5.1150.1"/>  </code>
</observation>
Example
Minimum Set (active propensity; agent known)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
    <statusCode code="completed"/>    <effectiveTime>
      <low nullFlavor="UNK"/>    </effectiveTime>
    <participant typeCode="CSM">
      <participantRole classCode="MANU">
        <playingEntity classCode="MMAT">
          <code code="13577000" codeSystem="2.16.840.1.113883.6.96" displayName="Nut"/>        </playingEntity>
      </participantRole>
    </participant>
  </code>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(IPS...nce)
 
Target.png
hl7ips-data​element-184Kyellow.png Allergy/Intolerance Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...nce)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.1
Treetree.pnghl7:id
II0 … *R(IPS...nce)
Treetree.pnghl7:code
CD.IPS1 … 1MThis element describes whether this condition refers to an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance).(IPS...nce)
 
Target.png
hl7ips-data​element-191Kyellow.png Type of propensity Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.2 Allergy or Intolerance Type (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1RThe text element if present points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.</reference> (IPS...nce)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...nce)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RWhen used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS1 … 1MA clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.</statusCode> (IPS...nce)
Treeblank.pngTreetree.png@code
cs1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1M The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago. The effectiveTime of the Allergy - Intolerance  Observation may give an indication of whether or not the underlying allergy/intolerance is resolved. 
The <low> and <high> values should be no more precise than known, but as precise as possible.
(IPS...nce)
Treeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active.(IPS...nce)
 
Target.png
hl7ips-data​element-187Kyellow.png Onset date Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1CThe effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
(IPS...nce)
 
Target.png
hl7ips-data​element-188Kyellow.png End Date Kyellow.png CEN/TC 251 prEN 17269
 ConstraintIf this condition is known to be resolved, then the effectiveTime/high would be present.
Treetree.pnghl7:value
CD.IPS (preferred)0 … 1(IPS...nce)
 
Target.png
hl7ips-data​element-185Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.10 IPS Allergy or Intolerance Conditions (DYNAMIC)
Treetree.pnghl7:participant
0 … 1CThe substance that causes the allergy or intolerance should be specified in the <participant> structure. 
This is the preferred way an allergy is supposed to be expressed.
However it is recognized that in some contexts a controlled vocabulary is used for describing the allergy to a substance; or for asserting known absence or unavailability of information. 
In this case the <participant> structure shall be omitted.
The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT" for all agents, manufactured or not.
(IPS...nce)
 
Target.png
hl7ips-data​element-173Kyellow.png Agent Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
 ConstraintIF the observation/value element is present and valued with a code derived form the  2.16.840.1.113883.11.22.9 Absent or Unknown Allergies value set THEN the  observation/participant element used to describe the agent SHALL be omitted.
Treeblank.pngTreetree.pnghl7:participantRole
1 … 1R(IPS...nce)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMANU
Treeblank.pngTreeblank.pngTreetree.pnghl7:playingEntity
1 … 1R(IPS...nce)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS (preferred)1 … 1RCode for the substance causing the allergy or intolerance.(IPS...nce)
 
Target.png
hl7ips-data​element-196Kyellow.png Agent code Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.65 IPS Allergy or Intolerance Substances (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 … *RThe contained entry describes the reactions that are manifestations (typeCode='MFST') of the reported allergy or intolerance.
Contains 2.16.840.1.113883.10.22.4.6 IPS Reaction Manifestation (DYNAMIC)
(IPS...nce)
 
Target.png
hl7ips-data​element-192Kyellow.png Reaction Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FMFST
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RCriticality
The contained entry describes the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual.
Contains 2.16.840.1.113883.10.22.4.18 IPS Criticality Observation (DYNAMIC)
(IPS...nce)
 
Target.png
hl7ips-data​element-189Kyellow.png Criticality Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RCertainty or Verification Status
The contained entry describes the certainty associated with a propensity, or potential risk, of a reaction to the identified substance.
Contains 2.16.840.1.113883.10.22.10 IPS Allergy Certainty Observation (DYNAMIC)
(IPS...nce)
 
Target.png
hl7ips-data​element-190Kyellow.png Certainty Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RStatus of the Allergy or Intolerance 
The contained entry describes the current status of the allergy or intolerance, for example, whether it is active, in remission, resolved, and so on ...
Contains 2.16.840.1.113883.10.22.4.21 IPS Allergy Status Observation (DYNAMIC)
(IPS...nce)
 
Target.png
hl7ips-data​element-186Kyellow.png Clinical Status Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ffalse

IPS Allergy Status Observation

Id2.16.840.1.113883.10.22.4.21Effective Date2017‑05‑24
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSAllergyStatusObservationDisplay NameIPS Allergy Status Observation
Description
This subordinated observation used by the allergy observation records information about the current status of an allergy or intolerance, for example, whether it is active, in remission, resolved, et cetera.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.21
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
hl7ips-data​element-186Kyellow.png Clinical Status Kyellow.png CEN/TC 251 prEN 17269
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.20 IPS Problem Status Observation (DYNAMIC)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 IHE Problem Status Observation (2013‑12‑20)
ref
IHE-PCC-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.21"/>  <templateId root="2.16.840.1.113883.10.22.4.20"/>  <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>  <text>
    <reference value="#cstatus-2"/>  </text>
  <statusCode code="completed"/>  <value code="active" displayName="Active" codeSystem="2.16.840.1.113883.4.642.3.155"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.21
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.20
Treetree.pnghl7:code
CD1 … 1R

This observation is of clinical status, as indicated by the <code> element. This element must be present.

(IPS...ion)
Treeblank.pngTreetree.png@code
CONF0 … 1F33999-4
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:text
ED0 … 1R

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

(IPS...ion)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS1 … 1M

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:value
CE.IPS1 … 1RThe value element contains the clinical status.(IPS...ion)
 
Target.png
hl7ips-data​element-186Kyellow.png Clinical Status Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.42 IPS Allergy Status Code (DYNAMIC)

IPS Body Author

Id2.16.840.1.113883.10.22.4.14Effective Date2017‑03‑02
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSBodyAuthorDisplay NameIPS Body Author
Description
This template represents the Author Participation (including the author timestamp). CDA R2 requires that Author and Author timestamp be asserted in the document header. From there, authorship propagates to contained sections and contained entries, unless explicitly overridden. The Author Participation template was added to those templates in scope for analysis in R2. Although it is not explicitly stated in all templates the Author Participation template can be used in any template.
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.9.2IncludeKorange.png IPS CDA Device (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.318 CDA Author (Body) (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)
ref
ccda-
Example
Example
<author>
  <templateId root="2.16.840.1.113883.10.22.4.14"/>  <time/>  <assignedAuthor>
    <id root="1.2.3.999" extension="__example only__"/>    <code code="..." codeSystem="1.2.3.999"/>    <!-- choice: 0..1
element hl7:assigned​Person
element hl7:assigned​Authoring​Device containing template 2.16.840.1.113883.10.22.9.2 (dynamic)
-->
    <representedOrganization>
      <id root="1.2.3.999" extension="__example only__"/>      <name>...</name>      <telecom value="tel:+1-12345678"/>      <addr>addr</addr>    </representedOrganization>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
0 … 1(IPS...hor)
Treetree.pnghl7:templateId
II1 … 1M(IPS...hor)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...hor)
Treetree.pnghl7:assignedAuthor
1 … 1M(IPS...hor)
Treeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...hor)
Treeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...hor)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...hor)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...hor)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...hor)
Treeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...hor)

IPS CDA Device

Id2.16.840.1.113883.10.22.9.2Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDADeviceDisplay NameIPS CDA Device
DescriptionThis template provides basic information about a device
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
@classCode
cs0 … 1FDEV
@determiner​Code
cs0 … 1FINSTANCE
hl7:code
CE0 … 1(IPS...ice)
hl7:manufacturer​Model​Name
SC0 … 1(IPS...ice)
hl7:softwareName
SC0 … 1(IPS...ice)

IPS Certainty Observation

Id2.16.840.1.113883.10.22.4.19Effective Date2024‑06‑10 09:59:19
Other versions this id:
  • Kblank.png IPSCertaintyObservation as of 2017‑03‑29
StatusKyellow.png DraftVersion LabelSTU1
NameIPSCertaintyObservationDisplay NameIPS Certainty Observation
DescriptionThis observation represents the verification status to support the clinical status of the condition.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.19
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.20.22.4.145 Criticality Observation (2015‑08‑13)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.19"/>  <code code="66455-7" codeSystem="2.16.840.1.113883.6.1" displayName="Condition status"/>  <statusCode code="completed"/>  <value code="unconfirmed" displayName="Unconfirmed" codeSystem="2.16.840.1.113883.4.642.3.115"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.19
Treetree.pnghl7:code
CD1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F66455-7
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:value
CD.IPS (required)1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.8 IPS Condition Verification Status (DYNAMIC)

IPS Comment Activity

Id2.16.840.1.113883.10.22.4.22Effective Date2017‑04‑05
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCommentActivityDisplay NameIPS Comment Activity
Description
Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. For example, a free text description of the severity of an allergic reaction would not be recorded in a comment.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.22
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.20.22.4.64 Comment Activity (2015‑08‑13)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
Example
<act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.22"/>  <code code="48767-8" codeSystem="2.16.840.1.113883.6.1"/>  <text>
    <reference value="#example"/>  </text>
  <author>
    <time/>    <assignedAuthor>
      <id root="1.2.3.999" extension="__example only__"/>      <addr>addr</addr>      <!-- choice: 1..1
element hl7:assigned​Person
element hl7:represented​Organization
-->
    </assignedAuthor>
  </author>
</act>
ItemDTCardConfDescriptionLabel
hl7:act
(IPS...ity)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1FEVN
 Constraint Data elements defined elsewhere in the specification SHALL NOT be recorded using the Comment Activity
Treetree.pnghl7:templateId
II1 … 1M(IPS...ity)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.22
Treetree.pnghl7:code
CD.IPS1 … 1M(IPS...ity)
Treeblank.pngTreetree.png@code
CONF1 … 1F48767-8
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:text
ED1 … 1M(IPS...ity)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...ity)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1R
 Schematron assertrole error 
 testnot(@value) or starts-with(@value, '#') 
 MessageThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
Treetree.pnghl7:author
0 … 1(IPS...ity)
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ity)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ity)
 ConstraintThe author, if present, SHALL include assignedPerson/name or representedOrganization/name
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1R(IPS...ity)
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *M(IPS...ity)
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ity)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *R(IPS...ity)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ity)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
0 … 1R(IPS...ity)

IPS Criticality Observation

Id2.16.840.1.113883.10.22.4.18Effective Date2017‑03‑27
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCriticalityObservationDisplay NameIPS Criticality Observation
Description
This observation represents the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.18
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
hl7ips-data​element-189Kyellow.png Criticality Kyellow.png CEN/TC 251 prEN 17269
RelationshipAdaptation: template 2.16.840.1.113883.10.20.22.4.145 Criticality Observation (2015‑08‑13)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.18"/>  <code code="82606-5" codeSystem="2.16.840.1.113883.6.1"/>  <statusCode code="completed"/>  <value code="CRITH" displayName="high criticality" codeSystem="2.16.840.1.113883.5.1063"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.18
Treetree.pnghl7:code
CD1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F82606-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:value
CD.IPS (required)1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-189Kyellow.png Criticality Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.60 Allergy-intolerance Criticality (DYNAMIC)

IPS Immunization

Id2.16.840.1.113883.10.22.4.15Effective Date2024‑08‑04 21:20:24
Other versions this id:
  • Kblank.png IPSImmunization as of 2017‑03‑08
StatusKyellow.png DraftVersion LabelSTU2
NameIPSImmunizationDisplay NameIPS Immunization
DescriptionAn Immunization entry describes immunization substance administrations that have actually occurred. 
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.15
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-215Kyellow.png Product Administration Process Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-45Kyellow.png Immunization Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-53Kyellow.png Date of Immunization Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 3 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.16IncludeKyellow.png IPS Immunization Medication Information (STU2)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.21.4.6ContainmentKyellow.png UV Subordinate Substance Administration (2023)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.15 IPS Immunization (2017‑03‑08)
Adaptation: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.52 Immunization Activity (V3) (2015‑08‑01)
ref
ccda-
Example
Example
<substanceAdministration classCode="SBADM" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.15"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="IMMUNIZ" displayName="Immunization" codeSystem="2.16.840.1.113883.5.4">
    <statusCode code="completed"/>    <effectiveTime value="20170721082737"/>    <consumable>
      <!-- template 2.16.840.1.113883.10.22.4.16 'IPS Immunization Medication Information' (dynamic) -->
    </consumable>
    <author>
      <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) -->
    </author>
  </code>
</substanceAdministration>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
(IPS...ion)
 
Target.png
hl7ips-data​element-215Kyellow.png Product Administration Process Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-45Kyellow.png Immunization Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.15
Treetree.pnghl7:id
II0 … *(IPS...ion)
Treetree.pnghl7:code
CV.IPS1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19709 ActSubstanceAdministrationImmunizationCode (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
TS1 … 1R(IPS...ion)
 
Target.png
hl7ips-data​element-53Kyellow.png Date of Immunization Kyellow.png CEN/TC 251 prEN 17269
 Example<effectiveTime value="20170322"/>
Treetree.pnghl7:consumable
1 … 1M(IPS...ion)
Included from 2.16.840.1.113883.10.22.4.16 IPS Immunization Medication Information (DYNAMIC)
Treeblank.pngTreetree.pnghl7:manufacturedProduct
(IPS...ion)
 
Target.png
hl7ips-data​element-54Kyellow.png Product Administered Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMANU
Treeblank.pngTreeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.16
Treeblank.pngTreeblank.pngTreetree.pnghl7:manufactured​Material
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS (preferred)1 … 1R(IPS...ion)
 
Target.png
hl7ips-data​element-46Kyellow.png Immunizations Content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-52Kyellow.png Vaccine for type of disease Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.44 IPS Vaccines (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
CE0 … *(IPS...ion)
 CONF
shall be drawn from concept domain "Product Code"
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
CE0 … 1candidate: for when WHO ATC code system is preferred(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.78 IPS Vaccines WHO ATC (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:lotNumberText
ST0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:manufacturerOrganization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(IPS...ion)
Treetree.pnghl7:author
0 … *RContains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRSON

IPS Immunization Medication Information

Id2.16.840.1.113883.10.22.4.16Effective Date2024‑08‑04 21:16:00
Other versions this id:
  • Kblank.png IPSImmunizationMedicationInformation as of 2017‑03‑08
StatusKyellow.png DraftVersion LabelSTU2
NameIPSImmunizationMedicationInformationDisplay NameIPS Immunization Medication Information
Description
The Immunization Medication Information represents product information about the immunization substance. The vaccine manufacturer and vaccine lot number are typically recorded in the medical record and should be included if known.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.16
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-46Kyellow.png Immunizations Content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-52Kyellow.png Vaccine for type of disease Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-54Kyellow.png Product Administered Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.9.1ContainmentKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.16 IPS Immunization Medication Information (2017‑03‑08)
Adaptation: template 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.54 Immunization Medication Information (V2) (2014‑06‑09)
ref
ccda-
Example
No previous immunizations
<manufacturedProduct classCode="MANU">
  <templateId root="2.16.840.1.113883.10.22.4.16"/>  <manufacturedMaterial>
    <code code="no-known-immunizations" displayName="No known immunizations" codeSystem="2.16.840.1.113883.5.1150.1"/>  </manufacturedMaterial>
  <manufacturerOrganization/></manufacturedProduct>
Example
MMR Vaccine
<manufacturedProduct classCode="MANU">
  <templateId root="2.16.840.1.113883.10.22.4.16"/>  <manufacturedMaterial>
    <code code="61153008" displayName="Measles + Mumps + Rubella vaccine" codeSystem="2.16.840.1.113883.6.96">
      <lotNumberText/>    </code>
  </manufacturedMaterial>
  <manufacturerOrganization/></manufacturedProduct>
ItemDTCardConfDescriptionLabel
hl7:manufacturedProduct
(IPS...ion)
 
Target.png
hl7ips-data​element-54Kyellow.png Product Administered Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FMANU
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.16
Treetree.pnghl7:manufactured​Material
1 … 1M(IPS...ion)
Treeblank.pngTreetree.pnghl7:code
CD.IPS (preferred)1 … 1R(IPS...ion)
 
Target.png
hl7ips-data​element-46Kyellow.png Immunizations Content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-52Kyellow.png Vaccine for type of disease Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.44 IPS Vaccines (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
CE0 … *(IPS...ion)
 CONF
shall be drawn from concept domain "Product Code"
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
CE0 … 1candidate: for when WHO ATC code system is preferred(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.78 IPS Vaccines WHO ATC (DYNAMIC)
Treeblank.pngTreetree.pnghl7:lotNumberText
ST0 … 1(IPS...ion)
Treetree.pnghl7:manufacturerOrganization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(IPS...ion)

IPS Internal Reference

Id2.16.840.1.113883.10.22.4.31Effective Date2017‑05‑02
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSEntryInternalReferenceDisplay NameIPS Internal Reference
DescriptionThis template is used to reference (point to) information contained in other entries within the same document.
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 IHE Internal Reference Entry (2013‑12‑20)
ref
IHE-PCC-
Example
Reference to an uncoded element
<act classCode="ACT" moodCode="cs">
  <templateId root="2.16.840.1.113883.10.22.4.31"/>  <id root="1.2.3.999" extension="__example only__"/>  <code nullFlavor="NA"/></act>
ItemDTCardConfDescriptionLabel
hl7:act
R(IPS...nce)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1RThe @moodCode of the reference SHALL match the @moodCode of the referenced element
 Variable letNamerefMoodCode 
 Value@moodCode 
 Variable letNamerefID 
 Valueconcat(hl7:id[1]/@root,'#',hl7:id[1]/@extension) 
 Variable letNamerefCode 
 Valueconcat(hl7:code[1]/@code,'#',hl7:code[1]/@codeSystem) 
 Variable letNamereffedObject 
 Value(ancestor::hl7:ClinicalDocument//*:id[concat(@root,'#',@extension)=$refID][not(preceding-sibling::hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1')]/parent::*)[1] 
 Schematron assertrole error 
 testnot(exists($reffedObject)) or $reffedObject[@moodCode=$refMoodCode] 
 MessageThe @moodCode of the reference SHALL match the @moodCode of the referenced element 
 Schematron assertrole error 
 testexists($reffedObject) 
 MessageThe root and extension attributes SHALL identify an element defined elsewhere in the same document. 
 Schematron assertrole error 
 testnot(exists($reffedObject)) or ($reffedObject[not(*:code/@code)] and hl7:code[@nullFlavor='NA']) or $reffedObject/*:code[concat(@code,'#',@codeSystem)=$refCode] 
 MessageThe code of the reference SHALL match the code of the referenced element 
Treetree.pnghl7:templateId
II1 … 1M(IPS...nce)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.31
Treetree.pnghl7:id
II1 … 1RThis element shall be present. The root and extension attributes shall identify an element defined elsewhere in the same document.(IPS...nce)
Treetree.pnghl7:code
CD1 … 1RThis element shall be present. It shall be valued when the internal reference is to element that has a <code> element, and shall have the same attributes as the <code> element in the act it references. If the element it references does not have a <code> element, then the nullFlavor attribute should be set to "NA".(IPS...nce)
Treeblank.pngTreetree.png@nullFlavor
cs0 … 1FNA

