Item | DT | Card | Conf | Description | Label |
---|
| | | R | CDA header | (HL7‑IPS |
| hl7:realmCode
|
| CS | 1 … 1 | R | | (HL7‑IPS |
| hl7:typeId
|
| II | 1 … 1 | M | The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier. | (HL7‑IPS |
| | @root
|
| uid | 1 … 1 | F | 2.16.840.1.113883.1.3 |
| | @extension
|
| st | 1 … 1 | F | POCD_HD000040 |
| Example | <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> |
| hl7:templateId
|
| II | 1 … 1 | M | | (HL7‑IPS |
| | @root
|
| uid | 1 … 1 | F | 2.16.840.1.113883.10.22.1.1 |
| hl7:id
|
| II | 1 … 1 | M | Unique identifier of this instance of the Patient Summary. | (HL7‑IPS |
| hl7:code
|
| CE.IPS | 1 … 1 | M | Determines the document type that is the "Patient Summary" document | (HL7‑IPS |
| | @displayName
|
| | 1 … 1 | R | |
| | @code
|
| CONF | 1 … 1 | F | 60591-5 |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| Example | <code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/> |
| | hl7:translation
|
| CD.IPS | 0 … * | R | This element can be here used either to provide the originally used document code if this IPS is the result of a transformation ; either to indicate that this Patient Summary has been assembled or that is the result of a human curation. | (HL7‑IPS |
| | where [1] |
| |
| hl7:title
|
| ST | 1 … 1 | M | ClinicalDocument/title is used for display purposes. | (HL7‑IPS |
| Example | <title>Patient Summary</title> |
| Example | <title>Profilo Sanitario Sintetico</title> |
| hl7:effectiveTime
|
| TS.IPS.TZ | 1 … 1 | M | Time of creation of the Patient Summary | (HL7‑IPS |
| Example | <effectiveTime value="20111113125600+0200"/> |
| hl7:confidentialityCode
|
| CE.IPS | 1 … 1 | R | | (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"/> |
| hl7:languageCode
|
| CS | 1 … 1 | M | Document Language Code | (HL7‑IPS |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (2017‑04‑11) |
|
| Example | <languageCode code="en-GB"/> |
| Schematron assert | role | error | |
| test | matches(@code,'[a-z]{2}-[A-Z]{2}') | |
| Message | The language code SHALL be in the form nn-CC where nn is ISO-639-1 and CC is ISO-3166 | |
| hl7:setId
|
| II | 0 … 1 | R | 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 |
| hl7:versionNumber
|
| | 0 … 1 | R | | (HL7‑IPS |
Included | 1 … 1 | M | from 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget (2017‑04‑11) |
| hl7:recordTarget
|
| | 1 … 1 | M | | (HL7‑IPS |
| | @typeCode
|
| cs | 0 … 1 | F | RCT |
| | @contextControlCode
|
| cs | 0 … 1 | F | OP |
| Example | <recordTarget typeCode="RCT" contextControlCode="OP"> <patientRole classCode="PAT"> <id root="1.2.3.999" extension="--example only--"/> <addr> <streetAddressLine>HSE M CASSAR STR</streetAddressLine> <city>ISLA</city> <country>MT</country> </addr> <telecom use="HP" value="tel:+356124567891"/> <telecom use="WP" value="mailto:elif@foo.too.mt"/> <patient> <name> <family>BORG</family> <given>TANIA</given> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/> <birthTime value="19430130"/> <!-- Optional guardian information ; see example below--> <!-- Optional languageCommunication information see example below --> </patient> </patientRole></recordTarget> |
| | hl7:patientRole
|
| | 1 … 1 | M | | (HL7‑IPS |
| cs | 0 … 1 | F | PAT |
| II | 1 … * | R | Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) | (HL7‑IPS |
| AD.IPS | 1 … 1 | R | The patient address.
