2.16.840.1.113883.10.22.1.1/static-2017-04-11T000000

Id	2.16.840.1.113883.10.22.1.1	Effective Date	2017‑04‑11 Other versions this id:
Status	Draft	Version Label
Name	HL7-IPS	Display Name	International 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
Context	Pathname /
Classification	CDA Document Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 0 templates, Uses 20 templates Uses as Name Version 2.16.840.1.113883.10.22.2.1 Include IPS CDA recordTarget DYNAMIC 2.16.840.1.113883.10.22.2.2 Include IPS CDA author DYNAMIC 2.16.840.1.113883.10.22.2.3 Include IPS CDA custodian DYNAMIC 2.16.840.1.113883.10.22.2.4 Include IPS CDA legalAuthenticator DYNAMIC 2.16.840.1.113883.10.22.2.5 Include IPS Patient Contacts DYNAMIC 2.16.840.1.113883.10.22.2.6 Include IPS CDA documentationOf DYNAMIC 2.16.840.1.113883.10.22.2.7 Include IPS CDA relatedDocument DYNAMIC 2.16.840.1.113883.10.22.3.1 Containment IPS Medication Summary Section DYNAMIC 2.16.840.1.113883.10.22.3.2 Containment IPS Allergies and Intolerances Section DYNAMIC 2.16.840.1.113883.10.22.3.3 Containment IPS Problems Section DYNAMIC 2.16.840.1.113883.10.22.3.4 Containment IPS History of Procedures Section DYNAMIC 2.16.840.1.113883.10.22.3.5 Containment IPS Immunizations Section DYNAMIC 2.16.840.1.113883.10.22.3.6 Containment IPS Medical Devices Section DYNAMIC 2.16.840.1.113883.10.22.3.14 Containment IPS Results Section DYNAMIC 2.16.840.1.113883.10.22.3.7 Containment IPS History of Past Illness Section DYNAMIC 2.16.840.1.113883.10.22.3.8 Containment IPS Functional Status Section DYNAMIC 2.16.840.1.113883.10.22.3.9 Containment IPS Plan of Care Section DYNAMIC 2.16.840.1.113883.10.22.3.10 Containment IPS Social History Section DYNAMIC 2.16.840.1.113883.10.22.3.11 Containment IPS History of Pregnancy Section DYNAMIC 2.16.840.1.113883.10.22.3.12 Containment IPS Advance Directives Section DYNAMIC
Relationship	Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 (2013‑12‑20) Adaptation: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
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>
Item DT Card Conf Description Label hl7:ClinicalDocument 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. (HL7-IPS) 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" displayName="normal"/> hl7:language​Code CS 1 … 1 M Document Language Code (HL7-IPS)   Constraint The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)   Example <languageCode code="en-GB"/>   Example <languageCode code="fil-PH"/>   Schematron assert role  error     test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')     Message The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO country code; CC is ISO language code)   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 (DYNAMIC) hl7:recordTarget 1 … 1 M (HL7-IPS) @typeCode cs 0 … 1 F RCT @context​Control​Code 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)   hl7ips-data​element-2.1  Patient Attributes  CEN/TC 251 prEN 17269 @classCode cs 0 … 1 F PAT hl7:id II 1 … * R Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) (HL7-IPS)   hl7ips-data​element-7  Insurance identifier  CEN/TC 251 prEN 17269 hl7ips-data​element-202  Healthcare related Identifiers  CEN/TC 251 prEN 17269 hl7:addr AD.IPS 1 … * R The patient address. (HL7-IPS)   hl7ips-data​element-162  Address  CEN/TC 251 prEN 17269   Constraint When used for cross-border exchange the country address part has to be provided. Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 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 cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Message If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line (HL7-IPS)   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Message If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City (HL7-IPS) hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code (HL7-IPS) hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province (HL7-IPS) hl7:country ADXP 0 … 1 C Subject's Country. (HL7-IPS)   Constraint The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300. hl7:telecom TEL 1 … * R Patient’s telecom information : e.g. telephone number, e-mail address.  (HL7-IPS)   hl7ips-data​element-100  Telecoms  CEN/TC 251 prEN 17269 @use 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) @nullFlavor 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"/> hl7:patient 1 … 1 M (HL7-IPS) @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE   Example Japanese example (Person Name) <patient>   <name use="IDE">     <family>木村</family>    <given>通男</given>  </name>  <name use="SYL">     <family>きむら</family>    <given>みちお</given>  </name>  <name use="ABC">     <family>KIMURA</family>    <given>MICHIO</given>  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient> hl7:name PN 1 … * M Patient Name (HL7-IPS)   hl7ips-data​element-3  Patient's Name  CEN/TC 251 prEN 17269   Constraint The Alphabetic representation of the name SHALL be always provided hl7:family 1 … * R Patient's Family Name/Surname (HL7-IPS) hl7:given 1 … * R Patient's Given Name (HL7-IPS) hl7:administrative​Gender​Code CE.IPS 1 … 1 R Patient's Gender (HL7-IPS)   hl7ips-data​element-4  Administrative Gender  CEN/TC 251 prEN 17269 @nullFlavor 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> hl7:birthTime TS 1 … 1 R Patient's Date of Birth. The patient date of birth may be a partial date such as only the year. (HL7-IPS)   hl7ips-data​element-5  Date of Birth  CEN/TC 251 prEN 17269 hl7:guardian 0 … * R The guardians of a patient. Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact. (HL7-IPS) @classCode cs 1 … 1 F GUARD   Example <guardian classCode="GUARD">   <code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/>  <addr nullFlavor="NI"/>  <telecom use="MC" value="tel:+33-12345678"/>  <guardianPerson>     <name>       <family>Curie</family>      <given>Marie</given>    </name>  </guardianPerson></guardian> hl7:code CD.IPS 0 … 1 R The 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) hl7:addr AD.IPS 1 … * R (HL7-IPS)   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. Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 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 cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Message If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line (HL7-IPS)   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Message If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City (HL7-IPS) hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code (HL7-IPS) hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province (HL7-IPS) hl7:country ADXP 0 … 1 C Subject's Country. (HL7-IPS)   Constraint The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300. hl7:telecom TEL 1 … * R Guardian’s telecom information: e.g. telephone number; e-mail address.  (HL7-IPS) @use 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) @nullFlavor 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. hl7:guardian​Person 1 … 1 R (HL7-IPS) hl7:name PN 1 … * R Patient Guardian's Name (HL7-IPS) hl7:family ENXP 1 … * R Patient Guardian's Family Name/Surname (HL7-IPS) hl7:given ENXP 1 … * R Patient Guardian's Given Name (HL7-IPS) hl7:language​Communication 0 … * R (HL7-IPS) hl7:language​Code CS 1 … 1 R Patient’s language (HL7-IPS)   hl7ips-data​element-135  Patient’s preferred language  CEN/TC 251 prEN 17269   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)   Example British English <languageCode code="en-GB"/>   Example Amurdak (Australia) <languageCode code="amg-AU"/>   Schematron assert role  error     test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')     Message The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO country code; CC is ISO language code)   Included 1 … * M from 2.16.840.1.113883.10.22.2.2 IPS CDA author (DYNAMIC) hl7:author 1 … * M (HL7-IPS) @typeCode cs 0 … 1 F AUT @context​Control​Code 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 'IPS CDA Organization' (dynamic) -->   </representedOrganization></author> hl7:functionCode CE.IPS 0 … 1 R (HL7-IPS) 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) @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * R Author Identifier(s) (HL7-IPS) @nullFlavor cs 0 … 1   hl7:code CE.IPS (extensible) 0 … 1 R A 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"/> hl7:addr 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> hl7:telecom TEL.IPS 1 … * R (HL7-IPS) @use 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) @value st 0 … 1     Example <telecom use="WP" value="tel:+39-051-34343434"/>   Example <telecom nullFlavor="NI"/> Choice 1 … 1 Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device containing template 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) hl7:assigned​Person 0 … 1 C (HL7-IPS) @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 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> hl7:family 1 … * R (HL7-IPS) hl7:given 1 … * R (HL7-IPS) hl7:assigned​Authoring​Device 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:represented​Organization 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 (DYNAMIC) 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 