IPS Laboratory Result Observation

Id2.16.840.1.113883.10.22.4.13Effective Date2024‑08‑04 11:10:20
Other versions this id:
  • Kblank.png IPSLaboratoryResultObservation as of 2017‑03‑21
StatusKyellow.png DraftVersion LabelSTU2
NameIPSLaboratoryResultObservationDisplay NameIPS Laboratory Result Observation
Description
This template constrains the results of a clinical laboratory observation. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.13
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.22ContainmentKorange.png IPS Comment Activity (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.13 IPS Laboratory Result Observation (2017‑03‑21)
Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.22.4.10 IPS Result Observation (2017‑03‑02)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.13"/>  <id root="1.2.3.999" extension="--example only--"/>  <code codeSystem="2.16.840.1.113883.6.1" code="41995-2" displayName="Hemoglobin A1c [Mass/volume] in Blood">
    <statusCode code="completed"/>    <effectiveTime>
      <low value="20171113173215"/>    </effectiveTime>
    <value xsi:type="PQ" value="4.8" unit="%"/>    <interpretationCode code="H" displayName="High" codeSystem="2.16.840.1.113883.5.83"/>    <author>
      <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
    </author>
    <referenceRange>
      <observationRange>
        <value xsi:type="IVL_PQ">
          <low value="1.5" unit="%"/>          <high value="4.5" unit="%"/>        </value>
        <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>      </observationRange>
    </referenceRange>
    <entryRelationship typeCode="COMP">
      <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' (dynamic) -->
    </entryRelationship>
  </code>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.13
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CD.IPS1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.75 IPS Results Laboratory/Pathology Observation (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...ion)
Choice1 … 1Elements to choose from:
  • hl7:value[@xsi:type='CE.IPS']
  • hl7:value[@xsi:type='PQ']
  • hl7:value[@xsi:type='IVL_PQ']
  • hl7:value[@xsi:type='ST']
  • hl7:value[@xsi:type='TS']
  • hl7:value[@xsi:type='RTO_QTY_QTY']
Treeblank.pngTreetree.pnghl7:value
CE.IPS (extensible)0 … 1R(IPS...ion)
where [@xsi:type='CE.IPS']
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.74 IPS Results Coded Values Laboratory/Pathology (DYNAMIC)
 Example
Blood group A+ from SNOMED CT
<value xsi:type="CE" code="278149003" codeSystem="2.16.840.1.113883.6.96" displayName="Blood group A Rh(D) positive"/>
 Example
Germ susceptible to antimicrobial agent from HL7 vocabulary
<value xsi:type="CE" code="S" codeSystem="2.16.840.1.113883.11.78" displayName="susceptible"/>
Treeblank.pngTreetree.pnghl7:value
PQ0 … 1R(IPS...ion)
where [@xsi:type='PQ']
 ConstraintIf Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC
 Example
Result physical quantity (data type PQ): 136 mmol per liter
<value xsi:type="PQ" value="136" unit="mmol/L"/>
Treeblank.pngTreetree.pnghl7:value
IVL_PQ0 … 1R(IPS...ion)
where [@xsi:type='IVL_PQ']
 Example
Result interval of physical quantities (data type IVL_PQ): 150 - 400 Billion per 10 exp 9 liter
<value xsi:type="IVL_PQ">
  <low value="150" unit="10+9/l"/>  <high value="400" unit="10+9/l"/></value>
Treeblank.pngTreetree.pnghl7:value
ST0 … 1R(IPS...ion)
where [@xsi:type='ST']
 Example
Result free text (data type ST)
<value xsi:type="ST">slight macrocytosis, check on alcohol consumption</value>
Treeblank.pngTreetree.pnghl7:value
TS0 … 1R(IPS...ion)
where [@xsi:type='TS']
 Example
Result time stamp (data type TS): 6-Aug-2014
<value xsi:type="TS" value="20140806"/>
Treeblank.pngTreetree.pnghl7:value
RTO_QTY_QTY0 … 1R(IPS...ion)
where [@xsi:type='RTO_QTY_QTY']
 Example
Result ratio (data type RTO_QTY_QTY): 1/179
<value xsi:type="RTO_QTY_QTY">
  <numerator xsi:type="INT" value="1"/>  <denominator xsi:type="INT" value="179"/></value>
Treetree.pnghl7:interpretationCode
CE.IPS0 … 1R(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Included0 … *R from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *R(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:referenceRange
0 … 1RThe referenceRange is constrained to represent the normal range for this observation and this patient.(IPS...ion)
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CDNP(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE.IPS0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.83 (Observation Interpretation)
Treetree.pnghl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP

IPS Manufactured Material

Id2.16.840.1.113883.10.22.4.3Effective Date2024‑08‑04 10:47:30
Other versions this id:
  • Kblank.png IPSMedMaterial as of 2021‑08‑02 16:52:27
  • Kblank.png IPSMedMaterial as of 2016‑11‑10
StatusKyellow.png DraftVersion LabelSTU2
NameIPSMedMaterialDisplay NameIPS Manufactured Material
Description
This entry provides details about the medicinal product.
Due to the current absence of global product identifiers the product is described through a set of identification and descriptive attributes (e.g. active substances, strength, unit of presentation,...)  that may be used to integrate jurisdictional product codes.
This shortage will be likely overcome when the ISO IDMP identifiers will be available for concrete usage in the next years, as well as the globally used value sets for products attributes agreed by the ISO IDMP implemention guides. (e.g. GInAs for substances).
Even though there is a quite common consensus about the attributes that should be provided in order to describe a medicine in the context of the international patient summary (e.g. the list of active substances, the strength(s); the administrable pharmaceutical forms;..), this template doesn't require any of them, recommending, above all for cross-borders services, to provide all the available information that could be helpful for the identification of medications
Jurisdictions could specialize this template making some ofthese attributes required.
It is also recognized that in many contexts structured information about the product, might not be available, and only textual information for describing products (e.g. the product scientific name "amoxicillin 400mg/5mL suspension”) or some of their attributes (e.g. textual strength "875 mg + 125 mg" ; "amoxycillin and clavulanic acid") could be used.
This template attempts to provide a solution that takes in account this current complexity being also ready for including the future IDMP-based solution as soon as they will become available for concrete use.
Since the CDA R2.0 model support only a very limited set of information about the products, extensions based on the R_ProductList (Common Product Model) CMET have been used for conveying such information, aiming to align this solution with that that will be likely used for the IDMP implementation Guide.
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 4 concepts
IdNameData Set
hl7ips-data​element-105Kyellow.png Product Code Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-117Kyellow.png Brand Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-171Kyellow.png Product Common Name (and Strength) Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-227Kyellow.png Pharmaceutical dose form Kyellow.png CEN/TC 251 prEN 17269
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.3 IPS Manufactured Material (2021‑08‑02 16:52:27)
Adaptation: template 2.16.840.1.113883.10.12.311 CDA Material (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.3.1937.777.11.10.147 OpenMed Material (2016‑05‑10 22:43:03)
ref
epsos-
Example
Example
<manufacturedMaterial>
  <!-- Example with all the IDMP Levels (PhPID,MPID, PCID) and other product attributes (e.g. ingredients, ATC Code, strengths) -->
  <templateId root="2.16.840.1.113883.10.22.4.3"/>  <code codeSystem="" code="MPID" displayName="" CodeSystemName="MP EMA">
    <name>Medicinal Product Name</name>    <formCode codeSystem="0.4.0.127.0.16.1.1.2.1" code="10219000" displayName="tablet" CodeSystemName="EDQM"/>    <asContent>
      <!-- Packaged Medicinal Product (PC) -->
      <containerPackagedProduct>
        <!-- PC ID-->
        <code codeSystem=" " code="PCID" displayName=" ">
          <name>...</name>          <formCode codeSystem="0.4.0.127.0.16.1.1.2.1" code="" displayName="" CodeSystemName="EDQM"/>        </code>
      </containerPackagedProduct>
    </asContent>
    <asSpecializedKind classCode="GRIC">
      <!-- Pharmaceutical Substance (ATC Code)-->
      <generalizedMaterialKind classCode="MMAT">
        <!-- Pharmaceutical Substance (ATC Code)-->
        <code code=" " codeSystem="2.16.840.1.113883.6.73" displayName=" " codeSystemName="WHO ATC"/>      </generalizedMaterialKind>
    </asSpecializedKind>
    <asSpecializedKind>
      <!-- Pharmaceutical Product (PhP)-->
      <generalizedMaterialKind classCode="MMAT">
        <code code="PhPID" codeSystem=" " displayName=" " codeSystemName="PhP EMA">
          <name>....</name>        </code>
      </generalizedMaterialKind>
    </asSpecializedKind>
    <!-- list of active ingredients -->
    <ingredient classCode="ACTI" determinerCode="KIND">
      <quantity>
        <!-- strength -->
        <numerator type="PQ" value="20" unit="mg"/>        <denominator type="PQ" value="1" unit="{tablet}"/>      </quantity>
      <ingredientSubstance>
        <code codeSystem=" " code="SubstanceID" displayName=" " CodeSystemName="G-SRS">
          <name>...</name>        </code>
      </ingredientSubstance>
    </ingredient>
  </code>
</manufacturedMaterial>
Example
Example
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
  <templateId root="2.16.840.1.113883.10.22.4.3"/>  <code code="..." codeSystem="1.2.3.999">
    <name>name</name>    <formCode code="10101000" displayName="Oral drops, solution" codeSystem="0.4.0.127.0.16.1.1.2.1"/>    <asContent classCode="CONT">
      <containerPackagedProduct classCode="CONT" determinerCode="KIND">
        <code>
          <name/>          <formCode code="..." displayName="..." codeSystem="0.4.0.127.0.16.1.1.2.1"/>          <capacityQuantity value="..." unit="..."/>          <asContent classCode="CONT">
            <containerPackagedProduct classCode="CONT" determinerCode="KIND">
              <code>
                <name/>                <formCode code="..." displayName="..." codeSystem="0.4.0.127.0.16.1.1.2.1"/>                <asContent classCode="CONT">
                  <containerPackagedProduct classCode="CONT" determinerCode="KIND">
                    <code>
                      <name/>                      <formCode code="..." displayName="..." codeSystem="0.4.0.127.0.16.1.1.2.1"/>                    </code>
                  </containerPackagedProduct>
                </asContent>
              </code>
            </containerPackagedProduct>
          </asContent>
        </code>
      </containerPackagedProduct>
    </asContent>
    <asSpecializedKind classCode="GRIC">
      <generalizedMaterialKind classCode="MMAT">
        <code code="..." codeSystem="2.16.840.1.113883.6.73">
          <name/>        </code>
      </generalizedMaterialKind>
    </asSpecializedKind>
    <asSpecializedKind classCode="GRIC">
      <generalizedMaterialKind classCode="MMAT">
        <code>
          <name/>        </code>
      </generalizedMaterialKind>
    </asSpecializedKind>
    <ingredient classCode="ACTI" determinerCode="KIND">
      <quantity>
        <numerator value="20" unit="mg"/>        <denominator value="100" unit="mL"/>      </quantity>
      <ingredientSubstance>
        <code>
          <name/>        </code>
      </ingredientSubstance>
    </ingredient>
  </code>
</manufacturedMaterial>
ItemDTCardConfDescriptionLabel
hl7:manufactured​Material
0 … *R(IPS...ial)
Treetree.png@classCode
cs0 … 1FMMAT
Treetree.png@determiner​Code
cs0 … 1FKIND
Treetree.pnghl7:templateId
II1 … 1M(IPS...ial)
Treeblank.pngTreetree.png@root
oid1 … 1F2.16.840.1.113883.10.22.4.3
Choice0 … 1Elements to choose from:
  • hl7:code
  • hl7:code[@codeSystem='2.16.840.1.113883.6.96']
Treeblank.pngTreetree.pnghl7:code
CE.IPS0 … 1RThis element is generally used to identify a medicinal product.
When the IDMP identifiers will be concretely available for usage this element will be used for conveying the Medicinal Product Identifier (MPID).
For the time being, it could be optionally used for conveying jurisdictional or agreed cross jurisdictional medicinal product code.
(IPS...ial)
 
Target.png
hl7ips-data​element-105Kyellow.png Product Code Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:code
CE.IPS0 … 1RNon IDMP codes from SNOMED CT value set(IPS...ial)
where [@codeSystem='2.16.840.1.113883.6.96']
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.71 IPS Medications Products (DYNAMIC)
Treetree.pnghl7:name
EN0 … 1R
This element is supposed to be valorized with the complete Medicinal Product Name as approved by the Medicines Regulatory Agency in a jurisdiction.
The name may be applicable in one or more country/language combinations.
(IPS...ial)
 
Target.png
hl7ips-data​element-117Kyellow.png Brand Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-171Kyellow.png Product Common Name (and Strength) Kyellow.png CEN/TC 251 prEN 17269
Treetree.pngpharm:formCode
CE.IPS0 … 1R
Administrable Pharmaceutical Dose Form.
This code represents the form of the medication (e.g. tablet, capsule, liquid)
Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms;Pakages and Route of Administration.
It is known that also alternative jurisdictional and international terminologies are known to be used for this concept domain, as NCI or SNOMED CT.
(IPS...ial)
 
Target.png
hl7ips-data​element-227Kyellow.png Pharmaceutical dose form Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.25 IPS Medicine Doseform (DYNAMIC)
 Example<formCode code="10211000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Capsule, soft">...</formCode>
Treetree.pngpharm:asContent
0 … *
This structure describes the packaging of the medication.
The <pharm:formCode> element provides the code for the particular package.
If the package has a brand name, it can be described in the <pharm:name> element.
The <pharm:capacity​Quantity> element describes the capacity of the packaging, while the <pharm:quantity> the actual quantity of inner packaged items in the outer packaging container.
The product might have a single (30 pills bottle) or multiple (5 vials 10 ml; box with 2 blisters of 20 tablets) layers of packaging.
In the latter case, the most inner (nested) item represents the most outer package item.
For example the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
is described as "20 tablets" contained by "a blister"; "2 blisters" contained by one box.


The most inner package represents the Packaged Medicinal Product.

When the IDMP Packaged Medicinal Product ID (PCID) will become actually available for usage, the most inner package <code> element will be used to convey the IDMP PCID.
(IPS...ial)
Treeblank.pngTreetree.png@classCode
cs1 … 1FCONT
 Example
Packaged Medicinal Product with multiple layers packaging
<asContent>
  <containerPackagedProduct>
    <!-- Inner Package -->
    <code codeSystem="..." code="..." displayName="...">
      <asContent>
        <containerPackagedProduct>
          <!-- Intermediate Package -->
          <asContent>
            <containerPackagedProduct>
              <!-- Outer Package / Packaged Medicinal Product -->
            </containerPackagedProduct>
          </asContent>
        </containerPackagedProduct>
      </asContent>
    </code>
  </containerPackagedProduct>
</asContent>
 Example
Packaged Medicinal Product with formCode
<asContent>
  <containerPackagedProduct>
    <!-- Packaged Medicinal Product -->
    <code codeSystem="1.999.999" code="PC_ID" displayName="Packaged Product Name">
      <name>100 MIRACLE PILLS(TM)</name>      <formCode codeSystem="0.4.0.127.0.16.1.1.2.1" code="30009000" displayName="Box" CodeSystemName="EDQM"/>    </code>
  </containerPackagedProduct>
</asContent>
Treeblank.pngTreetree.pngpharm:quantity
PQ0 … 1The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RIt represents the most inner Package Item or the Packaged Medicinal Product.(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreetree.pngpharm:code
0 … 1
If this is also the most outer <pharm:containerPackagedProduct> than the <code> element can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).
 
The presence of the PCID indicates that that element represents the "Packaged Medicinal Product".
(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1
It represents the Name of the Package Item or of the Packaged Medicinal Product.
If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name.
(IPS...ial)
 Example<name>AMOXIFEN(R) 20 compresse 20 mg</name>
Treeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS0 … 1RThis element encodes the type of the most inner package item or of the or the Packaged Medicinal Product.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...ial)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
 Example<formCode code="30007000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" codeSystemVersion="2010" displayName="Blister">...</formCode>
Treeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *R
In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product.
For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the "2 blisters" 
In the case of 
  \--Box 
  \-----5 vials
it represents the Packaged Medicinal Product. 
(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1RThe quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RIt represents the intermediate Package Item or the Packaged Medicinal Product(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS0 … 1
If this is also the most inner  <pharm:containerPackagedProduct> than the <code> element can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).
 
The presence of the PCID indicates that that element represents the "Packaged Medicinal Product".
(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1R
It represents the Name of the Package Item or of the Packaged Medicinal Product
If this is also the most inner  <pharm:containerPackagedProduct> than this element can be used for the brand name.
(IPS...ial)
 Example<name>...</name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS1 … 1RThis element encodes the type of the most inner package item or of the or the Packaged Medicinal Product.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as reference terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...ial)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *R
In case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product.
For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the Packaged Medicinal Product. 
(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1RThe quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RWhen present, it represents the Packaged Medicinal Product(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS0 … 1When present, it can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1RWhen present, it can be used for the representing the brand name.(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS1 … 1RWhen present, it encodes the type of the outer package.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...ial)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treetree.pngpharm:asSpecializedKind
0 … 1R
This module is used for representing the classification of the Substance according to the WHO Anatomical Therapeutic Chemical (ATC) Classification System.
The classCode of "GRIC" identifies this structure as the representation of a generic equivalent of the medication described in the current Medicine entry.
(IPS...ial)
where [generalizedMaterialKind/code/@codeSystem='2.16.840.1.113883.6.73']
Treeblank.pngTreetree.png@classCode
cs1 … 1FGRIC
 Example<asSpecializedKind classCode="GRIC">
  <generalizedMaterialKind classCode="MMAT">
    <!-- Pharmaceutical Substance (ATC Code)-->
    <code code=" " codeSystem="2.16.840.1.113883.6.73" displayName=" " codeSystemName="WHO ATC"/>  </generalizedMaterialKind>
</asSpecializedKind>
Treeblank.pngTreetree.pngpharm:generalizedMaterialKind
1 … 1M(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS1 … 1RThe <code> element contains the ATC code of this medicine.(IPS...ial)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.29 IPS WHO ATC (DYNAMIC)
 Example<code codeSystem="2.16.840.1.113883.6.73" code=" " displayName=" " codeSystemName="WHO ATC"/>
Treeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … *(IPS...ial)
Treetree.pngpharm:asSpecializedKind
0 … *RThe Medicinal Product can be classified according to various classification systems, which may be jurisdictional or international.
The classification system itself is specified using an appropriate identification system; the controlled term and the controlled term identifier shall be specified.