| (HL7‑IPS |
| cs | 0 … 1 | F | NI |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
|
| Example | <addr use="HP"> <country>TR</country> <city>Ankara</city> <streetAddressLine>Silikon Blok Kat:1</streetAddressLine></addr> |
| 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 | <addr nullFlavor="NI"/> |
| | 0 … * | C | Patient's Number of Street/Patient's Number of Street | (HL7‑IPS |
| | 0 … 1 | C | Patient's City | (HL7‑IPS |
| | 0 … 1 | C | Patient's Postal Code | (HL7‑IPS |
| | 0 … 1 | C | Patient's State or Province | (HL7‑IPS |
| | 0 … 1 | C | Patient's Country. | (HL7‑IPS |
| TEL | 1 … * | R | Patient’s telecom information : e.g. telephone number, e-mail address. | (HL7‑IPS |
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) |
|
| cs | 0 … 1 | F | NI |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
|
| Example | <telecom use="HP" value="tel:+356124567891"/> |
| Example | <telecom use="WP" value="mailto:elif@foo.too.mt"/> |
| Example | <telecom nullFlavor="NI"/> |
| | 1 … 1 | M | | (HL7‑IPS |
| cs | 0 … 1 | F | PSN |
| cs | 0 … 1 | F | INSTANCE |
| PN | 1 … * | R | Patient Name | (HL7‑IPS |
| | 1 … * | M | Patient's Family Name/Surname | (HL7‑IPS |
| | 1 … * | M | Patient's Given Name | (HL7‑IPS |
| | | | hl7:administrativeGenderCode
|
| CE.IPS | 1 … 1 | R | Patient's Gender | (HL7‑IPS |
| cs | 0 … 1 | F | UNK |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (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> |
| TS | 1 … 1 | M | Patient's Date of Birth. The patient date of birth may be a partial date such as only the year. | (HL7‑IPS |
| | 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 |
| cs | 1 … 1 | F | GUARD |
| Example | <guardian classCode="GUARD"> <code code="AUNT" displayName="aunt" codeSystem="2.16.840.1.113883.5.111"> <translation displayName="tante"/> </code> <addr nullFlavor="NI"/> <telecom use="MC" value="tel:+33-12345678"/> <guardianPerson> <name> <family>Curie</family> <given>Marie</given> </name> </guardianPerson></guardian> |
| CD.IPS | 0 … 1 | R | The relationship between the patient and the guardian or other contact may be recorded in the <code> element.
| (HL7‑IPS |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC) |
|
| AD.IPS | 1 … 1 | R | | (HL7‑IPS |
| cs | 0 … 1 | F | NI |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
|
| | 0 … * | R | Guardian's Number of Street/Guardian's Number of Street | (HL7‑IPS |
| | 0 … 1 | R | Guardian's City | (HL7‑IPS |
| | 0 … 1 | R | Guardian's Postal Code | (HL7‑IPS |
| | 0 … 1 | R | Guardian's State or Province | (HL7‑IPS |
| | 0 … 1 | R | Guardian's Country. | (HL7‑IPS |
| TEL | 1 … * | R | Guardian’s telecom information: e.g. telephone number; e-mail address. | (HL7‑IPS |
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) |
|
| cs | 0 … 1 | F | NI |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
|
| | 1 … 1 | R | | (HL7‑IPS |
| PN | 1 … * | R | Patient Guardian's Name | (HL7‑IPS |
| ENXP | 1 … * | R | Patient Guardian's Family Name/Surname
| (HL7‑IPS |
| ENXP | 1 … * | R | Patient Guardian's Given Name
| (HL7‑IPS |
| | | | hl7:languageCommunication
|
| | 0 … * | R | | (HL7‑IPS |
| CS | 1 … 1 | R | Patient’s language | (HL7‑IPS |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (2017‑04‑11) |
|
| Example | British English <languageCode code="en-GB"/> |
| Example | Amurdak (Australia) <languageCode code="amg-AU"/> |
| Schematron assert | role | error | |
| test | matches(@code,'[a-z]{2}-[A-Z]{2}') | |
| Message | The language code SHALL be in the form nn-CC where nn is ISO-639-1 and CC is ISO-3166 | |
Included | 1 … * | M | from 2.16.840.1.113883.10.22.2.2 IPS CDA author (2017‑04‑11) |
| hl7:author
|
| | 1 … * | M | | (HL7‑IPS |
| | @typeCode
|
| cs | 0 … 1 | F | AUT |
| | @contextControlCode
|
| cs | 0 … 1 | F | OP |
| Example | <author> <time value="201212290600+0100"/> <assignedAuthor> <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/> <addr use="WP"> <streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country> </addr> <telecom use="WP" value="tel:+39-051-34343434"/> <assignedPerson> <name> <given>Paolo</given> <family>Rossi</family> </name> </assignedPerson> </assignedAuthor> <representedOrganization> <!-- template 2.16.840.1.113883.3.1937.777.13.10.35 'IPS CDA Organization' (dynamic) --> </representedOrganization></author> |