'IPS CDA Organization' (dynamic) -->     </representedCustodianOrganization>  </assignedCustodian></custodian> hl7:assignedCustodian 1 … 1 R (HL7-IPS) @classCode cs 0 … 1 F ASSIGNED hl7:represented​Custodian​Organization 1 … 1 R Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) (HL7-IPS) @classCode cs 0 … 1 F ORG @determiner​Code cs 0 … 1 F INSTANCE Included 0 … 1 R from 2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator (DYNAMIC) 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) @code CONF 0 … 1 F S hl7:assignedEntity 0 … 1 R The entity that is responsible for the legal authentication of the CDA document (HL7-IPS) hl7:id 1 … * R Unique identification of legal authenticator (HL7-IPS) hl7:addr AD.IPS 1 … * R (HL7-IPS) hl7:telecom TEL.IPS 1 … * R (HL7-IPS) hl7:assigned​Person 1 … 1 R (HL7-IPS) @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 1 … * R Name of the legal authenticator (HL7-IPS)   Example <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * R HP Family Name/Surname (HL7-IPS) hl7:given 1 … * R HP Given Name (HL7-IPS) hl7:represented​Organization 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) where [not(@nullFlavor)] Included 0 … * from 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (DYNAMIC) hl7:participant 0 … * R Patient 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']   hl7ips-data​element-154  Patient’s Address Book  CEN/TC 251 prEN 17269 hl7ips-data​element-163  Preferred Healthcare providers  CEN/TC 251 prEN 17269 @typeCode cs 1 … 1 F IND   Example <participant typeCode="IND">   <templateId root="2.16.840.1.113883.10.22.2.5"/>  <associatedEntity classCode="NOK">     <addr>       <streetAddressLine>Promenade des Anglais 111</streetAddressLine>      <city>Lyon</city>      <postalCode>69001</postalCode>      <country>FR</country>    </addr>    <telecom value="tel:(+33)555-20036" use="WP"/>    <associatedPerson>       <name>         <given>Martha</given>        <family>Mum</family>      </name>    </associatedPerson>  </associatedEntity></participant> hl7:templateId II 1 … 1 M (HL7-IPS) @root 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.</functionCode> (HL7-IPS) @code CONF 0 … 1 F PCP @codeSystem 0 … 1 F 2.16.840.1.113883.5.88 (Participation Function) hl7:associated​Entity R The <associatedEntity> element identifies the type of contact. </associatedEntity> (HL7-IPS) @classCode 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> hl7:code 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 2.16.840.1.113883.11.22.54 IPS Personal Relationship (DYNAMIC) or The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)   Example <code code="AUNT" displayName="θεία" codeSystem="2.16.840.1.113883.5.111"/> hl7:addr AD.IPS 1 … * R Patient Contact's / Preferred HP's Address (HL7-IPS)   Schematron assert role  error     test @nullFlavor or hl7:*     Message If addr is not nullflavored at least one sub element has to be provided   Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 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 cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Message If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line (HL7-IPS)   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Message If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City (HL7-IPS) hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code (HL7-IPS) hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province (HL7-IPS) hl7:country ADXP 0 … 1 C Subject's Country. (HL7-IPS)   Constraint The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300. hl7:telecom TEL 1 … * R Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required.</telecom> (HL7-IPS)   hl7ips-data​element-174  Telecoms  CEN/TC 251 prEN 17269 hl7ips-data​element-169  Telecoms  CEN/TC 251 prEN 17269 @use 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) @nullFlavor 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="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/> Choice 1 … 2 Elements to choose from: hl7:associated​Person hl7:scoping​Organization hl7:associated​Person 0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided (HL7-IPS)   hl7ips-data​element-165  Healthcare Provider (person)  CEN/TC 251 prEN 17269 hl7:name PN 1 … * R Patient Contact's Name / Preferred HP's Name (HL7-IPS)   hl7ips-data​element-121  Name  CEN/TC 251 prEN 17269   Example <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * R Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname (HL7-IPS) hl7:given 1 … * R Patient Contact's Given Name / Preferred HP's Given Name (HL7-IPS) hl7:scoping​Organization 