When the IDMP Pharmaceutical Product Identifier(s) (PhPID Set) will become actually available for use, the PhPID will be represented by the generalizedMaterialKind/code element.
(IPS...ial)
Treeblank.pngTreetree.png@classCode
cs1 … 1FGRIC
 Example<asSpecializedKind classCode="GRIC">
  <generalizedMaterialKind classCode="MMAT">
    <code code="PhPID_Lvl1" codeSystem="1.999.999" displayName="Pharmaceutical Product Name" codeSystemName="PhPID Level 1">
      <name/>    </code>
  </generalizedMaterialKind>
</asSpecializedKind>
Treeblank.pngTreetree.pngpharm:generalizedMaterialKind
R(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS1 … 1R
When the IDMP Pharmaceutical Product Identifier(s) (PhPID Set) will become actually available for use, this element will be used for representing the IDMP PhP Id.
The level and the stratum of the PhPID will be distiguished by the OID of the code system.
(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … *R(IPS...ial)
Treetree.pngpharm:ingredient
0 … *R
This module provides the list of the ingredients (substances with a role) used for this product; one or more ingredients may be present.
The classCode of "ACTI" indicates that this is an active ingredient.
(IPS...ial)
Treeblank.pngTreetree.png@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC)
Treeblank.pngTreetree.pngpharm:quantity
1 … 1MThe medication strength is represented as the ratio of the active ingredient(s) to a unit of medication. The <quantity> element contains the numerator and denominator of the strength ratio.</quantity> (IPS...ial)
 Example<quantity>...</quantity>
Treeblank.pngTreeblank.pngTreetree.pnghl7:numerator
PQ1 … 1R(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.30 Medicine Strength Numerator (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreetree.pnghl7:denominator
PQ1 … 1R(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.31 Medicine Strength Denominator (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreetree.pngpharm:ingredientSubstance
1 … 1R(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS (extensible)0 … 1CThe IDMP ISO 11238 standard addresses the identification and exchange of regulated information on substances. 
The Global Ingredient Archival System (GInAS)  will provide a common global identifier for all of the substances used in medicinal products, providing a definition of substances globally consistent with this standard.
Those identifiers however are yet available for concrete usage, therefore in this version of the template, SNOMED CT has been chosen as reference terminology also for the active substances.
This choice will be revised based on the availability and the maturity of GInAS.
(IPS...ial)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.32 IPS Medicine Active Substances (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED0 … *(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL0 … *(IPS...ial)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
CD0 … *This element can be used to provide alternative identifications for the described substance.(IPS...ial)
Treeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … 1CName of the substance(IPS...ial)
 Schematron assertrole error 
 testpharm:code or pharm:name 
 MessageEither the name or the code of the substance (or both) shall be provided 

IPS Medical Device

Id2.16.840.1.113883.10.22.4.26Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSMedicalDeviceDisplay NameIPS Medical Device
DescriptionThe medical devices entry content module describes the kind of device that is, or has been used by the patient
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.26
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 6 concepts
IdNameData Set
hl7ips-data​element-150Kyellow.png Use end date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-218Kyellow.png Device content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-57Kyellow.png Device Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-58Kyellow.png Device Type Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-59Kyellow.png Use start date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-60Kyellow.png Device Identifier Kyellow.png CEN/TC 251 prEN 17269
RelationshipAdaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.3.5 Medical Devices (2013‑12‑20)
ref
epsos-
Example
Example
<supply moodCode="EVN" classCode="SPLY">
  <templateId root="2.16.840.1.113883.10.22.4.26"/>  <id root="2.16.840.1.113883.19.811.3"/>  <text>
    <reference value="#dev_1"/>  </text>
  <effectiveTime xsi:type="IVL_TS">
    <low value="20070728"/>  </effectiveTime>
  <participant typeCode="DEV">
    <participantRole classCode="MANU">
      <id/>      <playingDevice classCode="DEV" determinerCode="INSTANCE">
        <code code="304184000" displayName="Ankle joint implant" codeSystem="2.16.840.1.113883.6.96"/>      </playingDevice>
    </participantRole>
  </participant>
</supply>
ItemDTCardConfDescriptionLabel
hl7:supply
RThe <supply> element shall be present. The moodCode attribute shall be EVN to reflect that a medical device has been provided.</supply>(IPS...ice)
Treetree.png@classCode
cs1 … 1FSPLY
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ice)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.26
Treetree.pnghl7:id
II0 … *RThis optional element identifies the provision of the device (e.g. implant procedure)(IPS...ice)
Treetree.pnghl7:text
ED0 … 1R(IPS...ice)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...ice)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R
This element provides the interval of time corresponding to the device usage by/presence in the patient.
(IPS...ice)
Treeblank.pngTreetree.png@xsi:type
st1 … 1FIVL_TS
Treeblank.pngTreetree.pnghl7:low
TS1 … 1RThe lower bound of the interval represents the start date/time.(IPS...ice)
 
Target.png
hl7ips-data​element-59Kyellow.png Use start date Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:high
TS0 … 1CThe upper bound represents the end date/time. If it is not present, the device is still used by or present in the patient.(IPS...ice)
 
Target.png
hl7ips-data​element-150Kyellow.png Use end date Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:participant
1 … *RThe device is represented as a participant in the supply structure. The following descriptions apply to the device structure.(IPS...ice)
 
Target.png
hl7ips-data​element-57Kyellow.png Device Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FDEV
 Example<participant typeCode="DEV">
  <participantRole classCode="MANU">
    <id root="1.2.3.999" extension="__example_only__"/>    <playingDevice classCode="DEV" determinerCode="INSTANCE">
      <code code="" codeSystem=""/>      <!-- ... -->
    </playingDevice>
  </participantRole>
</participant>
 Example
Presence of implanted device not known (situation)
<participant typeCode="DEV">
  <participantRole classCode="MANU">
    <playingDevice>
      <code code="000000" codeSystem="2.16.840.1.113883.6.96" displayName="Presence of implanted device not known (situation)"/>    </playingDevice>
    <scopingEntity>
      <id root="2.16.840.1.113883.3.3719"/>    </scopingEntity>
  </participantRole>
</participant>
 Example
No implant in situ (situation)
<participant typeCode="DEV">
  <participantRole classCode="MANU">
    <playingDevice>
      <code code="000000" codeSystem="2.16.840.1.113883.6.96" displayName="No implant in situ (situation)"/>    </playingDevice>
    <scopingEntity>
      <id root="2.16.840.1.113883.3.3719"/>    </scopingEntity>
  </participantRole>
</participant>
Treeblank.pngTreetree.pnghl7:participantRole
1 … 1R(IPS...ice)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMANU
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *R
The device ID, e.g. using UDI, is represented by the id element of the participant role. This element is optional, as not all production identifiers (e.g., serial number, lot/batch number, distinct identification number) may be known to the provider or patient.
(IPS...ice)
 
Target.png
hl7ips-data​element-60Kyellow.png Device Identifier Kyellow.png CEN/TC 251 prEN 17269
 Example
UDI GS1: DeviceIdentifier 00844588003288, Serial# 10987654d321, Lot# 7654321D
<id root="2.16.840.1.113883.3.3719" extension="{01}00844588003288{17}141120{10}7654321D{21}10987654d321"/>
 Example
UDI ICCBBA: DeviceIdentifier 00844588003288
<id root="2.16.840.1.113883.3.3719" extension="A9999XYZ100T0474"/>
 Example
UDI HIBCC: Serial# XYZ456789012345678, Lot# LOT123456789012345
<id root="2.16.840.1.113883.3.3719" extension="+H123PARTNO1234567890120/$$420020216LOT123456789012345/SXYZ456789012345678/16D20130202C"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:playingDevice
1 … 1RThe playingDevice element describes the device instance. (IPS...ice)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS (preferred)1 … 1RThe device code describes the type of device (e.g. arm prosthesis, arterial stent).(IPS...ice)
 
Target.png
hl7ips-data​element-218Kyellow.png Device content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-58Kyellow.png Device Type Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.23 IPS Medical Devices (DYNAMIC)
or
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.61 Absent or Unknown Devices (DYNAMIC)

IPS Medication Information (detail)

Id2.16.840.1.113883.10.22.4.2Effective Date2024‑08‑04 10:45:46
Other versions this id:
  • Kblank.png IPSManufacturedProduct as of 2016‑11‑10
StatusKyellow.png DraftVersion LabelSTU2
NameIPSManufacturedProductDisplay NameIPS Medication Information (detail)
DescriptionThis entry describes the consumable subject of the medication statement.
All the information about the  medication is provided in the included IPS Manufactured Material template.
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
hl7ips-data​element-2Kyellow.png Medicinal Product Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.4.3IncludeKyellow.png IPS Manufactured Material (STU2)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.2 IPS Medication Information (detail) (2016‑11‑10)
Adaptation: template 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (2005‑09‑07)
ref
ad1bbr-

Specialization: template 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
ref
pharmcda-
Example
Example
<manufacturedProduct classCode="MANU">
  <templateId root="2.16.840.1.113883.10.22.4.2"/>  <!-- include template 2.16.840.1.113883.10.22.4.3 'IPS Manufactured Material' (dynamic) 1..1 R -->
</manufacturedProduct>
ItemDTCardConfDescriptionLabel
hl7:manufacturedProduct
0 … *R(IPS...uct)
 
Target.png
hl7ips-data​element-2Kyellow.png Medicinal Product Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FMANU
Treetree.pnghl7:templateId
II1 … 1M(IPS...uct)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.2
Included1 … 1R from 2.16.840.1.113883.10.22.4.3 IPS Manufactured Material (DYNAMIC)
Treetree.pnghl7:manufactured​Material
1 … 1R(IPS...uct)
Treeblank.pngTreetree.png@classCode
cs0 … 1FMMAT
Treeblank.pngTreetree.png@determiner​Code
cs0 … 1FKIND
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...uct)
Treeblank.pngTreeblank.pngTreetree.png@root
oid1 … 1F2.16.840.1.113883.10.22.4.3
Choice0 … 1Elements to choose from:
  • hl7:code
  • hl7:code[@codeSystem='2.16.840.1.113883.6.96']
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS0 … 1RThis element is generally used to identify a medicinal product.
When the IDMP identifiers will be concretely available for usage this element will be used for conveying the Medicinal Product Identifier (MPID).
For the time being, it could be optionally used for conveying jurisdictional or agreed cross jurisdictional medicinal product code.
(IPS...uct)
 
Target.png
hl7ips-data​element-105Kyellow.png Product Code Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS0 … 1RNon IDMP codes from SNOMED CT value set(IPS...uct)
where [@codeSystem='2.16.840.1.113883.6.96']
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.71 IPS Medications Products (DYNAMIC)
Treeblank.pngTreetree.pnghl7:name
EN0 … 1R
This element is supposed to be valorized with the complete Medicinal Product Name as approved by the Medicines Regulatory Agency in a jurisdiction.
The name may be applicable in one or more country/language combinations.
(IPS...uct)
 
Target.png
hl7ips-data​element-117Kyellow.png Brand Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-171Kyellow.png Product Common Name (and Strength) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pngpharm:formCode
CE.IPS0 … 1R
Administrable Pharmaceutical Dose Form.
This code represents the form of the medication (e.g. tablet, capsule, liquid)
Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms;Pakages and Route of Administration.
It is known that also alternative jurisdictional and international terminologies are known to be used for this concept domain, as NCI or SNOMED CT.
(IPS...uct)
 
Target.png
hl7ips-data​element-227Kyellow.png Pharmaceutical dose form Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.25 IPS Medicine Doseform (DYNAMIC)
 Example<formCode code="10211000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Capsule, soft">...</formCode>
Treeblank.pngTreetree.pngpharm:asContent
0 … *
This structure describes the packaging of the medication.
The <pharm:formCode> element provides the code for the particular package.
If the package has a brand name, it can be described in the <pharm:name> element.
The <pharm:capacity​Quantity> element describes the capacity of the packaging, while the <pharm:quantity> the actual quantity of inner packaged items in the outer packaging container.
The product might have a single (30 pills bottle) or multiple (5 vials 10 ml; box with 2 blisters of 20 tablets) layers of packaging.
In the latter case, the most inner (nested) item represents the most outer package item.
For example the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
is described as "20 tablets" contained by "a blister"; "2 blisters" contained by one box.


The most inner package represents the Packaged Medicinal Product.

When the IDMP Packaged Medicinal Product ID (PCID) will become actually available for usage, the most inner package <code> element will be used to convey the IDMP PCID.
(IPS...uct)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
 Example
Packaged Medicinal Product with multiple layers packaging
<asContent>
  <containerPackagedProduct>
    <!-- Inner Package -->
    <code codeSystem="..." code="..." displayName="...">
      <asContent>
        <containerPackagedProduct>
          <!-- Intermediate Package -->
          <asContent>
            <containerPackagedProduct>
              <!-- Outer Package / Packaged Medicinal Product -->
            </containerPackagedProduct>
          </asContent>
        </containerPackagedProduct>
      </asContent>
    </code>
  </containerPackagedProduct>
</asContent>
 Example
Packaged Medicinal Product with formCode
<asContent>
  <containerPackagedProduct>
    <!-- Packaged Medicinal Product -->
    <code codeSystem="1.999.999" code="PC_ID" displayName="Packaged Product Name">
      <name>100 MIRACLE PILLS(TM)</name>      <formCode codeSystem="0.4.0.127.0.16.1.1.2.1" code="30009000" displayName="Box" CodeSystemName="EDQM"/>    </code>
  </containerPackagedProduct>
</asContent>
Treeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RIt represents the most inner Package Item or the Packaged Medicinal Product.(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
0 … 1
If this is also the most outer <pharm:containerPackagedProduct> than the <code> element can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).
 
The presence of the PCID indicates that that element represents the "Packaged Medicinal Product".
(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1
It represents the Name of the Package Item or of the Packaged Medicinal Product.
If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name.
(IPS...uct)
 Example<name>AMOXIFEN(R) 20 compresse 20 mg</name>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS0 … 1RThis element encodes the type of the most inner package item or of the or the Packaged Medicinal Product.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...uct)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
 Example<formCode code="30007000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" codeSystemVersion="2010" displayName="Blister">...</formCode>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *R
In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product.
For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the "2 blisters" 
In the case of 
  \--Box 
  \-----5 vials
it represents the Packaged Medicinal Product. 
(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1RThe quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RIt represents the intermediate Package Item or the Packaged Medicinal Product(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS0 … 1
If this is also the most inner  <pharm:containerPackagedProduct> than the <code> element can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).
 
The presence of the PCID indicates that that element represents the "Packaged Medicinal Product".
(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1R
It represents the Name of the Package Item or of the Packaged Medicinal Product
If this is also the most inner  <pharm:containerPackagedProduct> than this element can be used for the brand name.
(IPS...uct)
 Example<name>...</name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS1 … 1RThis element encodes the type of the most inner package item or of the or the Packaged Medicinal Product.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as reference terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...uct)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *R
In case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product.
For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the Packaged Medicinal Product. 
(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1RThe quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RWhen present, it represents the Packaged Medicinal Product(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS0 … 1When present, it can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1RWhen present, it can be used for the representing the brand name.(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS1 … 1RWhen present, it encodes the type of the outer package.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...uct)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreetree.pngpharm:asSpecializedKind
0 … 1R
This module is used for representing the classification of the Substance according to the WHO Anatomical Therapeutic Chemical (ATC) Classification System.
The classCode of "GRIC" identifies this structure as the representation of a generic equivalent of the medication described in the current Medicine entry.
(IPS...uct)
where [generalizedMaterialKind/code/@codeSystem='2.16.840.1.113883.6.73']
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FGRIC
 Example<asSpecializedKind classCode="GRIC">
  <generalizedMaterialKind classCode="MMAT">
    <!-- Pharmaceutical Substance (ATC Code)-->
    <code code=" " codeSystem="2.16.840.1.113883.6.73" displayName=" " codeSystemName="WHO ATC"/>  </generalizedMaterialKind>
</asSpecializedKind>
Treeblank.pngTreeblank.pngTreetree.pngpharm:generalizedMaterialKind
1 … 1M(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS1 … 1RThe <code> element contains the ATC code of this medicine.(IPS...uct)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.29 IPS WHO ATC (DYNAMIC)
 Example<code codeSystem="2.16.840.1.113883.6.73" code=" " displayName=" " codeSystemName="WHO ATC"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … *(IPS...uct)
Treeblank.pngTreetree.pngpharm:asSpecializedKind
0 … *RThe Medicinal Product can be classified according to various classification systems, which may be jurisdictional or international.
The classification system itself is specified using an appropriate identification system; the controlled term and the controlled term identifier shall be specified.

When the IDMP Pharmaceutical Product Identifier(s) (PhPID Set) will become actually available for use, the PhPID will be represented by the generalizedMaterialKind/code element.
(IPS...uct)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FGRIC
 Example<asSpecializedKind classCode="GRIC">
  <generalizedMaterialKind classCode="MMAT">
    <code code="PhPID_Lvl1" codeSystem="1.999.999" displayName="Pharmaceutical Product Name" codeSystemName="PhPID Level 1">
      <name/>    </code>
  </generalizedMaterialKind>
</asSpecializedKind>
Treeblank.pngTreeblank.pngTreetree.pngpharm:generalizedMaterialKind
R(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS1 … 1R
When the IDMP Pharmaceutical Product Identifier(s) (PhPID Set) will become actually available for use, this element will be used for representing the IDMP PhP Id.
The level and the stratum of the PhPID will be distiguished by the OID of the code system.
(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … *R(IPS...uct)
Treeblank.pngTreetree.pngpharm:ingredient
0 … *R
This module provides the list of the ingredients (substances with a role) used for this product; one or more ingredients may be present.
The classCode of "ACTI" indicates that this is an active ingredient.
(IPS...uct)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pngpharm:quantity
1 … 1MThe medication strength is represented as the ratio of the active ingredient(s) to a unit of medication. The <quantity> element contains the numerator and denominator of the strength ratio.</quantity> (IPS...uct)
 Example<quantity>...</quantity>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:numerator
PQ1 … 1R(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.30 Medicine Strength Numerator (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:denominator
PQ1 … 1R(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.31 Medicine Strength Denominator (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreetree.pngpharm:ingredientSubstance
1 … 1R(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS (extensible)0 … 1CThe IDMP ISO 11238 standard addresses the identification and exchange of regulated information on substances. 
The Global Ingredient Archival System (GInAS)  will provide a common global identifier for all of the substances used in medicinal products, providing a definition of substances globally consistent with this standard.
Those identifiers however are yet available for concrete usage, therefore in this version of the template, SNOMED CT has been chosen as reference terminology also for the active substances.
This choice will be revised based on the availability and the maturity of GInAS.
(IPS...uct)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.32 IPS Medicine Active Substances (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED0 … *(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL0 … *(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
CD0 … *This element can be used to provide alternative identifications for the described substance.(IPS...uct)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … 1CName of the substance(IPS...uct)
 Schematron assertrole error 
 testpharm:code or pharm:name 
 MessageEither the name or the code of the substance (or both) shall be provided 

IPS Medication Statement

Id2.16.840.1.113883.10.22.4.4Effective Date2024‑08‑04 10:41:54
Other versions this id:
  • Kblank.png IPSMedicationStatement as of 2021‑09‑02 12:17:54
  • Kblank.png IPSMedicationStatement as of 2016‑11‑11
StatusKyellow.png DraftVersion LabelSTU2
NameIPSMedicationStatementDisplay NameIPS Medication Statement
Description
An IPS Medication entry describes a medication statement, that is a substance administration that has actually occurred (e.g., pills ingested or injections given) or are intended to occur (e.g., "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. For example, a clinician may intend that a patient to be administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered was Lisinopril 10 mg., then the Medication activities in the "EVN" mood would reflect actual use.
The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. A common scenario where this information is captured is during the history taking process during a patient visit or stay, but it could be derived from the medications information recorded into a GP's EHR-system, in form of prescribed medication, or administration statements.
The medication information may come from sources such as the patient's memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains.
A medication statement is usually less specific than an a prescription or a medication administration record.  
This entry is composed by a main substanceAdministration act and a subordinate substanceAdministration act, unless it is asserted that there are no medications data. 
The first conveys information as the product, the period of administration and the route of administration; the latter is used to provide dosage information as the frequency of intakes or the amount of the medication given.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.4
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-102Kyellow.png Route of administration Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-104Kyellow.png Medication Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-220Kyellow.png Medication Summary content status Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.21.9.1IncludeKyellow.png UV Use Period (2023)DYNAMIC
2.16.840.1.113883.10.22.4.2IncludeKyellow.png IPS Medication Information (detail) (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.21.4.6ContainmentKyellow.png UV Subordinate Substance Administration (2023)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.4 IPS Medication Statement (2021‑09‑02 12:17:54)
Version: template 2.16.840.1.113883.10.22.4.4 IPS Medication Statement (2016‑11‑11)
Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.3.4 Medication Item (2013‑12‑20)
ref
epsos-

Specialization: template 2.16.840.1.113883.10.21.4.7 UV Medication Statement (DYNAMIC)
ref
pharmcda-
Example
Example
<substanceAdministration classCode="SBADM" moodCode="INT">
  <templateId root="2.16.840.1.113883.10.22.4.4"/>  <code code="DRUG" codeSystem="2.16.840.1.113883.5.4" displayName="Drug">
    <statusCode code="active"/>    <effectiveTime>
      <width value="2" unit="wk"/>    </effectiveTime>
    <consumable typeCode="CSM">
      <!-- template 'IPS ManufacturedProduct' (dynamic) -->
    </consumable>
    <entryRelationship typeCode="COMP">
      <substanceAdministration classCode="SBADM" moodCode="EVN">
        <statusCode code="active"/>        <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
          <period value="12" unit="h"/>        </effectiveTime>
        <doseQuantity value="2" unit="{puff}"/>        <consumable>
          <manufacturedProduct>
            <manufacturedMaterial nullFlavor="NA"/>          </manufacturedProduct>
        </consumable>
      </substanceAdministration>
    </entryRelationship>
  </code>
</substanceAdministration>
Example
No medication infos
<substanceAdministration classCode="SBADM" moodCode="INT">
  <templateId root="2.16.840.1.113883.10.22.4.4"/>  <code code="no-medication-info" codeSystem="2.16.840.1.113883.5.1150.1" displayName="No information about medications">
    <statusCode code="completed"/>    <effectiveTime nullFlavor="NA" xsi:type="IVL_TS"/>    <consumable>
      <manufacturedProduct>
        <manufacturedMaterial nullFlavor="NA"/>      </manufacturedProduct>
    </consumable>
  </code>
</substanceAdministration>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
R(IPS...ent)
 
Target.png
hl7ips-data​element-104Kyellow.png Medication Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1RIf the statement refers to a prescribed medication then a <substanceAdministration> intent (moodCode='INT') is used; otherwise, to record medications which are stated to have taken, the moodCode shall be set to 'EVN'.</substanceAdministration>
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
Treetree.pnghl7:templateId
II1 … 1M(IPS...ent)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.4
Treetree.pnghl7:id
II0 … *R(IPS...ent)
Treetree.pnghl7:code
CD.IPS1 … 1R
The <code> element is valorized with the Substance Administration ACT code "DRUG" unless it is used for asserting the  known absence of medication treatments or no information about them.
(IPS...ent)
 
Target.png
hl7ips-data​element-220Kyellow.png Medication Summary content status Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.14 DRUGActCode (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.79 IPS No Medications (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1R
The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication.
In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication.
(IPS...ent)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ent)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.12 ActStatusActiveCompletedAbortedSuspended (DYNAMIC)
 Example<statusCode code="active"/>
Included1 … 1R from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC)
Choice1 … 1
The effectiveTime element encodes the use period of the medication, it is always expressed as an interval of time.
It may be expressed using the low and high OR with the width element.
The first is used to indicate a specified interval (e.g. from march 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks).
Elements to choose from:
  • hl7:effectiveTime[hl7:low | hl7:high][not(hl7:width)]
  • hl7:effectiveTime[hl7:width][not(hl7:low|hl7:high)]
  • hl7:effectiveTime[hl7:low | hl7:width][not(hl7:high)]
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 1: specified interval


The low and high values of the first effectiveTime element represent the start and stop times for the medication. The low value represents the start time, and the high value represents the stop time. If either the low or the high value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK.

