2.16.840.1.113883.3.1937.777.11.10.102

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Template epSOSCDAauthor

Description

Keine Beschreibung in Deutsch (de-DE) verfügbar
en-US:

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 maybe the only one for this document);
• an application that transforms a prescription record into a epSOS eP CDA may not be an author instead;
• The NCP that modifies the concepts conveyed, should appear as one of the authors.
• The author of the parent document is often also an author of the document generated through a transformation process (in that case also the author time should be the same).

Further to this, is therefore possible to determine the Nature of Patient Summary as follows [Excluding the NCPs as authors]:

• if there is a person author only, there the Patient Summary is the result of a practitioner clinical act;
• if there is a device author only, the summary was automatically generated according to well defined rules defined by the responsible organization;
• if there are both a person and a device as authors, the summary was created via a mixed approach.

The CDA provides a mechanism to better specify who authored what within the document, allowing the specification of authorship at the whole document level, at the section level and finally at the entry level. In any case is not required to repeat this information for each level, taking advantage of the context conduction propriety. Infact “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).

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/ClinicalDocument/author/assignedAuthor
/ClinicalDocument/documentationOf/serviceEvent/performer (this applies to the prescriber and the dispenser).

The template ID referenced here refers to HP information in the /ClinicalDocument/documentationOf/serviceEvent/performer structure. In this document, the same requriements apply to the person author of the document (if there is one), and to the prescrober and dispenser (see body).

When there is no HP but we have the method of assembly of data by a device, such as the “spider” method, we have the following expression; ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice.

When the data is collected from different sources & pre-existing documents that are part of a bigger system. In that case the organization responsible of that collection “signed” the PS as responsible.