0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided (HL7-IPS)   hl7ips-data​element-166  Healthcare Provider (organisation)  CEN/TC 251 prEN 17269 hl7:name ON 1 … * R Organization's Name (HL7-IPS)   hl7ips-data​element-172  Organisation’s Name  CEN/TC 251 prEN 17269 Included 1 … 1 M from 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (DYNAMIC) 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 0 … 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) @classCode cs 1 … 1 F PCPR @moodCode cs 1 … 1 F EVN hl7:id II 0 … * R (HL7-IPS) hl7:effectiveTime IVL_TS 1 … 1 R (HL7-IPS) hl7:low TS 1 … 1 R (HL7-IPS) hl7:high TS 1 … 1 R (HL7-IPS) hl7:performer 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) @typeCode 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">   <assignedEntity>     <id assigningAuthorityName="MEF" displayable="false" extension="DVLMMG57R07F205G" root="2.16.840.1.113883.2.9.4.3.2"/>    <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors">       <translation codeSystem="2.16.840.1.113883.2.9.5.1.111" code="MMG" displayName="Medico di Medicina Generale"/>    </code>    <addr nullFlavor="NI"/>    <telecom nullFlavor="NI"/>    <assignedPerson>       <name>         <family>DVALUNO</family>        <given>MMG</given>      </name>    </assignedPerson>    <representedOrganization>       <id assigningAuthorityName="A.S.L. DELLA PROVINCIA DI LECCO" extension="030305" root="2.16.840.1.113883.2.9.4.1.1"/>      <name>A.S.L. DELLA PROVINCIA DI LECCO</name>      <telecom nullFlavor="NI"/>      <addr>         <state>LECCO</state>        <city>LECCO</city>        <country>IT</country>        <postalCode>23900</postalCode>        <streetAddressLine>CORSO CARLO ALBERTO,120</streetAddressLine>      </addr>    </representedOrganization>  </assignedEntity></performer> hl7:functionCode CE.IPS 0 … 1 R (HL7-IPS) hl7:time IVL_TS.IPS.TZ 0 … 1 R (HL7-IPS) hl7:assignedEntity 1 … 1 M (HL7-IPS) hl7:id II 1 … * R Healthcare provider ID number (HL7-IPS) hl7:code CE.IPS (extensible) 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 should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC) hl7:addr AD.IPS 1 … * R (HL7-IPS) hl7:telecom TEL.IPS 1 … * R (HL7-IPS) hl7:assigned​Person 0 … 1 Contains 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC) (HL7-IPS) hl7:represented​Organization 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 (DYNAMIC) hl7:relatedDocument 0 … * R (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) hl7:parentDocument 1 … 1 R (HL7-IPS) @classCode cs 0 … 1 F DOCCLIN @moodCode cs 0 … 1 F EVN hl7:id II 1 … * R (HL7-IPS) hl7:code CD.IPS 0 … 1 R (HL7-IPS) @codeSystem CONF 0 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) hl7:text ED 0 … 1 R (HL7-IPS) hl7:setId II 0 … 1 R (HL7-IPS) hl7:versionNumber INT 0 … 1 R (HL7-IPS) hl7:component 1 … 1 M (HL7-IPS) hl7:structuredBody 1 … 1 M Note: the proposed order of the sections hereafter indicated is not mandatory (HL7-IPS) @classCode cs 0 … 1 F DOCBODY hl7:component 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')]]] hl7:component 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')]]] hl7:component 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')]]] hl7:component 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 = '47519-4' and @codeSystem = '2.16.840.1.113883.6.1')]]] hl7:component 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')]]] hl7:component 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')]]] hl7:component 0 … 1 R Contains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC) (HL7-IPS) where [hl7:section [hl7:code [(@code = '30954-2' and @codeSystem = '2.16.840.1.113883.6.1')]]] hl7:component 0 … 1 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')]]] hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC) (HL7-IPS) where [hl7:section [hl7:code [(@code = '47420-5' and @codeSystem = '2.16.840.1.113883.6.1')]]] hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC) (HL7-IPS) where [hl7:section [hl7:code [(@code = '18776-5' and @codeSystem = '2.16.840.1.113883.6.1')]]] hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC) (HL7-IPS) where [hl7:section [hl7:code [(@code = '29762-2' and @codeSystem = '2.16.840.1.113883.6.1')]]] hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC) (HL7-IPS) where [hl7:section [hl7:code [(@code = '82810-3' and @codeSystem = '2.16.840.1.113883.6.1')]]] hl7:component 0 … 1 Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC) (HL7-IPS) where [hl7:section [hl7:code [(@code = '42348-3' and @codeSystem = '2.16.840.1.113883.6.1')]]]