In case of unbounded period (continuous therapy) the high element will be valued with the nullFlavor attribute to NA.


The high value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later then the low value. The rationale is that a provider, seeing a prescription that has not been refilled would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely.
(IPS...ent)
where [hl7:low or
[not(hl7:width)]
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
 Example
Known Interval
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <high value="20140321"/></effectiveTime>
 Example
Information not available about the period
<effectiveTime type="IVL_TS" nullFlavor="NI"/>
 Example
Unknown end date
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>
 Example
continous therapy
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1R(IPS...ent)
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 2: 'floating' period:
The width element is used to specify a period of (actual or intended) administration that is not anchored to any specific date (e.g. a two weeks therapy)
(IPS...ent)
where [hl7:width] [not(hl7:lowor
hl7:high)]
 Example
2 week period
<effectiveTime type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
NP(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
NP(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:center
NP(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 3: anchored period:
The width element is used to specify a period of (actual or intended) administration anchored to a specific date (e.g. a two weeks therapy starting today)
(IPS...ent)
where [hl7:low or
[not(hl7:high)]
 Example
2 week period starting on 2013-03-21
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <width value="2" unit="w"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS0 … 1C(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treetree.pnghl7:routeCode
CE.IPS0 … 1R
The <routeCode> element specifies the route of administration using the EDQM route of administration vocabulary.
A code must be specified if the route is known. 
Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
It is known that also alternative jurisdictional and international terminologies are also used for this concept domain, as NCI or SNOMED CT.
Official NCI and EDQM maps for the route of administration are available from the EDQM site.
(IPS...ent)
 
Target.png
hl7ips-data​element-102Kyellow.png Route of administration Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.33 IPS Medicine Route of Administration (DYNAMIC)
Treetree.pnghl7:doseQuantity
IVL_PQNP(IPS...ent)
Treetree.pnghl7:rateQuantity
IVL_PQNP(IPS...ent)
Treetree.pnghl7:administrationUnitCode
CENP(IPS...ent)
Treetree.pnghl7:consumable
1 … 1M(IPS...ent)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Included from 2.16.840.1.113883.10.22.4.2 IPS Medication Information (detail) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:manufacturedProduct
0 … *R(IPS...ent)
 
Target.png
hl7ips-data​element-2Kyellow.png Medicinal Product Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FMANU
Treeblank.pngTreeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.2
Included1 … 1R from 2.16.840.1.113883.10.22.4.3 IPS Manufactured Material (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:manufactured​Material
1 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
oid1 … 1F2.16.840.1.113883.10.22.4.3
Choice0 … 1Elements to choose from:
  • hl7:code
  • hl7:code[@codeSystem='2.16.840.1.113883.6.96']
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS0 … 1RThis element is generally used to identify a medicinal product.
When the IDMP identifiers will be concretely available for usage this element will be used for conveying the Medicinal Product Identifier (MPID).
For the time being, it could be optionally used for conveying jurisdictional or agreed cross jurisdictional medicinal product code.
(IPS...ent)
 
Target.png
hl7ips-data​element-105Kyellow.png Product Code Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS0 … 1RNon IDMP codes from SNOMED CT value set(IPS...ent)
where [@codeSystem='2.16.840.1.113883.6.96']
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.71 IPS Medications Products (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
EN0 … 1R
This element is supposed to be valorized with the complete Medicinal Product Name as approved by the Medicines Regulatory Agency in a jurisdiction.
The name may be applicable in one or more country/language combinations.
(IPS...ent)
 
Target.png
hl7ips-data​element-117Kyellow.png Brand Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-171Kyellow.png Product Common Name (and Strength) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS0 … 1R
Administrable Pharmaceutical Dose Form.
This code represents the form of the medication (e.g. tablet, capsule, liquid)
Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms;Pakages and Route of Administration.
It is known that also alternative jurisdictional and international terminologies are known to be used for this concept domain, as NCI or SNOMED CT.
(IPS...ent)
 
Target.png
hl7ips-data​element-227Kyellow.png Pharmaceutical dose form Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.25 IPS Medicine Doseform (DYNAMIC)
 Example<formCode code="10211000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Capsule, soft">...</formCode>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *
This structure describes the packaging of the medication.
The <pharm:formCode> element provides the code for the particular package.
If the package has a brand name, it can be described in the <pharm:name> element.
The <pharm:capacity​Quantity> element describes the capacity of the packaging, while the <pharm:quantity> the actual quantity of inner packaged items in the outer packaging container.
The product might have a single (30 pills bottle) or multiple (5 vials 10 ml; box with 2 blisters of 20 tablets) layers of packaging.
In the latter case, the most inner (nested) item represents the most outer package item.
For example the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
is described as "20 tablets" contained by "a blister"; "2 blisters" contained by one box.


The most inner package represents the Packaged Medicinal Product.

When the IDMP Packaged Medicinal Product ID (PCID) will become actually available for usage, the most inner package <code> element will be used to convey the IDMP PCID.
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
 Example
Packaged Medicinal Product with multiple layers packaging
<asContent>
  <containerPackagedProduct>
    <!-- Inner Package -->
    <code codeSystem="..." code="..." displayName="...">
      <asContent>
        <containerPackagedProduct>
          <!-- Intermediate Package -->
          <asContent>
            <containerPackagedProduct>
              <!-- Outer Package / Packaged Medicinal Product -->
            </containerPackagedProduct>
          </asContent>
        </containerPackagedProduct>
      </asContent>
    </code>
  </containerPackagedProduct>
</asContent>
 Example
Packaged Medicinal Product with formCode
<asContent>
  <containerPackagedProduct>
    <!-- Packaged Medicinal Product -->
    <code codeSystem="1.999.999" code="PC_ID" displayName="Packaged Product Name">
      <name>100 MIRACLE PILLS(TM)</name>      <formCode codeSystem="0.4.0.127.0.16.1.1.2.1" code="30009000" displayName="Box" CodeSystemName="EDQM"/>    </code>
  </containerPackagedProduct>
</asContent>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RIt represents the most inner Package Item or the Packaged Medicinal Product.(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
0 … 1
If this is also the most outer <pharm:containerPackagedProduct> than the <code> element can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).
 
The presence of the PCID indicates that that element represents the "Packaged Medicinal Product".
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1
It represents the Name of the Package Item or of the Packaged Medicinal Product.
If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name.
(IPS...ent)
 Example<name>AMOXIFEN(R) 20 compresse 20 mg</name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS0 … 1RThis element encodes the type of the most inner package item or of the or the Packaged Medicinal Product.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...ent)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
 Example<formCode code="30007000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" codeSystemVersion="2010" displayName="Blister">...</formCode>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *R
In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product.
For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the "2 blisters" 
In the case of 
  \--Box 
  \-----5 vials
it represents the Packaged Medicinal Product. 
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1RThe quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RIt represents the intermediate Package Item or the Packaged Medicinal Product(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS0 … 1
If this is also the most inner  <pharm:containerPackagedProduct> than the <code> element can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).
 
The presence of the PCID indicates that that element represents the "Packaged Medicinal Product".
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1R
It represents the Name of the Package Item or of the Packaged Medicinal Product
If this is also the most inner  <pharm:containerPackagedProduct> than this element can be used for the brand name.
(IPS...ent)
 Example<name>...</name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS1 … 1RThis element encodes the type of the most inner package item or of the or the Packaged Medicinal Product.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as reference terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...ent)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *R
In case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product.
For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the Packaged Medicinal Product. 
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1RThe quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Example<quantity value="20" unit="{tablet}"/>
 Example<quantity value="10" unit="mL"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … 1RWhen present, it represents the Packaged Medicinal Product(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS0 … 1When present, it can be used to convey the (IDMP) Packaged Medicinal Product ID (e.g. the IDMP PCID when it will become actually available for usage).(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1RWhen present, it can be used for the representing the brand name.(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE.IPS1 … 1RWhen present, it encodes the type of the outer package.

Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
(IPS...ent)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.27 Medicine Package (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asSpecializedKind
0 … 1R
This module is used for representing the classification of the Substance according to the WHO Anatomical Therapeutic Chemical (ATC) Classification System.
The classCode of "GRIC" identifies this structure as the representation of a generic equivalent of the medication described in the current Medicine entry.
(IPS...ent)
where [generalizedMaterialKind/code/@codeSystem='2.16.840.1.113883.6.73']
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FGRIC
 Example<asSpecializedKind classCode="GRIC">
  <generalizedMaterialKind classCode="MMAT">
    <!-- Pharmaceutical Substance (ATC Code)-->
    <code code=" " codeSystem="2.16.840.1.113883.6.73" displayName=" " codeSystemName="WHO ATC"/>  </generalizedMaterialKind>
</asSpecializedKind>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:generalizedMaterialKind
1 … 1M(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS1 … 1RThe <code> element contains the ATC code of this medicine.(IPS...ent)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.29 IPS WHO ATC (DYNAMIC)
 Example<code codeSystem="2.16.840.1.113883.6.73" code=" " displayName=" " codeSystemName="WHO ATC"/>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … *(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asSpecializedKind
0 … *RThe Medicinal Product can be classified according to various classification systems, which may be jurisdictional or international.
The classification system itself is specified using an appropriate identification system; the controlled term and the controlled term identifier shall be specified.

When the IDMP Pharmaceutical Product Identifier(s) (PhPID Set) will become actually available for use, the PhPID will be represented by the generalizedMaterialKind/code element.
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FGRIC
 Example<asSpecializedKind classCode="GRIC">
  <generalizedMaterialKind classCode="MMAT">
    <code code="PhPID_Lvl1" codeSystem="1.999.999" displayName="Pharmaceutical Product Name" codeSystemName="PhPID Level 1">
      <name/>    </code>
  </generalizedMaterialKind>
</asSpecializedKind>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:generalizedMaterialKind
R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS1 … 1R
When the IDMP Pharmaceutical Product Identifier(s) (PhPID Set) will become actually available for use, this element will be used for representing the IDMP PhP Id.
The level and the stratum of the PhPID will be distiguished by the OID of the code system.
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … *R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:ingredient
0 … *R
This module provides the list of the ingredients (substances with a role) used for this product; one or more ingredients may be present.
The classCode of "ACTI" indicates that this is an active ingredient.
(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
1 … 1MThe medication strength is represented as the ratio of the active ingredient(s) to a unit of medication. The <quantity> element contains the numerator and denominator of the strength ratio.</quantity> (IPS...ent)
 Example<quantity>...</quantity>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:numerator
PQ1 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.30 Medicine Strength Numerator (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:denominator
PQ1 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.31 Medicine Strength Denominator (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:ingredientSubstance
1 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD.IPS (extensible)0 … 1CThe IDMP ISO 11238 standard addresses the identification and exchange of regulated information on substances. 
The Global Ingredient Archival System (GInAS)  will provide a common global identifier for all of the substances used in medicinal products, providing a definition of substances globally consistent with this standard.
Those identifiers however are yet available for concrete usage, therefore in this version of the template, SNOMED CT has been chosen as reference terminology also for the active substances.
This choice will be revised based on the availability and the maturity of GInAS.
(IPS...ent)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.32 IPS Medicine Active Substances (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED0 … *(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL0 … *(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
CD0 … *This element can be used to provide alternative identifications for the described substance.(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … 1CName of the substance(IPS...ent)
 Schematron assertrole error 
 testpharm:code or pharm:name 
 MessageEither the name or the code of the substance (or both) shall be provided 
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ent)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ent)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ent)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ent)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ent)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ent)
Treetree.pnghl7:entryRelationship
0 … *C
Subordinate Substance Administration Statement as a component of the overall medication statement.
Unless medications are unknown or known absent, at least one subordinated <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..).
Subordinated <substanceAdministration> elements can be also used either to handle split dosing, or to support combination medications.

Contains 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC)
(IPS...ent)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintAt least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent. </substanceAdministration>
 Example<hl7:entryRelationship typeCode="COMP">
  <!-- component: Subordinate Substance Administration Statement. -->
  <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
    <hl7:templateId root="2.16.840.1.113883.10.22.4.33"/>    <!-- .. -->
  </hl7:substanceAdministration>
  <hl7:sequenceNumber value="1"/></hl7:entryRelationship>
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1Sequence number of the Subordinate Substance Administration(IPS...ent)

IPS ObservationMedia

Id2.16.840.1.113883.10.22.4.23Effective Date2021‑09‑02 12:02:16
Other versions this id:
  • Kblank.png IPSObservationMedia as of 2017‑04‑06
StatusKyellow.png DraftVersion Label2021
NameIPSObservationMediaDisplay NameIPS ObservationMedia
Description
Template CDA ObservationMedia for IPS (prototype, directly derived from POCD_RM000040 MIF)
This element is intended to carry a small multimedia content, like an image or a graph to be rendered in the body of the patient summary document.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.23
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.12.323ContainmentKgreen.png CDA Performer (Body)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.4.23 IPS ObservationMedia (2017‑04‑06)
Adaptation: template 2.16.840.1.113883.10.12.304 CDA ObservationMedia (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observationMedia ID="Unique_String" moodCode="EVN" classCode="OBS">
  <!-- The rendering of the multimedia object in the body of the CDA document is triggered by a <renderMultiMedia referencedObject="Unique_String"/>
in the narrative of the <section> -->
  <templateId root="2.16.840.1.113883.10.22.4.23"/>  <value mediaType="image/png" representation="B64">content encoded in Base 64</value>  <performer>
    <!-- template 2.16.840.1.113883.10.12.323 'CDA Performer (Body)' (dynamic) -->
  </performer>
  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) -->
  </author>
</observationMedia>
ItemDTCardConfDescriptionLabel
hl7:observationMedia
This element must have an ID attribute  to be referenced from a <renderMultimedia> element in the narrative of the section</renderMultimedia>(IPS...dia)
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...dia)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.23
Treetree.pnghl7:language​Code
CS0 … 1(IPS...dia)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)
Treetree.pnghl7:value
ED1 … 1M(IPS...dia)
Treeblank.pngTreetree.png@representation
cs1 … 1R
Treeblank.pngTreetree.png@mediaType
cs1 … 1R
Treetree.pnghl7:performer
0 … 1Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC)(IPS...dia)
Treetree.pnghl7:author
0 … *Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)(IPS...dia)

IPS Pathology Result Observation

Id2.16.840.1.113883.10.22.4.11Effective Date2024‑08‑04 11:10:42
Other versions this id:
  • Kblank.png IPSPathologyResultObservation as of 2017‑03‑21
StatusKyellow.png DraftVersion LabelSTU2
NameIPSPathologyResultObservationDisplay NameIPS Pathology Result Observation
Description
This template constrains the results of an  anatomic pathology observation. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be repnresented as “active” ActStatus.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.11
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.22ContainmentKorange.png IPS Comment Activity (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.11 IPS Pathology Result Observation (2017‑03‑21)
Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.22.4.10 IPS Result Observation (2017‑03‑02)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.11"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="44638-5" codeSystem="2.16.840.1.113883.6.1" displayName="Histologic type in Breast tumor by CAP cancer protocols">
    <statusCode code="completed"/>    <effectiveTime>
      <low value="20171210085407"/>    </effectiveTime>
    <value xsi:type="CD" code="399935008" displayName="Ductal carcinoma in situ - category (morphologic abnormality)" codeSystem="2.16.840.1.113883.6.96"/>    <methodCode code="104157003" displayName="Light microscopy" codeSystem="2.16.840.1.113883.6.96"/>  </code>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.11
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CD.IPS1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.75 IPS Results Laboratory/Pathology Observation (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...ion)
Choice1 … 1Elements to choose from:
  • hl7:value[@xsi:type='CE.IPS']
  • hl7:value[@xsi:type='PQ']
  • hl7:value[@xsi:type='IVL_PQ']
  • hl7:value[@xsi:type='ST']
  • hl7:value[@xsi:type='TS']
  • hl7:value[@xsi:type='RTO_QTY_QTY']
Treeblank.pngTreetree.pnghl7:value
CE.IPS (extensible)0 … 1R(IPS...ion)
where [@xsi:type='CE.IPS']
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.74 IPS Results Coded Values Laboratory/Pathology (DYNAMIC)
 Example
Result code: code '201' from code system 2.16.840.1.113883.2.4.4.30.1045
<value xsi:type="CE" code="399935008" displayName="Ductal carcinoma in situ - category (morphologic abnormality)" codeSystem="2.16.840.1.113883.6.96"/>
 Example
Result code: code 'POS' from code system 2.16.840.1.113883.5.83
<value xsi:type="CE" code="369790002" displayName="Nottingham Combined Grade I: 3-5 points (finding)" codeSystem="2.16.840.1.113883.6.96"/>
Treeblank.pngTreetree.pnghl7:value
PQ0 … 1R(IPS...ion)
where [@xsi:type='PQ']
 ConstraintIf Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC
 Example
Result physical quantity (data type PQ): 136 mmol per liter
<value xsi:type="PQ" value="85" unit="%"/>
Treeblank.pngTreetree.pnghl7:value
IVL_PQ0 … 1R(IPS...ion)
where [@xsi:type='IVL_PQ']
 Example
Result interval of physical quantities (data type IVL_PQ): 150 - 400 Billion per 10 exp 9 liter
<value xsi:type="IVL_PQ">
  <low value="150" unit="10+9/l"/>  <high value="400" unit="10+9/l"/></value>
Treeblank.pngTreetree.pnghl7:value
ST0 … 1R(IPS...ion)
where [@xsi:type='ST']
 Example
Result free text (data type ST)
<value xsi:type="ST">This is a result as a free text</value>
Treeblank.pngTreetree.pnghl7:value
TS0 … 1R(IPS...ion)
where [@xsi:type='TS']
 Example
Result time stamp (data type TS): 6-Aug-2014
<value xsi:type="TS" value="20140806"/>
Treeblank.pngTreetree.pnghl7:value
RTO_QTY_QTY0 … 1R(IPS...ion)
where [@xsi:type='RTO_QTY_QTY']
 Example
Result ratio (data type RTO_QTY_QTY): 1/179
<value xsi:type="RTO_QTY_QTY">
  <numerator xsi:type="INT" value="1"/>  <denominator xsi:type="INT" value="179"/></value>
Treetree.pnghl7:interpretationCode
CE.IPS0 … 1R(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Included0 … *R from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *R(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:referenceRange
0 … *R(IPS...ion)
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CDNP(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.83 (Observation Interpretation)
Treetree.pnghl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP

IPS Pregnancy Expected Delivery Date Observation

Id2.16.840.1.113883.10.22.4.29Effective Date2024‑08‑04 11:02:42
Other versions this id:
  • Kblank.png IPSPregnancyExpectedDeliveryDateObservation as of 2017‑04‑13
StatusKyellow.png DraftVersion LabelSTU2
NameIPSPregnancyExpectedDeliveryDateObservation Display NameIPS Pregnancy Expected Delivery Date Observation
Description

This observation records the Pregnancy Expected Delivery Date for pregnant patients, expressed as a time stamp.
The code reflects the method (operationalisation) of how the date was determined, e.g. clinically estimated, estimated from last menstruation date or last ovulation date.

ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.29
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
hl7ips-data​element-213Kyellow.png Expected delivery date Kyellow.png CEN/TC 251 prEN 17269
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.29 IPS Pregnancy Expected Delivery Date Observation (2017‑04‑13)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Pregnancy Observation (2013‑12‑20)
ref
epsos-

Adaptation: template 2.16.840.1.113883.10.20.1.33 Social history observation (DYNAMIC)
ref
ccd1-
Example
Example
<observation typeCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.29"/>  <code code="11778-8" codeSystem="2.16.840.1.113883.6.1" displayName="Delivery date estimated (clinical)" codeSystemName="LOINC">
    <text>
      <reference value="#xxx"/>    </text>
    <statusCode code="completed"/>    <effectiveTime value="20160819"/>    <value xsi:type="TS" value="20170414"/>  </code>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(IPSPregnancyExpectedDeliveryDateObservation )
Treetree.pnghl7:templateId
II1 … 1M(IPSPregnancyExpectedDeliveryDateObservation )
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.29
Treetree.pnghl7:code
CD.IPS1 … 1M(IPSPregnancyExpectedDeliveryDateObservation )
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.72 IPS Pregnancy Expected Delivery Date Method (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1R(IPSPregnancyExpectedDeliveryDateObservation )
Treeblank.pngTreetree.png@code
CONF0 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1R
The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago.
(IPSPregnancyExpectedDeliveryDateObservation )
Treetree.pnghl7:value
TS1 … 1R(IPSPregnancyExpectedDeliveryDateObservation )
 
Target.png
hl7ips-data​element-213Kyellow.png Expected delivery date Kyellow.png CEN/TC 251 prEN 17269

IPS Pregnancy Outcome Observation

Id2.16.840.1.113883.10.22.4.28Effective Date2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSPregnancyOutcomeObservationDisplay NameIPS Pregnancy Outcome Observation
Description

A pregnancy outcome observation records a summary over all pregnancies.

ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.28
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
hl7ips-data​element-214Kyellow.png Summary Metric Kyellow.png CEN/TC 251 prEN 17269
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Pregnancy Observation (2013‑12‑20)
ref
epsos-

Adaptation: template 2.16.840.1.113883.10.20.1.33 Social history observation (DYNAMIC)
ref
ccd1-
Example
Example
<observation>
  <templateId root="2.16.840.1.113883.10.22.4.28"/>  <code code="11636-8" displayName="[#] Births.live" codeSystem="2.16.840.1.113883.6.1"/>  <statusCode code="completed"/>  <value value="1"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(IPS...ion)
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.28
Treetree.pnghl7:code
CD.IPS1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.21 IPS Pregnancies Summary (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1R(IPS...ion)
Treeblank.pngTreetree.png@code
CONF0 … 1Fcompleted
Treetree.pnghl7:value
INT1 … 1R(IPS...ion)
 
Target.png
hl7ips-data​element-214Kyellow.png Summary Metric Kyellow.png CEN/TC 251 prEN 17269

IPS Pregnancy Status Observation

Id2.16.840.1.113883.10.22.4.27Effective Date2020‑07‑14 16:31:53
Other versions this id:
  • Kblank.png IPSPregnancyStatusObservation as of 2020‑07‑14 16:31:28
  • Kblank.png IPSPregnancyStatusObservation as of 2020‑05‑07 19:22:01
  • Kblank.png IPSPregnancyStatusObservation as of 2017‑04‑13
StatusKyellow.png DraftVersion Label2021
NameIPSPregnancyStatusObservationDisplay NameIPS Pregnancy Status Observation
DescriptionA pregnancy status observation records whether the patient is currently pregnant or not.
If pregnant, an Expected Delivery Date may be specified as an subordinate observation.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.27
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-211Kyellow.png Date of Observation Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-212Kyellow.png Pregnancy State Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-213Kyellow.png Expected delivery date Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.4.29ContainmentKyellow.png IPS Pregnancy Expected Delivery Date Observation (STU2)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.4.27 IPS Pregnancy Status Observation (2020‑05‑07 19:22:01)
Version: template 2.16.840.1.113883.10.22.4.27 IPS Pregnancy Status Observation (2017‑04‑13)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Pregnancy Observation (2013‑12‑20)
ref
epsos-

Adaptation: template 2.16.840.1.113883.10.20.1.33 Social history observation (DYNAMIC)
ref
ccd1-
Example
Example
<observation>
  <templateId root="2.16.840.1.113883.10.22.4.27"/>  <code code="82810-3" codeSystem="2.16.840.1.113883.6.1"/>  <statusCode code="completed"/>  <value value="false"/>  <entryRelationship typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.22.4.29 'IPS Pregnancy Expected Delivery Date Observation' (dynamic) -->
  </entryRelationship>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(IPS...ion)
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.27
Treetree.pnghl7:code
CD.IPS (extensible)1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F82810-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:statusCode
CS1 … 1R(IPS...ion)
Treeblank.pngTreetree.png@code
CONF0 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R
The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago.
(IPS...ion)
 
Target.png
hl7ips-data​element-211Kyellow.png Date of Observation Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:value
CE.IPS (required)1 … 1R(IPS...ion)
 
Target.png
hl7ips-data​element-212Kyellow.png Pregnancy State Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.68 IPS Pregnancy Status (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 … 1RContains 2.16.840.1.113883.10.22.4.29 IPS Pregnancy Expected Delivery Date Observation (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-213Kyellow.png Expected delivery date Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP

IPS Problem Concern Entry

Id2.16.840.1.113883.10.22.4.7Effective Date2021‑08‑04 08:49:27
Other versions this id:
  • Kblank.png IPSProblemConcernEntry as of 2017‑02‑15
StatusKyellow.png DraftVersion Label2021
NameIPSProblemConcernEntryDisplay NameIPS Problem Concern Entry
Description

This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list. 
The purpose of the concern act is that of supporting the tracking of a problem or a condition.

There are different kinds of status that could be related to a condition:

  • The status of the concern (active, inactive,..) 
  • The status of the condition (e.g. active, inactive, resolved,..) 
  • The confirmation status [clinical workflow status, certainty] (e.g. confirmed, likely, unlikely,…) 
Not all of them can be represented in a CDA using the statusCode elements of the concern (ACT) and observation (condition). 

So long as the underlying conditions are of concern to the provider (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”.
Only when the underlying conditions are no longer of concern is the statusCode set to “completed”. 

The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, the clinician may remain concerned about a prior heart attack).
The effectiveTime/low of the Problem Concern Act asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. 
The effectiveTime/high asserts when the concern become inactive, and it is present if the statusCode of the concern act is "completed".

A Problem Concern Act can contain many Problem Observations.

The many Problem Observations nested under a Problem Concern Act reflect the change in the clinical understanding of a condition over time. For instance, a Concern may initially contain a Problem Observation of “chest pain”:

- Problem Concern 1

--- Problem Observation: Chest Pain

Later, a new Problem Observation of “esophagitis” will be added, reflecting a better understanding of the nature of the chest pain. The later problem observation will have a more recent author time stamp.

- Problem Concern 1

--- Problem Observation (author/time Jan 3, 2012): Chest Pain

--- Problem Observation (author/time Jan 6, 2012): Esophagitis

Many systems display the nested Problem Observation with the most recent author time stamp, and provide a mechanism for viewing prior observations.

ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.7
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.4.8ContainmentKyellow.png IPS Problem Entry (2021)DYNAMIC
RelationshipVersion: template 2.16.840.1.113883.10.22.4.7 IPS Problem Concern Entry (2017‑02‑15)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5.1 IHE Concern Entry (DYNAMIC)
ref
IHE-PCC-

Adaptation: template 2.16.840.1.113883.10.20.1.27 Problem act (DYNAMIC)
ref
ccd1-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 eHDSI Problem Concern (DYNAMIC)
ref
epsos-
Example
Active Concern with several conditions
<act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.7"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>  <statusCode code="active"/>  <effectiveTime>
    <low value="20170309"/>  </effectiveTime>
  <entryRelationship typeCode="SUBJ" inversionInd="false">
    <!-- template 2.16.840.1.113883.10.22.4.8 'IPS Problem Entry' (dynamic) -->
    <!-- A condition could be active, inactive,.... -->
  </entryRelationship>
  <entryRelationship typeCode="SUBJ" inversionInd="false">
    <!-- template 2.16.840.1.113883.10.22.4.8 'IPS Problem Entry' (dynamic) -->
  </entryRelationship>
</act>
Example
Concern no longer tracked
<act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.7"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20161210"/>    <low value="20170309"/>  </effectiveTime>
  <entryRelationship typeCode="SUBJ" inversionInd="false">
    <!-- template 2.16.840.1.113883.10.22.4.8 'IPS Problem Entry' (dynamic) -->
  </entryRelationship>
</act>
ItemDTCardConfDescriptionLabel
hl7:act
R(IPS...try)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...try)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.7
Treetree.pnghl7:id
II0 … *R(IPS...try)
Treetree.pnghl7:code
CD1 … 1M(IPS...try)
Treeblank.pngTreetree.png@code
1 … 1FCONC
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.5.6
Treetree.pnghl7:statusCode
CS1 … 1RSo long as the underlying conditions are of concern to the provider (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”. 

Only when the underlying conditions are no longer of concern is the statusCode set to “completed”.
(IPS...try)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1M(IPS...try)
Treeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RThis element asserts when the concern became active. This equates to the time the concern was authored in the patient's chart and the author started tracking this concern.(IPS...try)
Treeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1CThis element asserts when the clinician deemed there is no longer any need to track the underlying conditions.(IPS...try)
 ConstraintIf the statusCode is completed this element is required
Treetree.pnghl7:entryRelationship
1 … *RContains 2.16.840.1.113883.10.22.4.8 IPS Problem Entry (DYNAMIC)(IPS...try)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl0 … 1Ffalse

IPS Problem Entry

Id2.16.840.1.113883.10.22.4.8Effective Date2024‑08‑04 11:06:03
Other versions this id:
  • Kblank.png IPSProblemEntry as of 2021‑08‑04 08:52:52
  • Kblank.png IPSProblemEntry as of 2017‑02‑15
StatusKyellow.png DraftVersion Label2021
NameIPSProblemEntryDisplay NameIPS Problem Entry
Description

This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago.

The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".

ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.8
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 12 concepts
IdNameData Set
hl7ips-data​element-101Kyellow.png Problem type Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-115Kyellow.png Problem content status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-127Kyellow.png Onset date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-128Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-131Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-136Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-140Kyellow.png Problem Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-209Kyellow.png Health condition / Problem Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-210Kyellow.png Problem Type Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-32Kyellow.png Onset Date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-34Kyellow.png Date resolved Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-36Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 3 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.25ContainmentKorange.png IPS Severity Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.19ContainmentKyellow.png IPS Certainty Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.20ContainmentKorange.png IPS Problem Status Observation (STU1)2017‑03‑29
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.8 IPS Problem Entry (2021‑08‑04 08:52:52)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
ch-pcc-
Example
Active Problem
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
    <text>
      <reference value="#problem-1"/>    </text>
    <statusCode code="completed"/>    <effectiveTime>
      <low value="20100507"/>    </effectiveTime>
    <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity Observation' (dynamic) -->
    </entryRelationship>
    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
    </entryRelationship>
    <entryRelationship typeCode="REFR" inversionInd="false">
      <!-- template 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->
      <!-- this referred observation should report that the condition is still active -->
    </entryRelationship>
  </code>
</observation>
Example
Closed Problem (resolution date known)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
    <statusCode code="completed"/>    <effectiveTime>
      <low value="2010"/>      <high value="2015"/>    </effectiveTime>
    <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity Observation' (dynamic) -->
    </entryRelationship>
    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
    </entryRelationship>
    <entryRelationship typeCode="REFR" inversionInd="false">
      <!-- template 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->
      <!-- this referred observation should report that the condition is resolved -->
    </entryRelationship>
  </code>
</observation>
Example
Known absent problems
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
    <statusCode code="completed"/>    <effectiveTime>
      <low nullFlavor="NI"/>    </effectiveTime>
    <value code="no-known-problems" displayName="No known problems" codeSystem="2.16.840.1.113883.5.1150.1"/>  </code>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(IPS...try)
 
Target.png
hl7ips-data​element-140Kyellow.png Problem Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-209Kyellow.png Health condition / Problem Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...try)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.8
Treetree.pnghl7:id
II0 … *R(IPS...try)
Treetree.pnghl7:code
CD.IPS1 … 1RThis element describes the type of condition this observation is referring to.(IPS...try)
 
Target.png
hl7ips-data​element-101Kyellow.png Problem type Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-210Kyellow.png Problem Type Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.16 IPS Problem Type (DYNAMIC)
 Example<code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>
Treetree.pnghl7:text
ED0 … 1RThe <text> element if present points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.</reference>

</text>

(IPS...try)
 Example<text>
  <reference value="#problem-1"/></text>
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...try)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RWhen used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS1 … 1MA clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.</statusCode> (IPS...try)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1M
The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago.
The <low> and <high> values should be no more precise than known, but as precise as possible.
(IPS...try)
 Example
Known onset date (active condition)
<effectiveTime>
  <low value="20100507"/></effectiveTime>
 Example
Unknown onset date (active condition)
<effectiveTime>
  <low nullFlavor="UNK"/></effectiveTime>
 Example
Unknown resolution date
<effectiveTime>
  <low value="2010"/>  <high nullFlavor="UNK"/></effectiveTime>
 Example
Known resolution date
<effectiveTime>
  <low value="201007"/>  <high value="201703"/></effectiveTime>
Treeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.(IPS...try)
 
Target.png
hl7ips-data​element-127Kyellow.png Onset date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-32Kyellow.png Onset Date Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1CThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition e became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
(IPS...try)
 
Target.png
hl7ips-data​element-34Kyellow.png Date resolved Kyellow.png CEN/TC 251 prEN 17269
 Constraint If this condition is known to be resolved, then the effectiveTime/high would be present.
Treetree.pnghl7:value
CD.IPS (preferred)1 … 1MThe <value> is the condition that was found.
It may a coded or an un-coded string, but its type is always coded.
The coded form shall be used also to indicate known absent conditions or the nonavailability of information about them.
(IPS...try)
 
Target.png
hl7ips-data​element-115Kyellow.png Problem content status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-131Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-36Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@xsi:type
0 … 1FCD
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.73 IPS Problems (DYNAMIC)
 Example
Multiple Coding
<value code="302231008" displayName="Salmonella infection" codeSystem="2.16.840.1.113883.6.96">
  <translate code="A02.9" displayName="Infezioni da Salmonella non specificate" codeSystem="2.16.840.1.113883.6.3"/></value>
 Example
Local code not mappable in the reference terminology
<value nullFlavor="OTH">
  <translate code="12345" displayName="Not in the reference value set" codeSystem="1.2.3.999" codeSystemName="--example only--"/></value>
 Example
Textual Information
<value nullFlavor="NI">
  <originalText>
    <reference value="#value_as_text"/>  </originalText>
</value>
 Example
Known absent problems
<value code="160245001" displayName="No current problems or disability" codeSystem="2.16.840.1.113883.6.96"/>
Treeblank.pngTreetree.pnghl7:originalText
EDR

The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus any dates, comments, et cetera). The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

(IPS...try)
Treeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL0 … 1R The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains

the complete text describing the medication. </reference> </reference>

(IPS...try)
 Example<reference value="#value_as_text"/>
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … *(IPS...try)
Treeblank.pngTreetree.pnghl7:translation
CD.IPS0 … *The translation element may be used to transmit a set of other concept descriptors, using for example ICD-10 or other international or jurisdictional code systems.(IPS...try)
Treetree.pnghl7:entryRelationship
0 … 1RSeverity
The contained entry describes a subjective assessment of the severity of the condition as evaluated by the clinician.
Contains 2.16.840.1.113883.10.22.4.25 IPS Severity Observation (DYNAMIC)
(IPS...try)
 
Target.png
hl7ips-data​element-128Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-136Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1R Certainty or Verification Status 
The contained entry describes the certainty associated with a condition.
Contains 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation (DYNAMIC)
(IPS...try)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RStatus of the Problem   
The contained entry describes the current status of the condition, for example, whether it is active, in remission, resolved, and so on ...
Contains 2.16.840.1.113883.10.22.4.20 IPS Problem Status Observation (2017‑03‑29)
(IPS...try)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@inversionInd
bl0 … 1Ffalse

IPS Problem Status Observation

Id2.16.840.1.113883.10.22.4.20Effective Date2021‑09‑02 11:41:28
Other versions this id:
  • Kblank.png IPSProblemStatusObservation as of 2017‑03‑29
StatusKyellow.png DraftVersion Label2021
NameIPSProblemStatusObservationDisplay NameIPS Problem Status Observation
DescriptionThis subordinated observation used by the problem observation records information about the current status of a condition, for example, whether it is active, in remission, resolved, et cetera.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.20
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipVersion: template 2.16.840.1.113883.10.22.4.20 IPS Problem Status Observation (2017‑03‑29)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 IHE Problem Status Observation (2013‑12‑20)
ref
IHE-PCC-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.20"/>  <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>  <text>
    <reference value="#example"/>  </text>
  <statusCode code="completed"/>  <value code="active" displayName="Active" codeSystem="2.16.840.1.113883.4.642.3.155"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.20
Treetree.pnghl7:code
CD.IPS1 … 1R

This observation is of clinical status, as indicated by the <code> element. This element must be present.

(IPS...ion)
Treeblank.pngTreetree.png@code
CONF0 … 1F33999-4
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:text
ED0 … 1R

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

(IPS...ion)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS1 … 1M

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:value
CE.IPS1 … 1RThe value element contains the clinical status.(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.4.642.3.164 Condition Clinical Status Codes (DYNAMIC)

IPS Procedure Entry

Id2.16.840.1.113883.10.22.4.17Effective Date2024‑08‑04 11:08:35
Other versions this id:
  • Kblank.png IPSProcedureEntry as of 2020‑07‑14 16:35:58
  • Kblank.png IPSProcedureEntry as of 2017‑03‑27
StatusKyellow.png DraftVersion LabelSTU2
NameIPSProcedureEntryDisplay NameIPS Procedure Entry
DescriptionThe procedure entry is used to record procedures that have occurred, or which are planned for in the future.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.17
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 5 concepts
IdNameData Set
hl7ips-data​element-216Kyellow.png Body site Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-44Kyellow.png Procedures Content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-47Kyellow.png Procedure Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-48Kyellow.png Procedure date Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-49Kyellow.png Procedure code Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.4.31ContainmentKorange.png IPS Internal Reference (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.17 IPS Procedure Entry (2020‑07‑14 16:35:58)
Version: template 2.16.840.1.113883.10.22.4.17 IPS Procedure Entry (2017‑03‑27)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.19 IHE Procedure Entry (2016‑09‑28 10:37:28)
ref
IHE-PCC-

Adaptation: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
ref
ad1bbr-
Example
Example
<hl7:procedure classCode="PROC" moodCode="EVN">
  <hl7:templateId root="2.16.840.1.113883.10.22.4.17"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code/>  <hl7:text>
    <hl7:reference value="value"/>  </hl7:text>
  <hl7:statusCode code="completed"/>  <hl7:effectiveTime>
    <hl7:low value="20200714163551"/>  </hl7:effectiveTime>
  <hl7:targetSiteCode/>  <hl7:entryRelationship typeCode="COMP" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.31 'IPS Internal Reference' (2017-05-02T00:00:00) -->
  </hl7:entryRelationship>
</hl7:procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
(IPS...try)
 
Target.png
hl7ips-data​element-47Kyellow.png Procedure Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1R
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
Treetree.pnghl7:templateId
II1 … 1M(IPS...try)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.17
Treetree.pnghl7:id
II0 … *R(IPS...try)
Treetree.pnghl7:code
CD.IPS (preferred)1 … 1R(IPS...try)
 
Target.png
hl7ips-data​element-44Kyellow.png Procedures Content Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-49Kyellow.png Procedure code Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.35 IPS Procedures (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1RThe <text> element if present points to the text describing the data being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the element (problem, procedure,...) in the document that is being described.</reference>

</text>

(IPS...try)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...try)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1R When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...try)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.22 ActStatusActiveCompletedAbortedCancelled (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...try)
 
Target.png
hl7ips-data​element-48Kyellow.png Procedure date Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:target​Site​Code
CD.IPS (preferred)0 … *(IPS...try)
 
Target.png
hl7ips-data​element-216Kyellow.png Body site Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.55 IPS Body Site (DYNAMIC)
Treetree.pnghl7:participant
1 … *RThe device is represented as a participant in the procedure structure. The following descriptions apply to the device structure.(IPS...try)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FDEV
 Example<participant typeCode="DEV">
  <participantRole classCode="MANU">
    <id root="1.2.3.999" extension="__example_only__"/>    <playingDevice classCode="DEV" determinerCode="INSTANCE">
      <code code="" codeSystem="">
        <!-- ... -->
      </code>
    </playingDevice>
  </participantRole>
</participant>
Treeblank.pngTreetree.pnghl7:participantRole
1 … 1R(IPS...try)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FMANU
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *R
The device ID, e.g. using UDI, is represented by the id element of the participant role. This element is optional, as not all production identifiers (e.g., serial number, lot/batch number, distinct identification number) may be known to the provider or patient.
(IPS...try)
 Example
UDI GS1: DeviceIdentifier 00844588003288, Serial# 10987654d321, Lot# 7654321D
<id root="2.16.840.1.113883.3.3719" extension="{01}00844588003288{17}141120{10}7654321D{21}10987654d321"/>
 Example
UDI ICCBBA: DeviceIdentifier 00844588003288
<id root="2.16.840.1.113883.3.3719" extension="A9999XYZ100T0474"/>
 Example
UDI HIBCC: Serial# XYZ456789012345678, Lot# LOT123456789012345
<id root="2.16.840.1.113883.3.3719" extension="+H123PARTNO1234567890120/$$420020216LOT123456789012345/SXYZ456789012345678/16D20130202C"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:playingDevice
1 … 1RThe playingDevice element describes the device instance. (IPS...try)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS (preferred)1 … 1RThe device code describes the type of device (e.g. arm prosthesis, arterial stent).(IPS...try)
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.23 IPS Medical Devices (DYNAMIC)
or
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.61 Absent or Unknown Devices (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC)(IPS...try)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue

IPS Radiology Result Observation

Id2.16.840.1.113883.10.22.4.12Effective Date2024‑08‑04 20:18:00
Other versions this id:
  • Kblank.png IPSRadiologyResultObservation as of 2017‑03‑21
StatusKyellow.png DraftVersion LabelSTU2
NameIPSRadiologyResultObservationDisplay NameIPS Radiology Result Observation
Description
This template represents an observation produced as one of the results of a radiology or other imaging study performed on a patient. 
In most cases, in the context of a patient summary this observation is final and validated, which is recorded with the value "completed" in the statusCode element. Should  the observation be not final, the statusCode would indicate "active", instead.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.12
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 3 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.22.17ContainmentKyellow.png IPS Radiology Result Observation Component (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.22ContainmentKorange.png IPS Comment Activity (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.12 IPS Radiology Result Observation (2017‑03‑21)
Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.22.4.10 IPS Result Observation (2017‑03‑02)
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.12
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CD.IPS (extensible)1 … 1M(IPS...ion)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.40 IPS Results Radiology Observation (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...ion)
Treetree.pnghl7:value
ST0 … 1RActual result, free text (data type ST)(IPS...ion)
Treetree.pnghl7:interpretationCode
CE.IPS0 … 1R(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CD.IPS (preferred)0 … 1(IPS...ion)
 ConstraintIf the observation site is not precoordinated in the observation/code or observation/value it SHALL be specified in the observation/targetSiteCode
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.55 IPS Body Site (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1Laterality(IPS...ion)
 ConstraintThe qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not pre-coordinated in the targetSiteCode
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (preferred)1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F272741003
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.96 (SNOMED-CT)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD.IPS (preferred)1 … 1M(IPS...ion)
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.57 Laterality (qualifier) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1Topographical modifier(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (preferred)1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F106233006
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.96 (SNOMED-CT)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD.IPS (preferred)1 … 1M(IPS...ion)
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.58 Topographical modifier (qualifier) (DYNAMIC)
Included0 … *R from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *R(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:referenceRange
0 … *R(IPS...ion)
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CDNP(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.83 (Observation Interpretation)
Treetree.pnghl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.22.17 IPS Radiology Result Observation Component (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP

IPS Reaction Manifestation

Id2.16.840.1.113883.10.22.4.6Effective Date2024‑08‑04 10:18:47
Other versions this id:
  • Kblank.png IPSAdverseReactionMFST as of 2016‑11‑15
StatusKyellow.png DraftVersion LabelSTU2
NameIPSAdverseReactionMFSTDisplay NameIPS Reaction Manifestation
Description
This clinical statement represents the response to an undesired symptom, finding, etc. due to administered or exposed substance. This reaction may be an undesired symptom, finding, etc. or it could be a desired response to a treatment. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.6
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-193Kyellow.png Manifestation of the reaction Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-194Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.4.25ContainmentKorange.png IPS Severity Observation (STU1)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.22.4.6 IPS Reaction Manifestation (2016‑11‑15)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
ch-pcc-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.6"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="404684003" displayName="Clinical finding" codeSystem="2.16.840.1.113883.6.96">
    <text>
      <reference value="#ref1"/>    </text>
    <statusCode code="completed"/>    <effectiveTime>
      <low value="201611"/>    </effectiveTime>
    <value xsi:type="CD" code="1985008" displayName="Vomitus" codeSystem="2.16.840.1.113883.6.96">
      <originalText>
        <reference value="#ref2"/>      </originalText>
    </value>
    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity Observation' (dynamic) -->
    </entryRelationship>
  </code>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(IPS...FST)
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...FST)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.6
Treetree.pnghl7:id
II0 … *R(IPS...FST)
Treetree.pnghl7:code
CD.IPS1 … 1R
This element describes the type of condition this observation is referring to.
(IPS...FST)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.16 IPS Problem Type (2017‑04‑07)
Treetree.pnghl7:text
ED0 … 1R
The <text> element if present points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.
(IPS...FST)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS...FST)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RWhen used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS (required)0 … 1R

A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.

(IPS...FST)
Treeblank.pngTreetree.png@code
CONF0 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1M
The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago.
The <low> and <high> values should be no more precise than known, but as precise as possible.
(IPS...FST)
Treeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.(IPS...FST)
Treeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1CThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition e became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
(IPS...FST)
 Constraint If this condition is known to be resolved, then the effectiveTime/high would be present.
Treetree.pnghl7:value
CD.IPS (preferred)1 … 1R
The <value> is the condition that was found. While the value may be a coded or an un-coded string, the type is always a coded value. 
If uncoded, it shall contain a <reference> to the <originalText> in the narrative where the reaction is described.
(IPS...FST)
 
Target.png
hl7ips-data​element-193Kyellow.png Manifestation of the reaction Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@xsi:type
1 … 1FCD
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.3 IPS Allergy Reaction (DYNAMIC)
Treeblank.pngTreetree.pnghl7:originalText
0 … 1R

The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus any dates, comments, et cetera). The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

(IPS...FST)
Treeblank.pngTreeblank.pngTreetree.pnghl7:reference
0 … 1R The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. </reference></reference>(IPS...FST)
 Example<reference value="#AdvReaction_1"/>
Treeblank.pngTreetree.pnghl7:translation
CD0 … *(IPS...FST)
Treetree.pnghl7:entryRelationship
0 … 1RSeverity
The contained entry describes a subjective assessment of the severity of the condition as evaluated by the clinician.
Contains 2.16.840.1.113883.10.22.4.25 IPS Severity Observation (DYNAMIC)
(IPS...FST)
 
Target.png
hl7ips-data​element-194Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue

IPS Result Observation

Id2.16.840.1.113883.10.22.4.10Effective Date2017‑03‑02
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSResultObservationDisplay NameIPS Result Observation
Description
This generic template is the basic set of constraints, which apply to any kind of observation grouped in a Result Organizer. The IPS Result Observation template is generic. It is further specialized by child templates, which  constrain  clinical laboratory observations or radiology observations or anatomic pathology observations. The generic IPS Result Observation template is usable in a patient summary for observations, which do not fall within one of the specialized categories.  
The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus. However, in most cases, observations selected for an international patient summary are  results that are final and approved, and thus, have a "completed" statusCode.
The result of the observation may be commented through an entryRelationship introducing an "IPS Comment activity" template.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.10
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 4 concepts
IdNameData Set
hl7ips-data​element-106Kyellow.png Observation Result Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-143Kyellow.png Date of observation Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-144Kyellow.png Observation Type Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-145Kyellow.png Value Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.22ContainmentKorange.png IPS Comment Activity (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01)
ref
ccda-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.10"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="..." codeSystem="1.2.3.999"/>  <statusCode/>  <effectiveTime>
    <low value="20170721091742"/>  </effectiveTime>
  <value xsi:type="PQ" value="136" unit="mmol/L"/>  <interpretationCode code="..." codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="..." codeSystem="1.2.3.999"/>  <targetSiteCode code="..." codeSystem="1.2.3.999"/>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <referenceRange>
    <observationRange>
      <value xsi:type="PQ" value=".." unit="..."/>      <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" displayName="Normal"/>    </observationRange>
  </referenceRange>
  <entryRelationship typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' (dynamic) -->
  </entryRelationship>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...ion)
 
Target.png
hl7ips-data​element-106Kyellow.png Observation Result Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.10
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CD.IPS1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-144Kyellow.png Observation Type Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.38 IPS Results Observation (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...ion)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...ion)
 
Target.png
hl7ips-data​element-143Kyellow.png Date of observation Kyellow.png CEN/TC 251 prEN 17269
Choice1 … 1Elements to choose from:
  • hl7:value[@xsi:type='CE.IPS']
  • hl7:value[@xsi:type='PQ']
  • hl7:value[@xsi:type='IVL_PQ']
  • hl7:value[@xsi:type='ST']
  • hl7:value[@xsi:type='TS']
  • hl7:value[@xsi:type='RTO_QTY_QTY']
Treeblank.pngTreetree.pnghl7:value
CE.IPS0 … 1R(IPS...ion)
where [@xsi:type='CE.IPS']
 
Target.png
hl7ips-data​element-145Kyellow.png Value Kyellow.png CEN/TC 251 prEN 17269
 Example
Result code: code '201' from code system 2.16.840.1.113883.2.4.4.30.1045
<value xsi:type="CE" code="201" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="regular"/>
 Example
Result code: code 'POS' from code system 2.16.840.1.113883.5.83
<value xsi:type="CE" code="POS" codeSystem="2.16.840.1.113883.5.83"/>
Treeblank.pngTreetree.pnghl7:value
PQ0 … 1R(IPS...ion)
where [@xsi:type='PQ']
 ConstraintIf Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC
 Example
Result physical quantity (data type PQ): 136 mmol per liter
<value xsi:type="PQ" value="136" unit="mmol/L"/>
Treeblank.pngTreetree.pnghl7:value
IVL_PQ0 … 1R(IPS...ion)
where [@xsi:type='IVL_PQ']
 Example
Result interval of physical quantities (data type IVL_PQ): 150 - 400 Milliard per 10 exp 9 liter
<value xsi:type="IVL_PQ">
  <low value="150" unit="10+9/l"/>  <high value="400" unit="10+9/l"/></value>
Treeblank.pngTreetree.pnghl7:value
ST0 … 1R(IPS...ion)
where [@xsi:type='ST']
 Example
Result free text (data type ST)
<value xsi:type="ST">This is a result as a free text</value>
Treeblank.pngTreetree.pnghl7:value
TS0 … 1R(IPS...ion)
where [@xsi:type='TS']
 Example
Result time stamp (data type TS): 6-Aug-2014
<value xsi:type="TS" value="20140806"/>
Treeblank.pngTreetree.pnghl7:value
RTO_QTY_QTY0 … 1R(IPS...ion)
where [@xsi:type='RTO_QTY_QTY']
 Example
Result ratio (data type RTO_QTY_QTY): 1/179
<value xsi:type="RTO_QTY_QTY">
  <numerator xsi:type="INT" value="1"/>  <denominator xsi:type="INT" value="179"/></value>
Treetree.pnghl7:interpretationCode
CE.IPS0 … 1R(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CD.IPS (preferred)0 … 1(IPS...ion)
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.55 IPS Body Site (DYNAMIC)
Included0 … *R from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *R(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:referenceRange
0 … *R(IPS...ion)
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CDNP(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.83 (Observation Interpretation)
Treetree.pnghl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP

IPS Result Organizer

Id2.16.840.1.113883.10.22.4.9Effective Date2017‑03‑02
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSResultOrganizerDisplay NameIPS Result Organizer
Description
This template provides a mechanism for grouping result observations. It contains information applicable to all of the contained result observations. The Result Organizer code categorizes the contained results into one of several commonly accepted values (e.g., “Hematology”, “Chemistry”, “Nuclear Medicine”). If any Result Observation within the organizer has a statusCode of "active", the Result Organizer must also have a statusCode of "active". However, the results selected for a patient summary are most often final results, with status "completed". So in most cases, the statusCode of the Organizer is "completed".

The  result observations contained within the organizer may use either of these templates:
  • Laboratory Result Observation
  • Radiology Result Observation
  • Pathology Result Observation
  • Result Observation (most generic template used whenever none of the above is applicable)
One Result Organizer entry groups results, which have a common context of production:
  • common specialty (imaging, bacteriology, serology, chemistry,  surgical pathology, clinical, radiology ...), 
  • common overall interpretation, (which interprets the set of results of the Organizer),
  • common biologic specimen for in vitro diagnostic observations, 
  • common associated illustrative image (ObservationMedia).
The ultimate choice for sorting out results between Organizer entries belongs to the authoring person or system of the section.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.9
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 6 concepts
IdNameData Set
hl7ips-data​element-106Kyellow.png Observation Result Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-143Kyellow.png Date of observation Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-144Kyellow.png Observation Type Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-146Kyellow.png Performer Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-177Kyellow.png Observer Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-23Kyellow.png Observation Result Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 9 templates
Uses as NameVersion
2.16.840.1.113883.10.12.323ContainmentKgreen.png CDA Performer (Body)DYNAMIC
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.13ContainmentKyellow.png IPS Laboratory Result Observation (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.12ContainmentKyellow.png IPS Radiology Result Observation (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.11ContainmentKyellow.png IPS Pathology Result Observation (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.10ContainmentKorange.png IPS Result Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.30ContainmentKyellow.png IPS Specimen Collection (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.22ContainmentKorange.png IPS Comment Activity (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.23ContainmentKyellow.png IPS ObservationMedia (2021)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.305 CDA Organizer (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.1 Result Organizer (V3) (2015‑08‑01)
ref
ccda-
Example
Example
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.9"/>  <code code="11529-5" displayName="Surgical pathology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>  <satusCode code="completed"/>  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - a pathologist -->
  </author>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.11 'IPS Pathology Result Observation' -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - excised tissue specimen -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - pathologist's interpretation -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.23 'IPS ObservationMedia' - an illustrative slide image -->
  </component>
</organizer>
Example
Example
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.9"/>  <code code="18719-5" displayName="Chemistry studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>  <satusCode code="completed"/>  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - a clinical laboratory director -->
  </author>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - common blood serum specimen -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of chemistry results -->
  </component>
</organizer>
Example
Example
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.9"/>  <code code="18748-4" displayName="Diagnostic imaging study" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>  <satusCode code="completed"/>  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - a radiologist -->
  </author>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.12 'IPS Radiology Result Observation' -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.23 'IPS ObservationMedia' - an illustrative image -->
  </component>
  <component>
    <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - overall interpretation -->
  </component>
</organizer>
ItemDTCardConfDescriptionLabel
hl7:organizer
(IPS...zer)
 
Target.png
hl7ips-data​element-106Kyellow.png Observation Result Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1R
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...zer)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.9
Treetree.pnghl7:id
II0 … *(IPS...zer)
Treetree.pnghl7:code
CD.IPS1 … 1R(IPS...zer)
 
Target.png
hl7ips-data​element-144Kyellow.png Observation Type Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.37 IPS Results Organizer (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...zer)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1(IPS...zer)
 
Target.png
hl7ips-data​element-143Kyellow.png Date of observation Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:low
IVXB_TS0 … 1(IPS...zer)
Treeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1(IPS...zer)
Treetree.pnghl7:performer
0 … *RWhen present, this element represents the organization who performed the set of observations grouped under this organizer.

Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC)
(IPS...zer)
 
Target.png
hl7ips-data​element-146Kyellow.png Performer Kyellow.png CEN/TC 251 prEN 17269
Included0 … *R from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
 
Target.png
hl7ips-data​element-177Kyellow.png Observer Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:author
0 … *R(IPS...zer)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...zer)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...zer)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...zer)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...zer)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...zer)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...zer)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...zer)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...zer)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...zer)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...zer)
Choice1 … *Elements to choose from:
  • hl7:component containing template 2.16.840.1.113883.10.22.4.13 IPS Laboratory Result Observation (DYNAMIC)
  • hl7:component containing template 2.16.840.1.113883.10.22.4.12 IPS Radiology Result Observation (DYNAMIC)
  • hl7:component containing template 2.16.840.1.113883.10.22.4.11 IPS Pathology Result Observation (DYNAMIC)
  • hl7:component containing template 2.16.840.1.113883.10.22.4.10 IPS Result Observation (DYNAMIC)
  • hl7:component containing template 2.16.840.1.113883.10.22.4.30 IPS Specimen Collection (DYNAMIC)
  • hl7:component containing template 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)
  • hl7:component containing template 2.16.840.1.113883.10.22.4.23 IPS ObservationMedia (DYNAMIC)
Treeblank.pngTreetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.4.13 IPS Laboratory Result Observation (DYNAMIC)(IPS...zer)
Treeblank.pngTreetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.4.12 IPS Radiology Result Observation (DYNAMIC)(IPS...zer)
Treeblank.pngTreetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.4.11 IPS Pathology Result Observation (DYNAMIC)(IPS...zer)
Treeblank.pngTreetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.4.10 IPS Result Observation (DYNAMIC)(IPS...zer)
 
Target.png
hl7ips-data​element-23Kyellow.png Observation Result Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.4.30 IPS Specimen Collection (DYNAMIC)(IPS...zer)
 ConstraintAn IPS Specimen Collection SHALL be present only if the organizer carries anatomic pathology or microbiology laboratory observations, which need to be associated with the specific anatomic site the specimen was collected from.
Treeblank.pngTreetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)(IPS...zer)
 ConstraintAn IPS Comment Activity SHALL contain a general comment applying to the whole set of observations present in the organizer
Treeblank.pngTreetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.4.23 IPS ObservationMedia (DYNAMIC)(IPS...zer)

IPS Severity Observation

Id2.16.840.1.113883.10.22.4.25Effective Date2017‑04‑07
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameEntrySeverityDisplay NameIPS Severity Observation
Description
This clinical statement represents the subjective assessment of the severity of the condition as evaluated by the clinician.