ClinicalDocument/author/assignedAuthor/representedOrganization

Actual version

Id	2.16.840.1.113883.3.1937.777.11.10.102	Effective Date	valid from 2013‑12‑20
Status	Draft	Version Label
Name	epSOSCDAauthor	Display Name	epSOS CDA author
Description <p>A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).</p> <p>For definition “The <code>author</code> element represents the creator of the clinical document. If the role of the actor is the <b>entry of information from his or her own knowledge or application of skills</b>, that actor is the author. If one actor provides information to another actor <b>who filters, reasons, or algorithmically creates new information</b>, then that second actor <b>is also an author, <u>having created information from his or her own knowledge or skills.</u>”</b> [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March 2009].</p> <p>According to this definition, not any device that generates the electronic document has to be considered as an author:</p> <ul> <li>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 maybe the only one for this document);</li> <li>an application that transforms a prescription record into a epSOS eP CDA may not be an author instead;</li> <li>The NCP that modifies the concepts conveyed, should appear as one of the authors.</li> <li>The author of the parent document is often also an author of the document generated through a transformation process (in that case also the author time should be the same).</li> </ul> <p>Further to this, is therefore possible to determine the Nature of Patient Summary as follows [Excluding the NCPs as authors]:</p> <ul> <li>if there is a person author only, there the Patient Summary is the result of a practitioner clinical act;</li> <li>if there is a device author only, the summary was automatically generated according to well defined rules defined by the responsible organization;</li> <li>if there are both a person and a device as authors, the summary was created via a mixed approach.</li> </ul> <p>The CDA provides a mechanism to better specify who authored what within the document, allowing the specification of authorship at the whole document level, at the section level and finally at the entry level. In any case is not required to repeat this information for each level, taking advantage of the context conduction propriety. Infact “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).</p> <hr/> <p>/ClinicalDocument/author/assignedAuthor<br/>/ClinicalDocument/documentationOf/serviceEvent/performer (this applies to the prescriber and the dispenser).</p> <p>The template ID referenced here refers to HP information in the /ClinicalDocument/documentationOf/serviceEvent/performer structure. In this document, the same requriements apply to the person author of the document (if there is one), and to the prescrober and dispenser (see body).</p> <p>When there is no HP but we have the method of assembly of data by a device, such as the “spider” method, we have the following expression; ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice.</p> <p>When the data is collected from different sources &amp; pre-existing documents that are part of a bigger system. In that case the organization responsible of that collection “signed” the PS as responsible.</p> <p>ClinicalDocument/author/assignedAuthor/representedOrganization</p>
Classification	CDA Header Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 9 concepts Id Name Data Set epsos-data​element-19 Author Full Name epSOS Data Set epsos-data​element-21 Family Name/Surname epSOS Data Set epsos-data​element-273 Prefix epSOS Data Set epsos-data​element-274 Suffix epSOS Data Set epsos-data​element-23 Author Healthcare Facility epSOS Data Set epsos-data​element-67 Author epSOS Data Set epsos-data​element-22 Author Identification epSOS Data Set epsos-data​element-20 Given Name epSOS Data Set epsos-data​element-180 Author Role epSOS Data Set
Used by / Uses	Used by 0 transactions and 1 template, Uses 2 templates Used by as Name Version 2.16.840.1.113883.3.1937.777.13.10.28 Include IPS Entry Comment (0) 2017‑04‑07 10:00:14 Uses as Name Version 2.16.840.1.113883.3.1937.777.11.10.129 Containment CDA Device () DYNAMIC 2.16.840.1.113883.3.1937.777.11.10.111 Containment epSOS CDA Organization () DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.102 CDA author (2005‑09‑07) ref (from repository: ad1bbr-)
Example	Example <author>   <time value="20121229"/>  <assignedAuthor>     <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr>       <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></author>
Item DT Card Conf Description Label hl7:author 1 … * R epSO...thor   epsos-data​element-67 Author epSOS Data Set @typeCode cs 0 … 1 F AUT @context​Control​Code cs 0 … 1 F OP hl7:functionCode CE.EPSOS 0 … 1 R R1.10.6   epsos-data​element-180 Author Role epSOS Data Set   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.1 epSOSHealthcareProfessionalRoles (DYNAMIC) hl7:time TS.EPSOS.TZ 1 … 1 R The author/time element represents the start time of the author’s participation in the creation of the clinical document. The author/time element SHALL be present. epSO...thor hl7:assignedAuthor 1 … 1 R epSO...thor @classCode cs 0 … 1 F ASSIGNED   Schematron assert role  error     test @nullFlavor or hl7:assigned​Person or hl7:assigned​Authoring​Device     Message 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" 2.16.840.1.113883.5.1008 NullFlavor STATIC.   hl7:id II.EPSOS 1 … * R HP ID number R1.10.5   epsos-data​element-22 Author Identification epSOS Data Set @nullFlavor cs 0 … 1 F NA hl7:code CE.EPSOS 0 … 1 R HP Specialty R1.10.7 hl7:addr AD.EPSOS 1 … * R IHE PCC hl7:telecom TEL.EPSOS 1 … * R Attribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLScheme IHE PCC / R1.10.8 / R1.10.8.1 / R1.10.8.2 @use set_cs 0 … 1     CONF The value of @use shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.40 epSOSTelecomAddress (DYNAMIC) Choice 0 … 1 Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device containing template 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC) hl7:assigned​Person R epSO...thor @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 1 … 1 R HP Name IHE PCC   epsos-data​element-19 Author Full Name epSOS Data Set   Example <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * M HP Family Name/Surname R1.10.1   epsos-data​element-21 Family Name/Surname epSOS Data Set hl7:given 1 … * M HP Given Name R1.10.2   epsos-data​element-20 Given Name epSOS Data Set hl7:prefix 0 … * R HP Prefix R1.10.3   epsos-data​element-273 Prefix epSOS Data Set hl7:suffix 0 … * R HP Suffix R1.10.4   epsos-data​element-274 Suffix epSOS Data Set hl7:assigned​Authoring​Device R Contains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC) epSO...thor hl7:represented​Organization 1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9   epsos-data​element-23 Author Healthcare Facility epSOS Data Set

List of all versions of this template

• 2013-12-20 (Under develeopment)