| | hl7:functionCode
|
| CE.IPS | 0 … 1 | R | | (HL7‑IPS |
| Example | <functionCode code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/> |
| | hl7:time
|
| TS.IPS.TZ | 1 … 1 | R | The author/time element represents the start time of the author’s participation in the creation of the clinical document. | (HL7‑IPS |
| Example | <time value="201212290600+0100"/> |
| | hl7:assignedAuthor
|
| | 1 … 1 | R | | (HL7‑IPS |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … * | R | Author Identifier(s) | (HL7‑IPS |
| cs | 0 … 1 | | |
| Constraint | If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for "ClinicalDocument/author/assignedAuthor/id/@nullFlavor" SHALL be "NA" "Not applicable"
|
| CE.IPS | 0 … 1 | R | | (HL7‑IPS |
| AD.IPS | 1 … * | 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> |
| TEL.IPS | 1 … * | R | Attribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLScheme | (HL7‑IPS |
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) |
|
| st | 0 … 1 | | |
| Example | <telecom use="WP" value="tel:+39-051-34343434"/> |
| Example | <telecom nullFlavor="NI"/> |
Choice | 0 … 1 | | Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice containing template 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
|
| | 0 … 1 | C | | (HL7‑IPS |
| cs | 0 … 1 | F | PSN |
| cs | 0 … 1 | F | INSTANCE |
| PN | 1 … 1 | R | Name of the person (e.g. the Healthcare Professional) authoring this document | (HL7‑IPS |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
| | 1 … * | R | | (HL7‑IPS |
| | 1 … * | R | | (HL7‑IPS |
| | | | hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | Contains 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) | (HL7‑IPS |
| Example | <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <softwareName displayName="Turriano"/></assignedAuthoringDevice> |
| | | hl7:representedOrganization
|
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) | (HL7‑IPS |
Included | 1 … 1 | M | from 2.16.840.1.113883.10.22.2.3 IPS CDA custodian (2017‑04‑11) |
| hl7:custodian
|
| | 1 … 1 | M | | (HL7‑IPS |
| | @typeCode
|
| cs | 0 … 1 | F | CST |
| Example | <custodian typeCode="CST"> <assignedCustodian classCode="ASSIGNED"> <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE"> <!-- template 2.16.840.1.113883.3.1937.777.13.10.35 'IPS CDA Organization' (dynamic) --> </representedCustodianOrganization> </assignedCustodian></custodian> |
| | hl7:assignedCustodian
|
| | 1 … 1 | R | | (HL7‑IPS |
| cs | 0 … 1 | F | ASSIGNED |
| | | hl7:representedCustodianOrganization
|
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) | (HL7‑IPS |
| cs | 0 … 1 | F | ORG |
| cs | 0 … 1 | F | INSTANCE |
Included | 0 … 1 | R | from 2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator (2017‑04‑11) |
| hl7:legalAuthenticator
|
| | 0 … 1 | R | | (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> |
| | hl7:time
|
| TS.IPS.TZ | 1 … 1 | M | Time of signing the document | (HL7‑IPS |
| | hl7:signatureCode
|
| CS | 0 … 1 | R | Signature code | (HL7‑IPS |
| CONF | 1 … 1 | F | S |
| | hl7:assignedEntity
|
| | 0 … 1 | R | The entity that is responsible for the legal authentication of the CDA document | (HL7‑IPS |
| | 1 … * | M | Unique identification of legal authenticator | (HL7‑IPS |
| AD.IPS | 1 … * | R | | (HL7‑IPS |
| TEL.IPS | 1 … * | R | | (HL7‑IPS |
| | 1 … 1 | R | Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) | (HL7‑IPS |
| cs | 0 … 1 | F | PSN |
| cs | 0 … 1 | F | INSTANCE |
| PN | 1 … 1 | R | Name of the legal authenticator | (HL7‑IPS |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
| | 1 … * | R | HP Family Name/Surname | (HL7‑IPS |
| | 1 … * | R | HP Given Name | (HL7‑IPS |
| | | hl7:representedOrganization
|
| | 1 … 1 | M | Organization the legal authenticator is acting for Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) | (HL7‑IPS |
| |
Included | 0 … * | | from 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (2017‑04‑12) |
| hl7:participant
|