The Severity Observation can be associated with a Reaction Observation. 
When the Severity Observation is associated with a Reaction Observation it characterizes a reaction. A person may manifest many symptoms in a reaction to a single substance, and each reaction to the substance can be represented. However, each reaction observation can have only one severity observation associated with it. For example, someone may have a rash reaction observation as well as an itching reaction observation, but each can have only one level of severity.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.25
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-128Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-136Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-194Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.1 eHDSI Severity (DYNAMIC)
ref
epsos-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.25"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4"/>  <text>
    <reference value="#example"/>  </text>
  <statusCode code="completed"/>  <value code="255604002" displayName="Mild" codeSystem="2.16.840.1.113883.6.96"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(Ent...ity)
 
Target.png
hl7ips-data​element-128Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-194Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(Ent...ity)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.25
Treetree.pnghl7:id
II0 … *R(Ent...ity)
Treetree.pnghl7:code
CD1 … 1R(Ent...ity)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20386 SeverityObservationCode (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1RIf present, the <text> element shall contain a <reference> element pointing to the narrative where the severity is recorded</reference></text>(Ent...ity)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(Ent...ity)
Treeblank.pngTreeblank.pngTreetree.png@value
url1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Treetree.pnghl7:statusCode
CS1 … 1M(Ent...ity)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:value
CD.IPS (preferred)1 … 1R

The <value> element contains the level of severity.

(Ent...ity)
 
Target.png
hl7ips-data​element-136Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.18 Problem Severity (DYNAMIC)

IPS Social History Alcohol Use

Id2.16.840.1.113883.10.22.4.35Effective Date2017‑06‑29
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSSocialHistoryObsAlcoholUseDisplay NameIPS Social History Alcohol Use
DescriptionThis template is a specialization of the Social History Observation that may be used to represent alcohol consumption habits.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.35
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-151Kyellow.png Reference date range Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-176Kyellow.png Life Style Factor Kyellow.png CEN/TC 251 prEN 17269
RelationshipAdaptation: template 2.16.840.1.113883.10.20.22.4.38 Social History Observation (V3) (2015‑08‑01)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.35"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="74013-4" codeSystem="2.16.840.1.113883.6.96" displayName="Alcoholic drinks per day"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170719113711"/>  </effectiveTime>
  <value xsi:type="PQ" value="1" unit="d"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...Use)
 
Target.png
hl7ips-data​element-176Kyellow.png Life Style Factor Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...Use)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.35
Treetree.pnghl7:id
II0 … *(IPS...Use)
Treetree.pnghl7:code
CD.IPS (preferred)1 … 1R(IPS...Use)
Treeblank.pngTreetree.png@code
CONF0 … 1F74013-4
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.pnghl7:translation
0 … *R(IPS...Use)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...Use)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...Use)
 
Target.png
hl7ips-data​element-151Kyellow.png Reference date range Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:value
PQ1 … 1R(IPS...Use)
Treeblank.pngTreetree.png@xsi:type
cs1 … 1FPQ
Treeblank.pngTreetree.png@unit
1 … 1F/d

IPS Social History Tobacco Use

Id2.16.840.1.113883.10.22.4.34Effective Date2017‑06‑20
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSSocialHistoryObsTobaccoUseDisplay NameIPS Social History Tobacco Use
DescriptionThis template is a specialization of the Social History Observation that may be used to represent smoking or tobacco habits.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.34
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
hl7ips-data​element-176Kyellow.png Life Style Factor Kyellow.png CEN/TC 251 prEN 17269
RelationshipAdaptation: template 2.16.840.1.113883.10.20.22.4.38 Social History Observation (V3) (2015‑08‑01)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation>
  <templateId/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="72166-2" codeSystem="2.16.840.1.113883.6.1" displayName="Tobacco smoking status NHIS"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20171214094510"/>  </effectiveTime>
  <value code="LA18976-3" codeSystem="2.16.840.1.113883.6.1" displayName="Current every day smoker"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(IPS...Use)
 
Target.png
hl7ips-data​element-176Kyellow.png Life Style Factor Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...Use)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.34
Treetree.pnghl7:id
II0 … *(IPS...Use)
Treetree.pnghl7:code
CD.IPS1 … 1M(IPS...Use)
Treeblank.pngTreetree.png@code
CONF1 … 1F72166-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.pnghl7:translation
0 … *R(IPS...Use)
Treetree.pnghl7:statusCode
CS1 … 1M(IPS...Use)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...Use)
Treetree.pnghl7:value
CD.IPS1 … 1R(IPS...Use)
Treeblank.pngTreetree.png@xsi:type
cs1 … 1FCD
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.59 IPS Current Smoking Status (DYNAMIC)

IPS Specimen Collection

Id2.16.840.1.113883.10.22.4.30Effective Date2024‑08‑04 21:03:07
Other versions this id:
  • Kblank.png IPSSpecimenCollection as of 2017‑04‑14
StatusKyellow.png DraftVersion LabelSTU2
NameIPSSpecimenCollectionDisplay NameIPS Specimen Collection
Description
Specimen Collection is used when a set of laboratory or pathology observations  produced on one or more specimens need to be associated with the minimal characteristics of the specimen(s): specimen source site and type of specimen.
In addition this template enables to convey when the specimen was collected.
In a patient summary there is no need to provide more data than these 4:
  • collection method, 
  • source site, 
  • type of specimen and 
  • time of collection.
An occurrence of this template describes one specimen collected, used by the set of observations present in the same Result Organizer.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.30
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (2008‑08‑08)
ref
XDLAB-

Adaptation: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
Example
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.30"/>  <code code="33882-2" codeSystem="2.16.840.1.113883.6.1" displayName="Collection date of Unspecified specimen"/>  <effectiveTime>
    <low value="20170719123716"/>  </effectiveTime>
  <targetSiteCode/>  <participant typeCode="PRD">
    <participantRole classCode="SPEC">
      <id root="1.2.3.999" extension="__example only__"/>      <playingEntity classCode="ENT" determinerCode="INSTANCE">
        <code code="122555007" codeSystem="2.16.840.1.113883.6.96" displayName="Venous blood specimen (specimen)"/>      </playingEntity>
    </participantRole>
  </participant>
</procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
(IPS...ion)
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.30
Treetree.pnghl7:code
CD.IPS0 … 1RLOINC code representing the act of specimen collection(IPS...ion)
Treeblank.pngTreetree.png@code
CONF0 … 1F33882-2
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1RDate and time of specimen collection(IPS...ion)
Treetree.pnghl7:methodCode
CE.IPS0 … 1R(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.76 IPS Results Specimen Collection Method (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CE.IPS0 … 1R(IPS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.55 IPS Body Site (DYNAMIC)
Treetree.pnghl7:participant
0 … 1ROne single participant, which is the product of the procedure (PRD), role of specimen (SPEC) played by the playingEntity, which conveys the type of specimen collected (blood, urine, tissue, ...)(IPS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FPRD
Treeblank.pngTreetree.pnghl7:participantRole
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:playingEntity
1 … 1R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FENT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE (preferred)1 … 1M(IPS...ion)
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.56 IPS Specimen Type (DYNAMIC)

IPS Subordinate SubstanceAdministration

Id2.16.840.1.113883.10.22.4.33Effective Date2017‑06‑15
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSSubordinateSubstanceAdministrationDisplay NameIPS Subordinate SubstanceAdministration
DescriptionThis entry is used by a main substanceAdministration act to provide dosage information as the frequency of intakes or the amount of the medication given.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.33
LabelIPSSubordSBADM
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-119Kyellow.png Dose Instruction Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-223Kyellow.png Number of units per intake Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-224Kyellow.png Frequency of intake Kyellow.png CEN/TC 251 prEN 17269
RelationshipSpecialization: template 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC)
ref
pharmcda-
Example
Example
<hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
  <hl7:templateId root="2.16.840.1.113883.10.22.4.33"/>  <hl7:statusCode code="active"/>  <!-- choice: 1..1
element hl7:effectiveTime[@value or @nullFlavor]
element hl7:effectiveTime[@xsi:type='PIVL_TS']
element hl7:effectiveTime[@xsi:type='EIVL_TS']
element hl7:effectiveTime[@xsi:type='SXPR_TS']
-->
  <hl7:effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
    <hl7:period value="12" unit="h"/>  </hl7:effectiveTime>
  <hl7:doseQuantity xsi:type="IVL_PQ" value="2" unit="{puff}"/>  <hl7:consumable>
    <hl7:manufacturedProduct>
      <hl7:manufacturedMaterial nullFlavor="NA"/>    </hl7:manufacturedProduct>
  </hl7:consumable>
</hl7:substanceAdministration>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
IPSS...BADM
 
Target.png
hl7ips-data​element-119Kyellow.png Dose Instruction Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1RIf the statement refers to a prescribed medication then a <substanceAdministration> intent (moodCode='INT') is used; otherwise, to record medications which are stated to have taken, the moodCode shall be set to 'EVN'.</substanceAdministration>
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
 ConstraintThe moodCode of this subordinate <substanceAdministration> SHALL be the same of the parent <substanceAdministration> .
Treetree.pnghl7:templateId
II1 … 1MIPSS...BADM
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.33
Treetree.pnghl7:statusCode
CS1 … 1MIPSS...BADM
 ConstraintThe statusCode of this subordinate <substanceAdministration> SHALL be the same of that of the parent <substanceAdministration>.
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.12 ActStatusActiveCompletedAbortedSuspended (2017‑03‑30)
 Example<statusCode code="active"/>
Choice1 … 1Elements to choose from:
  • hl7:effectiveTime[@value or @nullFlavor]
  • hl7:effectiveTime[@xsi:type='PIVL_TS']
  • hl7:effectiveTime[@xsi:type='EIVL_TS']
  • hl7:effectiveTime[@xsi:type='SXPR_TS']
Treeblank.pngTreetree.pnghl7:effectiveTime
TS0 … 1CThis required element describes the frequency of intakes. If not known it shall be valued with the nullflavor "UNK"IPSS...BADM
where [@value or @nullFlavor]
 
Target.png
hl7ips-data​element-224Kyellow.png Frequency of intake Kyellow.png CEN/TC 251 prEN 17269
 Example
Once (known date)
<effectiveTime value="20170404"/>
 Example
Unknown
<effectiveTime nullFlavor="UNK"/>
Treeblank.pngTreetree.pnghl7:effectiveTime
PIVL_TS0 … 1CIPSS...BADM
where [@xsi:type='PIVL_TS']
 
Target.png
hl7ips-data​element-224Kyellow.png Frequency of intake Kyellow.png CEN/TC 251 prEN 17269
 Example
Every 4 hours
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false">
  <period value="4" unit="h"/></effectiveTime>
 Example
Twice a day
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
  <period value="12" unit="h"/></effectiveTime>
Treeblank.pngTreetree.pnghl7:effectiveTime
EIVL_TS0 … 1CIPSS...BADM
where [@xsi:type='EIVL_TS']
 
Target.png
hl7ips-data​element-224Kyellow.png Frequency of intake Kyellow.png CEN/TC 251 prEN 17269
 Example
After meal
<effectiveTime xsi:type="EIVL_TS">
  <event code="PC" codeSystem="2.16.840.1.113883.5.139"/></effectiveTime>
 Example
One hour before breakfast
<effectiveTime xsi:type="EIVL_TS">
  <event code="ACM" codeSystem="2.16.840.1.113883.5.139"/>  <offset>
    <low value="1" unit="h"/>  </offset>
</effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:event
EIVL.event0 … 1CIPSS...BADM
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1 
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10706 TimingEvent (DYNAMIC)
Treeblank.pngTreetree.pnghl7:effectiveTime
SXPR_TS0 … 1RIPSS...BADM
where [@xsi:type='SXPR_TS']
 
Target.png
hl7ips-data​element-224Kyellow.png Frequency of intake Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:doseQuantity
IVL_PQ0 … 1RThe <doseQuantity> describes the amount of the medication given (the dosage).

If a dose range is given (e.g., 1-2 tablets, or 325-750mg), then the <low> and <high> bounds are specified in their respective elements; otherwise only one physical quantity is specified (e.g. 2 drops)

The dose can be in some known and measurable unit, such as grams, milligrams,or described in "administration" units (unit of presentation, such as capsules).

If the dose is in countable items (tablets, caplets, "eaches"), then the unit could be omitted or valorized using the UCUM annotations for describing the type of countable items (e.g. .{tablet}, {puff},..).

The unit attribute – when expresses unit of measures- shall be derived from the UCUM code system.
The used elements should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document.
IPSS...BADM
 
Target.png
hl7ips-data​element-223Kyellow.png Number of units per intake Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@unit
cs0 … 1 
 Example
Not pre-coordinated consumable
<doseQuantity value="25" unit="mg"/>
 Example
Pre-coordinated consumable - Dose Range
<doseQuantity>
  <low value="1" unit="{tablet}"/>  <high value="2" unit="{tablet}"/></doseQuantity>
 Example
Pre-coordinated consumable
<doseQuantity value="2" unit="{puff}"/>
 Example
Pre-coordinated consumable with text reference
<doseQuantity value="2" unit="{puff}">
  <translation>
    <originalText>
      <reference value="#text-ref-1"/>    </originalText>
  </translation>
</doseQuantity>
 Example
Textual dosage
<doseQuantity nullFlavor="OTH">
  <translation>
    <originalText>
      <reference value="#text-ref-1"/>    </originalText>
  </translation>
</doseQuantity>
Treetree.pnghl7:rateQuantity
IVL_PQ0 … 1IPSS...BADM
Treetree.pnghl7:consumable
1 … 1RIPSS...BADM
Treeblank.pngTreetree.pnghl7:manufacturedProduct
1 … 1RIPSS...BADM
Treeblank.pngTreeblank.pngTreetree.pnghl7:manufactured​Material
1 … 1RIPSS...BADM
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1FNA


HL7 V2/V3 Datatype Level Template

IPS Address

Id2.16.840.1.113883.10.22.11Effective Date2018‑04‑04 15:41:36
Other versions this id:
  • Kblank.png IPSAddress as of 2018‑04‑04 15:42:34
  • Kblank.png IPSAddress as of 2018‑04‑04 15:41:43
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSAddressDisplay NameIPS Address
DescriptionReusable address template
ClassificationHL7 V2/V3 Datatype Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)
ref
ccda-
Example
Example
<addr use="HP">
  <country>TR</country>  <city>Ankara</city>  <streetAddressLine>Silikon Blok Kat:1</streetAddressLine></addr>
Example
Example
<addr use="WP">
  <state>FI</state>  <city>FIRENZE</city>  <country>IT</country>  <postalCode>50122</postalCode>  <streetAddressLine>Palazzo Vecchio, Piazza della Signoria</streetAddressLine></addr>
Example
Example
<addr nullFlavor="NI"/>
ItemDTCardConfDescriptionLabel
@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 assertrole 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 Line(IPS...ess)
 Schematron assertrole 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 City(IPS...ess)
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...ess)
hl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...ess)
hl7:country
ADXP0 … 1CSubject's Country.(IPS...ess)
 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.

Appendix (Informative)

Acronyms and abbreviations

  • CCD: Continuity of Care Document
  • C-CDA: Consolidated CDA
  • CDA: Clinical Document Architecture
  • CEN: Comité Européen de Normalisation (European Committee for Standardization)
  • CEN/TC 251 : CEN Technical Committe 251
  • DSTU: Draft Standard for Trial Use
  • EC: European Commission
  • EDQM: European Directorate for the Quality of Medicines & Healthcare
  • eHDSI: Digital Service Infrastructure for eHealth
  • eHN: eHealth Network
  • EHR: Electronic Healthcare Record
  • EN: European Normative [or Standard] (CEN)
  • epSOS: European Patient Smart Open Services
  • EU: European; Europe
  • FDA: Food and Drug Administration (USA)
  • GP: General Practitioner
  • HL7: Health Level Seven
  • HP: Healthcare Professional
  • IDMP: IDentification of Medicinal Products (ISO Standard)
  • IHE: Integrating the Healthcare Enterprise
  • INTERPAS: International Patient Summary (HL7 International Project)
  • IPS: International Patient Summary
  • ISO: International Organization for Standardization
  • JAseHN: Joint Action to Support the eHealth Network
  • JIC: Joint Initiative Council on SDO Global Health Informatics Standardization
  • LOINC: Logical Observation Identifiers Names & Codes
  • MOU: Memorandum of Understanding (on cooperation surrounding health related information and communication technologies, that between EU and US)
  • MPID: Medicinal Product Identifier
  • ONC: Office of the National Coordinator for Health Information Technology (USA)
  • PCC: Patient Care Coordination
  • PCID : Medicinal Product Package Identifier
  • PhPID(s): Pharmaceutical Product Identifier(s)
  • prEN: Draft European Normative [or Standard] (CEN)
  • prTS: Draft Technical Specifications (CEN)
  • PS: Patient Summary
  • S&I: Standards and Interoperability (S&I) Framework (run by ONC)
  • SAIF: Service Aware Interoperability Framework
  • SDO: Standards Developing Organization
  • STU: Standard for Trial Use
  • TS: Technical Specifications (CEN)
  • UCUM: Unified Code for Units of Measure
  • WHO: World Health Organization

Glossary

  • Compliance. A standard or specification is compliant with another standard or specification if all propositions that are true in the initial standard are also true in the complying standard. The target artifact is compliant with the source artifact if and only if all conforming implementations of the target are also conforming with the source (RM-ODP). The term compliance is also used to state expectations as to how certain specifications need to satisfy possible legislative or regulatory constraints or requirements.
  • Conformance relates an implementation to a standard. Any proposition that is true of the specification must be true in its implementation. (ISO, 2010).
  • Conformance Assessment is a process whereby a given implementation instance is evaluated to determine which of its various Conformance Assertions are valid implementations of a given specification’s Conformance Statements.
  • Conformance Statement is a statement that identifies testable requirements at a specified Conformance Point within a specification, explicitly defining the behavior which must be satisfied at these points. Conformance Statements will only occur in standard which are intended to constrain some feature of a real implementation, so that there exists, in principle, the possibility of testing.
  • Conformance Assertion is a testable, verifiable statement made about a specific implementation instance against a corresponding Conformance Statement.
  • Conformance Points are the evaluation of conformance at specific points in the implementation or specification. See Conformance.
  • Electronic Patient Summary: electronic health record extract containing essential healthcare information intended for specific uses . (EN ISO 13940: 2016)
  • International Patient Summary : electronic patient summary for use in the unscheduled, cross-border care scenario comprising at least the required elements of the IPS dataset.
  • International Patient Summary dataset: a minimal and non-exhaustive patient summary dataset, specialty-agnostic, condition-independent, but readily usable by clinicians for the cross-border unscheduled care of a patient.

Real World User Stories

This section reports a series of real world user stories adapted from the Trillium Bridge project [27] and the eHDSI initiative [28].

IPS Storyboard 1: Martha, a traveling corporate executive

Martha, a 45-year old corporate executive and breast cancer survivor travels frequently on business between the US and EU countries. She carries a clinical summary on her mobile phone and on paper just in case she needs to seek medical care regarding recurring symptoms. Martha’s summary includes

  • Breast cancer Stage II with no evidence of recurrence following treatment
  • hot flashes as problems
  • Anastrozole 1 mg. once daily
  • Black Cohosh Extract herbal supplement as medications
  • the indication of an allergy to Penicillin
  • and finally as Plan of Care, to continue hormone medication with Anastrozole for total of 5 years
  • and monitor for potential breast cancer recurrence.

During a visit in Austria, Martha walks up a hill and experiences shortness of breath, faints, and wakes up a few minutes later after hitting her head on a stone step. A passerby helps her get to the emergency department of a local hospital. An ambulance is called and she is brought to the emergency ward.

During registration and admission, Martha hands in her patient summary in a USB key. At the hospital, Martha is evaluated by an oncologist and a cardiologist.

Following care provision, Martha receives an encounter report. When back home she hands in the encounter report to her primary physician, who updates her record.

IPS Storyboard 2: Paolo, a retired businessman

Paolo Cerruti is a 67-year-old retired businessman, who normally lives in the outskirts Bergamo, near Lake Como, in Lombardy. He is generally healthy, but has long-standing hypertension. His regular physician changed his medication two weeks ago because of poor blood pressure control on his previous medication. He is on holiday going through New England, US, travelling on his own to enjoy the autumn foliage, and is presently in Boston, MA. He is nearing the end of his holiday, and will be returning to Italy in three days’ time. Two days ago he lost his day bag. The bag included his hypertension medication, and he has not been able to take his tablets for two days.

This morning he has woken up feeling dizzy and has blurred vision. The hotel is able to put him in urgent contact with a local general practitioner (GP). Having assessed him, the GP noted a raised blood pressure, but is uncertain about whether to attribute these symptoms to the raised blood pressure or a side effect of the new medication. Now, the GP in Boston needs to know the medication, and the past few blood pressure readings to determine how exceptional the present reading is and manage Paolo appropriately.

Immediate access to his International Patient Summary would be the perfect answer. Paolo may retrieve his online European Patient Summary for emergency access that is retrieved, transformed into an IPS and shown its content translated in English.

The GP notes that visual disturbances are a recognized side effect of this medication. No specific treatment is indicated, and Paolo is reassured that side effects will gradually subside, and his GP can prescribe a suitable antihypertensive medication upon his return to Lake Como.

IPS Storyboard 3: Diana, a pregnant woman

Diana is a 34-year-old pregnant woman from Lisbon with a past medical history of allergic asthma and thyroid cancer during adolescence; for the latter she had a surgical procedure done (thyroidectomy) and, as a consequence, suffers hypothyroidism which requires hormone replacement for life (levothyroxine). At the age of 31 she was diagnosed with a hereditary cardiac disorder – Brugada Syndrome – and had a cardioverter defibrillator implanted to control potentially lethal arrhythmias.

During the pregnancy of her first child (C-section delivery), she suffered gestational diabetes that developed into type 2 diabetes after giving birth and needs now to receive subcutaneous insulin. As chronic treatment she also needs nebulizations three-time per day for her asthma - this condition is aggravated in her case by being a smoker (1 pack per day) as included in the Social History Section.

At this moment, she presents severe pre-eclampsia (hypertension during pregnancy) in treatment with two oral antihypertensive agents (a combination medication). Additionally, she is following a 14-day-course of antibiotic treatment due to an acute pyelonephritis (kidney infection more likely to be develop in pregnant women due to the physiological changes that may interfere with the flow of urine).

Other sections of her Summary include allergies to latex and kiwi (which are very often associated) and to aspirin, and intolerance to lactose; immunizations administered during childhood and adolescence are also present.

Although being real choices for the different diseases and conditions, the selection of the patient's current medication tries to present some easily described medication as well as not so easily ones: e.g. insulin degludec, amoxicilin+clavulanic acid, and the combination of ipratropium bromide+salbutamol for nebulization. For the oral treatment of the pre-eclampsia the agents selected would not be used in real practice during pregnancy.

Integrated examples

The IPS specification releases are published at hl7intl.art-decor.org the International Patient Summary Project Publication Page [29]. The actual release has a link to the XML materials that the W3C schemas are part of; it also includes example CDA document instances. A set of use cases have been defined and represented in IPS format. Also multiple languages are covered.

It is likely that the publication site will move to hl7.org permanently, and we will inform the community about that process.

Validation artifacts

You can test your implementation (instances) against the IPS specification. To download materials to your computer for local testing and validation consider...

  • ...the W3C schemas (actually valid for any CDA specification) located at the Publication Page[29]. The actual release has a link to the XML materials as which the W3C schemas are part of; it also includes example CDA document instances.
  • ..the ISO schematron, automatically generated by the tool. These are files to do validation locally by associating IPS CDA instances with the main schematron using an XML editor or to use the derived XSLT conversions and apply the according XSLT derivation to your local IPS CDA instance.

For further information you can follow the documentation.

Operational information

  • The IPS project has an official mailing list address ips(at)lists.hl7.org, hosted at the HL7 listserver. Visit your Listserv Subscriptions at hl7.org and subscribe to the International Patient Summary (IPS) that is summarised under the Structured Documents Work Group.
  • The original specification is hosted on the logical ART-DECOR main server art-decor.org under the Governance Group HL7 International, the project is reachable at the Live Project Landing Page.
  • Any IPS specification release in HTML format resides at the Publication Page[29]. It is likely that the publication site will move to hl7.org permanently, we will inform about that process.
  • The IPS specification on the wiki is hosted here (international-patient-summary.net). It is likely that the publication site will move to hl7.org permanently, we will inform about that process.

Licenses

Following is a non-exhaustive list of third-party terminologies that may require a separate license:

  • SNOMED CT: SNOMED International (formerly know as International Healthcare Terminology Standards Development Organization IHTSDO)[30] or info@ihtsdo.org
  • Logical Observation Identifiers Names & Codes (LOINC): This material contains content from LOINC® (http://loinc.org). The LOINC Table, LOINC Table Core, LOINC Panels and Forms File, LOINC Answer File, LOINC Part File, LOINC Group File, LOINC Document Ontology File, LOINC Hierarchies, LOINC Linguistic Variants File, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright © 1995-2017, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license.
  • Unified Code for Units of Measure (UCUM) : Regenstrief Institute, Inc. and the UCUM Organization
  • EDQM Standard Terms  : European Directorate for the Quality of Medicines & Healthcare (EDQM) [31]

FAQ’s

This is a placeholder for future Frequently Asked Questions about the International Patient Summary.

List of all artifacts used in this guide

CDA Templates

CDA Template References

Unconstrained Templates from the original CDA specification

Value Sets

Value Sets References

Data Types

Data types for element definitions used

  • AD – Address
  • AD.IPS – IPS Address (see [1])
  • ANY – ANY
  • BL – Boolean
  • CD – Concept Descriptor
  • CD.IPS – IPS CD (see [2])
  • CE – Coded with Equivalents
  • CE.IPS – IPS CE (see [3])
  • CR – Concept Role
  • CS – Coded Simple Value
  • CV – Coded Value
  • CV.IPS – IPS CV (see [4])
  • ED – Encapsulated Data
  • EIVL.event – Event-Related Interval of Time
  • EIVL_TS – Event-related time interval
  • EN – Entity Name
  • ENXP – Entity Name Part
  • II – Instance Identifier
  • INT – Integer
  • IVL_PQ – Interval of Physical Quantity
  • IVL_TS – Interval of Time Stamp
  • IVL_TS.IPS.TZ – IPS IVL Time Stamp TZ (see [5])
  • IVL_TS.IPS.TZ.OPT
  • IVXB_TS – Interval Boundary of Time Stamp
  • ON – Organization Name
  • PIVL_TS – Periodic Interval of Timezone
  • PN – Person Name
  • PQ – Physical Quantity
  • SC – String with Codes
  • SD.TEXT – Structured Document Text
  • ST – Character String
  • SXPR_TS – Parenthetic Set Expression of Time Stamp
  • TEL – Telecommunication Address
  • TEL.IPS – IPS TEL (see [6])
  • TS – Time Stamp
  • TS.IPS.TZ – IPS Time Stamp TZ (see [7])

Data types for attributes used

  • bl – boolean code
  • cs – code
  • oid – identifier
  • set_cs – code
  • st – string
  • uid – identifier

Extensions

Detailed medications information

This specification uses CDA extensions in order to provide details about medications, as further described in the section on the design conventions for Medicinal Product Identification and as used in template 2.16.840.1.113883.10.22.4.3 IPS Manufactured Material. The extension uses the namespace urn:hl7-org:pharm.

This is the list of elements defined for that template.

  • pharm:formCode (Administrable Pharmaceutical Dose Form)
  • pharm:asContent (Packaging of the medication)
    • pharm:quantity
    • pharm:containerPackagedMedicine (Most inner Package Item or the Packaged Medicinal Product)
      • pharm:code
      • pharm:name (Name of the Package Item or of the Packaged Medicinal Product)
      • pharm:formCode (type of the most inner package item or of the or the Packaged Medicinal Product)
      • pharm:capacityQuantity (the functional capacity of the container)
      • pharm:asContent (Containing package)
        • pharm:quantity
        • pharm:containerPackagedMedicine (Intermediate Package Item or the Packaged Medicinal Product)
          • pharm:code
          • pharm:name (Name of the Package Item or of the Packaged Medicinal Product)
          • pharm:formCode (type of the intermediate package item or of the or the Packaged Medicinal Product)
          • pharm:capacityQuantity (the functional capacity of the container)
          • pharm:asContent (Containing package)
            • pharm:quantity
            • pharm:containerPackagedMedicine (Packaged Medicinal Product)
              • pharm:code
              • pharm:name (Name of the Packaged Medicinal Product)
              • pharm:formCode (type of the Packaged Medicinal Product)
              • pharm:capacityQuantity (the functional capacity of the container)
  • pharm:asSpecializedKind (used to represent any classification of the product (ATC code, future PhPIDs,..) )
    • pharm:generalizedMaterialKind
      • pharm:code
      • pharm:name
  • pharm:ingredient (list of active substances used for this product)
    • pharm:quantity (strength)
    • pharm:ingredientSubstance (active substance)
      • pharm:code
      • pharm:name

Translation of designations

This specification recommends the introduction of an optional extension for properly recording multilingual designations, that is further described in the section on the translation of designations

  • ips:designation

How to read the table view for templates

The template definitions are shown in a table view. It is comprised of Template Meta data and the Template Design. For further information please refer to the HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1[8].

Templates may also be included in the hierarchical graph view (often used for CDA), see below.

Template Meta data

TemplatePublication1.png

TemplatePublication1.png

The upper right part of the template table contains the template meta data. Template id, status and the template name are shown (1). Furthermore the Version (effective date), a possible version label and the display name are shown (2).

The description area (plain or an accordion) contains the template descriptions/purpose (3), followed by classifications and whether the template is defined as open or closed (4).

The usage part (5) may list templates that uses this template or what templates this templates uses. A relationship list (6) may show all relationships to other templates or models.

Examples may show the correct use of the template by an XML fragment (7).

TemplatePublication5a.png

TemplatePublication5a.png

The relationship list shows all relationships to other templates or models for this template. It is divided in the "Used by" part listing templates that make use of this template, and a "Uses" listing all templates that are used by this templates, either as inclusion or containment. Indirect relationships like the parent Document Level Template for a Section Level Template are marked with a chain symbol.

The PDF version is rendered in the same way, but maybe with different fonts etc. to fit customized publication requirements.

TemplatePublication2.png

TemplatePublication2.png

Table view of Template Design

TemplatePublication3.png

TemplatePublication3.png

The headings of the table view of a template design are:

Item (1) contains the XML document tree view of all elements and attributes specified in the template design. Elements are denoted by a preceding triangle and attributes by a preceding "@".

DT (2) data types, contains the data type of the item, for more information on valid data types for element and attributes (see [8]).

Card / Conf (3) cardinality (Card) and conformance (Conf) of the item. Cardinality is the usual notion of min and max occurrences of the element. For attributes 0..1 denotes optionality, 1..1 say that the attribute is required and NP denotes prohibited attributes. Conformance may display values as shown in the following table.

Values of the conformance column
Conf Short Description
O optional Data is truly optional
R required If data is present and not masked (e.g. for privacy reasons), it must be provided, otherwise it may be omitted or explicitly null flavored.
Sender and receiver must support this element.
M mandatory The data must be populated with a valid value from the associated value domain, otherwise the instance is not valid and may not be communicated.
Sender and receiver must support this element.
C conditional There are conditions when data has to be provided (e.g. co-constraints like "information about pregnancy IF the patient is "female".
Sender and receiver must support this element.
F fixed The data has a fixed value.
NP not permitted Data shall not be present

Description (4) contains a textual description of the item, may also contain constraints and values for fixed attributes.

Label (5) is a human readable label that is displayed upon errors, warnings or notes during validation.

Details of the table view

TemplatePublication4.png

TemplatePublication4.png

The actual template design shows the XML structure in a hierarchical list of elements (items) that are typically prefixed by the namespace "hl7:" or "cda:" (1).

Elements are denoted with a triangle, attributes with an @ sign (2).

Data types are specified according to the list of supported data types (3). They may be simple data types (lowercase), regular data types (uppercase) or flavors thereof. In case of coded elements, the coding strength (Required/CNE, Extensible/CWE, Preferred or Example) can be highlighted near the datatype (e.g. “CD.IPS (Extensible/CWE)”) ; the absence of indications about the strength (e.g. “CE.IPS”) shall be interpreted as “Required/CNE”.

Values of the coding strength column
Strength Displayed as Description
Required Required/CNE Coded with no exceptions; this element SHALL be from the specified value set
Extensible Extensible/CWE Coded with Exceptions; this element SHALL be from the specified value set if any of the codes within the value set can apply to the concept being communicated. If the value set does not cover the concept (based on human review), alternate codings (or, data type allowing, text) may be included instead.
Preferred Preferred Instances are encouraged to draw from the specified codes for interoperability purposes but are not required to do so to be considered conformant.
Example Example Instances are not expected or even encouraged to draw from the specified value set. The value set merely provides examples of the types of concepts intended to be included.

The cardinality and conformance column is explained above (4).

Fixed values for e.g. attributes are also shown in the "description" column (5), preceded by a "F" in the Conf column.

Conformance statements are shown together with a CONF box, e.g. a @code and a @codeSystem with fixed and required values (6).

An optional label is displayed at the rightmost column (7).

Inclusion or containments of other templates, e.g. an entry within a section, are shown accordingly (8) along with their template id, display name and flexibility/stability indication, i.e. "DYNAMIC" (the most recent version) or a STATIC binding together with a version date.

TemplatePublication5b.png

TemplatePublication5b.png

Choices of elements are shown as a choice list with the elements in questions summarised in a bullet point list.

TemplatePublication6b.png

TemplatePublication6b.png

A typical Conformance Statement is the binding of a coded element to a value set. This is expressed in the way shown. The value set is represented with the id, display name and the flexibility/stability of the binding.

TemplatePublication6c.png

TemplatePublication6c.png

In case a constraint is expressed in words, a box "Constraint" accompanies the textual expression of the constraint.

TemplatePublication6a.png

TemplatePublication6a.png

In cases where constraints are expressed by formalised rules in ISO Schematron, the rule along with the role (error, warning), the test and the assertion message is shown.

How to read the Templates hierarchical graph view

TemplatePublication8a.png

TemplatePublication8a.png

Templates are often included in the hierarchical graph view (often used for CDA). It gives an overview of e.g. section and entries and their nesting/relationships.

TemplatePublication8b.png

TemplatePublication8b.png

In case a template has more that one type (CDA Person for header, section and entry templates), it is denoted with a *, if a recursive definition is detected, this is shown with the symbol @.

How to read the where criteria

Templates sometimes include criteria for identifying distinct elements from a list (e.g. in a choice).

The criteria used to identify the items are shown in square brackets using the assertion where [ criteria ]

Criteria can be:

  1. an xpath expression as in the example : where [hl7:low or hl7:high]
  2. or an integer indexing the items of the list: e.g. where [1]; where [2]

References

Literature

  • Whiting-O'Keefe QE, Simborg DW, Epstein WV, Warger A: A computerized summary medical record system can provide more information than the standard medical record. JAMA. 1985 Sep 6;254(9):1185-92.
  • Boone KW: The CDA Book. Springer 2011, ISBN 978-0-85729-336-7

Links

  1. The epSOS Project http://epsos.eu/
  2. The Trillium Bridge Project http://www.trilliumbridge.eu
  3. The Sequoia Project https://sequoiaproject.org/
  4. Memorandum of Understanding between the United States Department of Health and Human Services and the European Commission on Cooperation Surrounding Health Related Information and Communication Technologies http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=1784
  5. http://www.jointinitiativecouncil.org/news/JIC_Standards_Set_development_20160101_v1.00.pdf
  6. Transatlantic eHealth/health IT Cooperation Roadmap http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=12123
  7. ART-DECOR® art-decor.org
  8. 8.0 8.1 8.2 8.3 8.4 HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=377
  9. EHN Guideline on the electronic exchange of health data under Cross-Border Directive 2011/24/EU. Release 2. https://ec.europa.eu/health/sites/health/files/ehealth/docs/ev_20161121_co10_en.pdf
  10. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379
  11. IHE Patient Care Coordination Technical Framework http://ihe.net/Technical_Frameworks/#pcc
  12. https://ec.europa.eu/cefdigital/wiki/display/EHOPERATIONS/Specifications
  13. JIC http://www.jointinitiativecouncil.org/index.asp
  14. HL7 CDA® Release 2 Implementation Guide: Data Provenance, Release 1 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=420
  15. HL7 Version 3 Publishing Facilitator's Guide http://www.hl7.org/v3ballot/html/help/pfg/pfg.htm
  16. ISO/TS 13582:2015 Health informatics -- Sharing of OID registry information
  17. 17.0 17.1 17.2 17.3 HL7 C-CDA Implementation Guide DSTU R2.1 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379
  18. HL7 V3 Normative Edition 2010 http://www.hl7.org/memonly/downloads/v3edition.cfm
  19. 19.0 19.1 Core Principles and Properties of HL7 Version 3 Models http://www.hl7.org/implement/standards/product_brief.cfm?product_id=58
  20. IPS Value Sets in ART-DECOR® https://art-decor.org/art-decor/decor-valuesets--hl7ips-
  21. EHN Guideline on the electronic exchange of health data under Cross-Border Directive 2011/24/EU. Release 2. (https://ec.europa.eu/cefdigital/wiki/display/EHOPERATIONS/Business+Analysis+and+Requirements+Management?preview=/55878732/55878698/(Adopted)%20Patient%20Summary%20Guideline%20cross-border%20exchange%20of%20health%20data%20(release%202).pdf
  22. IHE Patient Care Coordination Technical Framework http://ihe.net/Technical_Frameworks/#pcc
  23. IDMP standards https://www.idmp1.com/idmp-standards
  24. European project OpenMedicine http://www.open-medicine.eu/home.html
  25. HL7 Service-Aware Interoperability Framework: Canonical Definition Specification, Release 2 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=3
  26. CDA R2 Standard http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7
  27. The Trillium Bridge Project http://www.trilliumbridge.eu
  28. The eHDSI initiative https://ec.europa.eu/cefdigital/wiki/display/EHOPERATIONS/eHealth+DSI+Operations+Home
  29. 29.0 29.1 29.2 International Patient Summary Project Publication Page http://hl7intl.art-decor.org/index.php?prefix=hl7ips-
  30. Get SNOMED CT http://www.ihtsdo.org/snomed-ct/get-snomed-ct
  31. EDQM Standard Terms https://standardterms.edqm.eu

Figures

  1. 1.0 1.1 1.2 IPS Standards in the HL7 SAIF Interoperability Matrix
  2. The IPS Principles
  3. The IPS meet-in-the-middle approach
  4. The European Commission CEN/TC 251 Grant Agreement
  5. Binding to a Single Code (tabular view)
  6. XML Expression of a Single-Code Binding
  7. Translation Code Example
  8. Intensional value set definition
  9. Examples of IPS usage
  10. Problem Concern Act (from C-CDA IG DTSU R2.1)
  11. Representation of medicines in CDA
  12. 12.0 12.1 CDA model has been enhanced with the R_Medication
  13. 13.0 13.1 The IPS World