| | 0 … * | R | Patient contacts or the Preferred Health Professional to contact in case of emergency. | (HL7‑IPS |
| where [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.2.4'] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | IND |
| Example | <participant typeCode="IND"> <templateId root="2.16.840.1.113883.3.1937.777.13.10.39"/> <associatedEntity classCode="NOK"> <addr> <streetAddressLine>Promenade des Anglais 111</streetAddressLine> <city>Lyon</city> <postalCode>69001</postalCode> <country>FR</country> </addr> <telecom value="tel:(+33)555-20036" use="WP"/> <associatedPerson> <name> <given>Martha</given> <family>Mum</family> </name> </associatedPerson> </associatedEntity></participant> |
| | hl7:templateId
|
| II | 1 … 1 | M | | (HL7‑IPS |
| uid | 1 … 1 | F | 2.16.840.1.113883.10.22.2.5 |
| | hl7:functionCode
|
| | 0 … 1 | C | The <functionCode> element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency. | (HL7‑IPS |
| CONF | 1 … 1 | F | PCP |
| 1 … 1 | F | 2.16.840.1.113883.5.88 (Participation Function) |
| | hl7:time
|
| IVL_TS.IPS.TZ.OPT | 0 … 1 | R | The <time> element may be present and indicates the time of the participation. | (HL7‑IPS |
| Example | Precision Day <time value="20070213"/> |
| Example | Precision minute (requires timezone) <time value="200702131234+0100"/> |
| | hl7:associatedEntity
|
| | | R | The <associatedEntity> element identifies the type of contact. | (HL7‑IPS |
| cs | 1 … 1 | R | |
| CONF | The value of @classCode shall be drawn from value set 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes (DYNAMIC) |
|
| Example | <associatedEntity classCode="ECON"> <addr> <streetAddressLine>Karl Strasse</streetAddressLine> <city>Freiberg</city> <postalCode>09599</postalCode> <country>DE</country> </addr> <telecom value="tel:+49-761-11110000" use="WP"/> <associatedPerson> <name> <given>Arzt</given> <family>Guter</family> </name> </associatedPerson></associatedEntity> |
| CV.IPS | 0 … 1 | R | This element indicates the relationship between the patient and this participant.
| (HL7‑IPS |
| CONF | The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.38 epSOSPersonalRelationship (DYNAMIC) |
|
| Example | <code code="AUNT" displayName="aunt" codeSystem="2.16.840.1.113883.5.111"> <translation displayName="θεία"/></code> |
| AD.IPS | 1 … 1 | R | Patient Contact's / Preferred HP's Address | (HL7‑IPS |
| cs | 0 … 1 | F | NI |
| Schematron assert | role | error | |
| test | @nullFlavor or hl7:* | |
| Message | If addr is not nullflavored at least one sub element has to be provided | |
| | 0 … * | R | Patient Contact's Street/Number of Street / Preferred HP's Street/Number of Street | (HL7‑IPS |
| | 0 … 1 | R | Patient Contact's City / Preferred HP's City | (HL7‑IPS |
| | 0 … 1 | R | Patient Contact's Postal Code / Preferred HP's Postal Code | (HL7‑IPS |
| | 0 … 1 | R | Patient Contact's State or Province / Preferred HP's State or Province | (HL7‑IPS |
| | 0 … 1 | R | Patient Contact's Country / Preferred HP's Country. When used addr.country it is always bound to the epSOSCountry value set | (HL7‑IPS |
| TEL | 1 … * | R | Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required. | (HL7‑IPS |
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) |
|
| cs | 0 … 1 | F | NI |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present
|
| Example | <art:placeholder> <telecom use="WP" value="tel:+45 20 7025 6161"/> <telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/></art:placeholder> |
Choice | 1 … 2 | | Elements to choose from:- hl7:associatedPerson
- hl7:scopingOrganization
|
| | 0 … 1 | C | | (HL7‑IPS |
| PN | 1 … 1 | R | Patient Contact's Name / Preferred HP's Name | (HL7‑IPS |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
| | 1 … * | R | Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname | (HL7‑IPS |
| | 1 … * | R | Patient Contact's Given Name / Preferred HP's Given Name | (HL7‑IPS |
| | 0 … 1 | C | | (HL7‑IPS |
| ON | 1 … 1 | R | Organization's Name | (HL7‑IPS |
Included | 1 … 1 | M | from 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (2017‑04‑12) |
| hl7:documentationOf
|
| | 1 … 1 | M | 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.
| (HL7‑IPS |
| | @typeCode
|
| cs | 1 … 1 | F | DOC |
| Example | <documentationOf> <serviceEvent classCode="PCPR"> <effectiveTime> <low nullFlavor="NI"/> <high value="20110308"/> </effectiveTime> <performer typeCode="PRF"> <!-- See example below --> </performer> </serviceEvent></documentationOf> |
| | hl7:serviceEvent
|
| | 1 … 1 | R | 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.
| (HL7‑IPS |
| cs | 1 … 1 | F | PCPR |
| cs | 1 … 1 | F | EVN |
| II | 0 … * | R | | (HL7‑IPS |
| IVL_TS | 1 … 1 | R | | (HL7‑IPS |
| TS | 1 … 1 | R | | (HL7‑IPS |
| TS | 1 … 1 | R | | (HL7‑IPS |
| | 0 … * | R | It 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 |
| cs | 1 … 1 | R | |
| CONF | The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC) |
|
| Example | <performer typeCode="PRF"> <functionCode 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"/> </functionCode> <assignedEntity> <id assigningAuthorityName="MEF" displayable="false" extension="DVLMMG57R07F205G" root="2.16.840.1.113883.2.9.4.3.2"/> <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> |
| CE.IPS | 0 … 1 | R | It 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 shall be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (2017‑06‑21) |
|
| IVL_TS.IPS.TZ | 0 … 1 | R | | (HL7‑IPS |
| | 1 … 1 | M | | (HL7‑IPS |
| II | 1 … * | R | Healthcare provider ID number | (HL7‑IPS |
| CE.IPS | 0 … 1 | R | Healthcare provider specialty | (HL7‑IPS |
| AD.IPS | 1 … * | R | | (HL7‑IPS |
| TEL.IPS | 1 … * | R | | (HL7‑IPS |
| | 0 … 1 | | Contains 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC) | (HL7‑IPS |
| | | | | hl7:representedOrganization
|
| | 0 … 1 | | Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) | (HL7‑IPS |
Included | 0 … * | R | from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (2017‑04‑12) |
| hl7:relatedDocument
|
| | 0 … * | R | 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). In some cross-border services legal agreements (see e.g. the European Digital Service Infrastructure for eHealth), for liability reasons, it is required that together with the Patient Summary also a printable representation of the original national data / document this IPS comes from is also transmitted or made available for consultation. 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 no one of the allowable relationships defined by the CDA standard (XFRM, RPLC, APND) fits perfectly with the described case; the APND relationship seems to be that 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.”
| (HL7‑IPS |
| | @typeCode
|
| cs | 1 … 1 | R | |
| CONF | The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC) |
|
| 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 <CDAfragment> <!-- 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 --> </CDAfragment> |
| | hl7:parentDocument
|
| | 1 … 1 | R | | (HL7‑IPS |
| cs | 0 … 1 | F | DOCCLIN |
| cs | 0 … 1 | F | EVN |
| II | 1 … * | R | | (HL7‑IPS |
| CD.IPS | 0 … 1 | R | | (HL7‑IPS |
| CONF | 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| ED | 0 … 1 | R | | (HL7‑IPS |
| II | 0 … 1 | R | | (HL7‑IPS |
| INT | 0 … 1 | R | | (HL7‑IPS |
| hl7:component
|
| | 1 … 1 | M | | (HL7‑IPS |
| | hl7:structuredBody
|
| | 1 … 1 | M | | (HL7‑IPS |
| cs | 0 … 1 | F | DOCBODY |
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.22.3.1 IPS Medication Summary Section (DYNAMIC) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='10160-0' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='48765-2' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.22.3.3 IPS Problems Section (DYNAMIC) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='11450-4' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='10167-5' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.5 IPS Immunizations Section (DYNAMIC) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='11369-6' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='46264-8' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section (DYNAMIC) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='11348-0' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.14 IPS Results Section (2017‑04‑30) | (HL7‑IPS |
| | 0 … 1 | | Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (2017‑04‑13) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='47420-5' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | | Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Treatment Section (2017‑04‑13) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='18776-5' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | | Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (2017‑04‑13) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='29762-2' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | | Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (2017‑04‑13) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='10162-6' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 0 … 1 | | Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (2017‑04‑13) | (HL7‑IPS |
| | | where [hl7:section [hl7:code [(@code='42348-3' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |