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This document contains: Implementation Guide International Patient Summary (0.10). The text materials belong to category cdaips.

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HL7 International Patient Summary
based on Clinical Document Architecture Release 2

Implementation Guide

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Primary Editor	Giorgio Cangioli, PhD Consultant, HL7 Italy giorgio.cangioli@gmail.com
Primary Editor	Rob Hausam Hausam Consulting LLC rob@hausamconsulting.com
Primary Editor	Dr Kai U. Heitmann Heitmann Consulting and Services, HL7 Germany, ART-DECOR Open Tools GmbH info@kheitmann.de
Primary Editor	François Macary Phast francois.macary@phast.fr
Contributor	Dr Philip Scott HL7 UK philip.scott@uwtsd.ac.uk
Contributor	Dr Christof Geßner Gematik christof.gessner@gematik.de
Contributor	Dr Stefan Sabutsch ELGA, HL7 Austria stefan.sabutsch@elga.gv.at
Contributor	Gary Dickinson CentriHealth gary.dickinson@ehr-standards.com
Contributor	Catherine Chronaki HL7 International Foundation chronaki@gmail.com
Contributor	Dr Stephen Chu HL7 Australia chuscmi88@gmail.com
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)

1 Introduction
2 Design conventions and principles
3 Conformance clause
4 Functional requirements and high-level use cases
- 4.1 Code mappings and multilinguistic support
  - 4.1.1 Concept code mapping
  - 4.1.2 Multilinguistic support
    - 4.1.2.1 Designations’ Translation
    - 4.1.2.2 Narrative Translation
5 Reading Guide
6 CDA Document Level Templates
- 6.1 International Patient Summary
7 CDA Header Level Templates
8 CDA Section Level Templates
9 CDA Entry Level Templates
10 HL7 V2/V3 Datatype Level Template
- 10.1 IPS Address
11 Appendix
12 List of all artifacts used in this guide
13 Examples (in progress)
14 References

Introduction

Responsible: Philip Scott

In Review

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

Please Note

Missing some explanation about the actual meaning of “specialty-agnostic, condition-independent”: not specialty or condition filtered PS, focused on actual situation and not the patient history non-exhaustive - not reproduce content of EHR... (Kai)

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 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.
Where possible, 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, ONC, Trillium Bridge, Sequoia eHealth Exchange), 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^[1]. 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; and the IPS became one of the main subjects of the new EU / US roadmap , having as declared goal “to enable a standardized international patient summary (IPS) to be in use by 2020”^[2].

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 both 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 European standard (EN) "The Patient Summary for Unscheduled, Cross-border Care" (the CEN/TC 251 EN PS in ^{[Figure 1]}); the HL7 ones on its implementation based on HL7 CDA R2 - this guide - and hopefully 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.

^{[Figure 1]} 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, which is specialty-agnostic and condition-independent, but still clinically relevant.”.

Scope

to be written

Responsible: Kai Heitmann

...a minimal and non-exhaustive patient summary, which is specialty-agnostic and condition-independent, but still clinically relevant. ...global use

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.

^{[Figure 2]}The IPS Principles

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
The standards specification for the IPS will be applicable for global use
- Strive for global accessibility of standards for free
- 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
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
The standards specifications 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 specifications 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 unplanned (cross-border) 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 implementers;with that of optimizing the fitness for purpose within the IPS scope. All this trying to avoid a pure technical exercise of templates harmonization; or, on the other hand, an academic exercise that does not take in account what is already implemented.

^{[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 available a set of free value sets that could be globally usable when the IPS would be implemented.
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 the global identification of that element.
Select a set of reference global terminologies, leaving however space for the inclusion of the locally used terminologies.
Do not choose solutions (e.g. identifiers, terminologies, standards) , even promising in the resolution of some of the well-known issues (as the medicinal product identification), that are not yet available for concrete global use. When possible, the IPS has been however already designed in order to be ready when these solutions will be made available for real use (e.g. the IDMP identifiers) or to support since now the parts of those solutions that could be used today.
Within the scope of the IPS and of the “implementable” principle, attempt to be enough generic in the design of the templates in order that the IPS templates might be hopefully extensible to support new scenarios; or specific specialties or conditions; through templates specialization or adaptation mechanisms.

Structuring Choices

The International Patient Summary is specified as a templated document using HL7 CDA R2. The specification has taken account of how FHIR represents equivalent concepts and in some cases has followed a FHIR style of representation rather than a conventional CDA style. The variations from CDA R2 are explained in the relevant detail sections. The mechanism for negation, unknown data and known absent data does not follow the CDA conventions and is explained here.

To be universally exchangeable, a patient summary must rely on multilingual international reference terminologies. The International Patient Summary defines SNOMED CT as a primary terminology (the meaning of "primary terminology" is explained in a later section) and it is used for the majority of value sets. Other primary terminologies used by this specification are LOINC for observations (e.g., laboratory tests) and document sections, UCUM for units of measure and EDQM for dose forms and routes.

This specification adopts ART-DECOR® as the specification platform for this Implementation Guide and uses the HL7 template exchange format. 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.

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 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 EHRs unplanned care system, personal health records and mobile health data applications.
System integrators.
Organizations that manage regional and national patient summaries.

Relationships with other projects and guidelines

Responsible: Giorgio Cangioli

In Review

This guide is one of the products of the International Patient Summary project (see the Project Background section for details). This project relates to a 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: 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 an European standard it is designed to be applicable in a wider global context.
- The CEN/TC 251 “prTS: 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.

^{[Figure 3]}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. (https://ec.europa.eu/health/sites/health/files/ehealth/docs/ev_20161121_co10_en.pdf).
This Guideline, together with the general guidelines for the electronic exchange of health data under Cross-Border Directive 2011/24/EU, document 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 the figure included in the section Conformance clause below.

The HL7 Consolidated CDA (C-CDA) 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 provide 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) – “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.”[ IHE Patient Care Coordination (PCC) 5 Technical Framework].
This is one of the primary sources for this Implementation Guide.
eHealth Digital Service Infrastructure (eHDSI) Patient Summary Service. 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. eHDSi specification are available at https://ec.europa.eu/cefdigital/wiki/display/EHOPERATIONS/Specifications.
This is one of the primary sources for this Implementation Guide.
The Data Provenance is a 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 is one of the products as result of 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.

How to read this document

Kai to write a paragraph
Balloter instructions

Responsible: Kai Heitmann

Responsible: Kai Heitmann, Giorgio Cangioli

IPS Technical Background

Design conventions and principles

Responsible: Rob Hausam, François Macary

How to use terminologies (preferred binding)

As stated above, 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, EDQM Standard Terms. These reference 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.

Nethertheless, 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 inteface 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.
The Display Name of the Primary Code shall be populated with a term representing this same code in the primary terminology, in the language chosen for the current instance of the patient summary.
When the Primary Code is not populated, the Original Text shall be populated with a textual expression representing the meaning for the producer.
One or more Alternate Codes from a local interface terminology may be provided, each with its associated Display Name.

Primary Code

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

Representing "known absent" and "not known"

In Review

Responsible: Philip Scott, Giorgio Cangioli, Kai Heitmann, Francois Macary

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-borders services, this guide explicitly addresses two general situations:

condition or activity unknown;
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, even if it is not precluded to provide them.

This specification represents this core set of negations (“condition/activity unknown” and “condition/activity known absent” ) by leveraging the expressiveness of SNOMED CT to use explicit coded elements rather than relying on specific mechanisms of the underlying syntactical standard (such as nullFlavor and negationInd attributes for CDA).

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 have a representation of the clinical content of the patient summary which is 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 either 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.

In some cases this required the creation of new SNOMED CT concepts. For example, a known absent Allergy/Intolerance would be represented by "716186003 |No known allergy (situation)|" (or any combination of its descendants), whereas no information about Allergy/Intolerance would be represented by a code with the meaning "Allergic disposition not known (situation)". For these cases an HL7 extension to SNOMED CT has been created, working for their future inclusion in the SNOMED CT International Release.

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.

Uncoded information

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

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

The first case, assuming that the coding strength is 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: datatype R1 doesn't allow to specify that there are no codes applicable in the referred value set, as instead possible with datatype R2. Future versions of this guide may consider to extend the datatype to better support this situation.

The second case, that applies both to CNE and 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 to be used here would be "UNC" (Uncoded) but this code is not part of the nullFlavors foreseen by the CDA R2 standard.

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, is recommended that the original code is reported in the IPS instance as well as the indication that the mapping didn’t occur. (See also the Concept code mapping in the functional requirements section.)

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

In the case of coding strength CNE the following statement can be used to express that no appropriate target coded concepts were found:

<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; datatype R1 doesn't allow to specify this difference, that is that there are no codes applicable in the reference value set, as instead possible with datatype R2. Future versions of this guide may consider to extend the datatype to better support this situation.

Even if, in case of CWE coding strength, it would be allowed to leave the orginal code as the primary code, this guide suggests that to highlight that a mapping to the reference value set was attempted and no suitable target codes were identified, it is reccomended to represent the original code in the <translation> sub-element and value with a nullFlavor the main coded element.

<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 sets. When this happens both the original and the reference codes should be reported in the IPS instance. Other conditions that should be considered are described in the Concept code mapping in the functional requirements section, and refer to the multiple coding; the preservation of the link to the original text; the mapping between a same code system.

All those aspects are considered in this section.

The simplest situation is the case of a single code mapped into a reference one, with original and reference codes belonging to different code systems. Hereafter the way to represent it:

<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

The second example is the case in which the originator provides a multiple mapping. In this case if the primary code is one belonging to the reference value set noting should be done. If not, as in the example below, all the original primary and alternate coded concepts are represented in a nested translation element, as described by the following example:

<value code="422479008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="FEMALE BREAST INFILTRATING DUCTAL CARCINOMA, STAGE 2" xsi:type="CD">
 <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>

The third case is when the 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 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 datatype 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 on representation in a single code system where code systems allow multiple representations, such as Snomed-CT”. Datatype R2 extended in fact 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).

It is known that there is not a “native” way to convey this kind of information using the coded descriptor (and derived) datatypes, in fact the @displayName attribute has cardinality 0..1 and the <translation> was designed for the coding translation, “that is to translate this concept descriptor into other code systems” and not for the translation of designations.

Note for balloters:
two options has been discussed and reported in this ballot version of this guide to collect feedback from ballotters.

The first one is base on an optional extension to the CD datatype ;
The second one doesn't require extensions, but some flexibility in the use of the <translation> element.

these two options are not mutually exclusive.

The first solution is based on an optional extension to the CD datatype ; A description of the extended CD and CE datatypes is provided in the Datatypes section.

Hereafter some examples of possible use of this extension in case of

No code mapping

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

Codes mapping

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

The second one doesn't require extensions, but it some flexibility in the use of the <translation> element. In this case the language code can be declared.

No code mapping

<code code="60591-5" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Patient Summary">
    <translation code="60591-5" codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC" displayName="Profilo Sanitario Sintetico" /> 
</code>

Codes mapping

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

Narrative Translations

With “narrative translation” is meant 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 to this process are described in the Designations’ Translation under the Functional requirements and high-level use cases section, and can be summarized in two main points : (a) language identification and (b) distinguishable original and translated narratives. It would be moreover good if the methodology applied for the narrative translation (e.g. derived from the coded entries; translated by a generic service;..) should be recognizable.

Considering that only one <text> element is allowed for section, the solution suggested by this guide is to document the narrative translations into subordinate sections (one for translation) as described by the template 2.16.840.1.113883.10.22.3.15.

Hereafter an example:

<section>
  <templateId root="2.16.840.1.113883.3.1937.777.13.10.5"/>
   <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>No known Allergies</text>
   <!--  OMISSIS --> 
   <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>

Medicinal Product Identifications

In Review

Responsible: Giorgio Cangioli

The identification of medicinal products – that in general is quite-easily solved within a single jurisdiction relaying on local drugs databases – is instead one of the major still open issue for cross-jurisdictional services.

The set of ISO standards call IDMP [ref] - designed initially for the regulatory scopes, but hopefully extensible to other domains- are the most promising solution for solving this known issue as also highlighted by the European project OpenMedicine [ref]. The completion of the IDMP implementation guides; the deployment of the needed supporting services; 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. Some further years are needed before these identifiers and attributes will be available for actual use.

Following therefore the IPS principles of “implementability” and “openness and extensibility” the solution here proposed will not then rely on the IDMP identifiers; being however already suitable for representing the IPS relevant IDMP identifiers and attributes: e.g. Pharmaceutical Product Identifiers (PhPIDs); Medicinal Product Identifier (MPID); Medicinal Product Package Identifier (PCID).

Note for ballotters: IPS members had no access to the latest version of the IDMP implementation guides; any indication that may help the alignment with those standards would be appreciated.

Note: IDMP Medicinal Product (MPID) and Medicinal Product Package (PCID) identifiers depends on the market authorization, the “same” product might therefore have different IDs if different authorizations have been required in different countries (the PhPID should be however the same). For the purpose of the IPS it might be useful if in future standards will be defined new global product identifiers that are independent by the drug registration process (as the Virtual Medicinal Product in SNOMED CT) and related to the IDMP identifiers.

Thus, in absence of a global identification system for products, the solution here proposed is based on the approach initially adopted by the European cross-border services (epSOS and currently by the eHDSI project), then reused by the IHE Pharmacy templates and more recently adopted (for specific cases) also by the HL7 Pharmacy Medication statement templates. The main idea is in fact that of integrating possible 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; (administrable) dose forms; strengths; route of administration; package description.

Medicines data are usually represented in the CDA Templates using the class manufacturedMaterial, that includes a code and a name used for describing any level of product: packaged product, medicinal product, classes or clusters or products, and so on. This information is not however sufficient for covering the defined needs.

^{[Figure 4]} Representation of medicines in CDA

Hence, in order to be able to describe these attributes an extension of the CDA model needs to be applied and this was done in epSOS enhancing the Manufactured Product and Material classes from the CDA model with the attributes and relationships derived from the Medication and Medicine classes from the R_Medication CMET.

The same design approach has been followed for this guide adopting the Common Product Model (R_ProductListed) instead.

This choice has been made:

considering the expected use of this 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 for there to be a single such representation, which could then be used as a common message element type (CMET) across those models.”)
to eventually have a common implementable solution to represent the future IDMP identifiers and attributes in the IPS and in other document based standards (as SPL).

^{[Figure 5]} shows how the CDA model has been enhanced with the Common Product Model: the relationship and classes of the CPM manufactured material (Product) class has been added as extensions to that of the CDA model (Material); the same has been done for the ManufacturedProduct classes.

^{[Figure 5]} CDA model and the Common Product Model

Medication Statement

Responsible: Giorgio Cangioli, Kai Heitmann

Provenance

Responsible: Philip Scott; Gary Dickinson

In Review

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:

Require document-level, not section level, provenance.
Define IPS document provenance as one of two types: human-curated or software-assembled.
- 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 document 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, this is not the same as legalAuthenticator. 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.

The 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.

General Implementation Guidance

Responsible: Kai Heitmann

How to populate IDs in an CDA XML instance, e.g. ClinicalDocument.id, setId
Where I can get IDs
Relevant times for a patient summary
Description of the different status definitions (condition, concern, observation) --> Giorgio
(Authorship is probably a part to go to Provenance)

Conformance clause

Responsible: Stephen Kay, Giorgio Cangioli

In Review

This section references the requirements, criteria, or conditions to be satisfied in order that a product (tangible) or a service may claim conformance about this guide, and how other artefacts 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^[3]. The fulfilment of these clauses indirectly assure that a product that is subject of a “conformity assessment” satisfies the business or the design requirements this specification complies to. It should be however clear that the compliance with specified business or the design requirements, for example in the future with the CEN prEN IPS, doesn’t 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, it is also true in the service or product that implements it. In most real-world cases conformance testing objects are used to technically validated the products. These objects provide a great help in the validation of the instances, even if it is not often these kind of validation is not self-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 6]} 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 artefacts 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 )

^{[Figure 6]}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 that applies 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^[4]) There are no additional requirements to be applied for this guide for what concern the Recipient and the Originator Responsibilities.

The formal representation used in this implementation guide for expressing the conformance statement is described in section ZZZ 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^[5] in order to facilitate also the automatic generation of consistent testing objects.

This standard (i.e. 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 an IPS specialized document level template, are fulfilled. Implementers may take advantage of the template openness to better support specific cases, “extended” parts may be however not 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 electronics implementation of the WHO yellow card for vaccinations; or the used section to send back a cross border encounter report after the Patient Summary has been used. Implementers may take advantage of the template openness to better support specific cases, “extended” parts may be however not interoperable among them.
IPS as a reference: the implementation is conformant with templates that are adaptation 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 be not so huge. Typical examples are templates in which alternatives vocabularies are used.

Jurisdiction may also decide to impose the closure of the template in order to limit the implementation optionality, this should be carefully evaluated in term of flexibility of the solution.

Functional requirements and high-level use cases

Responsible: Giorgio Cangioli

In Review

Several 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 (in progress) provides examples 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.

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

an IPS could be a created when requested and used (before or during a care episode); or can be asynchronously generated and made available for future usage (e.g. store and retrieve).
the IPS can be retrieved using a document exchange infrastructure; transported by the patient ; or shared using a cloud-services.
the IPS may be subject of a transformation process, that may include syntactical conversions; coded concepts 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 reception for example using an external service.
Finally, the received CDA may be expected to be displayed using a common CDA stylesheet; may be used to extract some relevant information to be displayed by the EHR-S or to be incorporated into the receiver’s EHR; or a specialized viewer may be adopted to enable the display of the translated content.

Moreover for cross-organizations/jurisdictions exchange the IPS could be used as :

shared format among jurisdictions (case A): jurisdictions originate and use IPS conformant documents;
pivot document among existing summaries / data formats (case B): for example 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.
Or in a mixed mode (Case C): either the originator or the consumer are expected to use an IPS conformant document.

^{[Figure 7]}Examples of IPS usage

Considering all those possible combinations and additional business requirements agreed by jurisdictions, the 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, use.

Having said that an International Patient Summary may be characterized by :

being the result of an automatic assembling (assembled IPS) or of a human summarization act (human curated IPS)
having one or more EHR sources
document information from a single or multiple jurisdictions/organizations
being the result of a single or multiple encounters

A clear determination of such a kind of contextual information helps the comprehension and the trustiness on the received IPS. Most of these aspects are related to the data provenance, introduced in section Provenance above.

Even if in many jurisdictions require that only one active Patient Summary for unscheduled care would be made available; no constraints on this purpose are imposed by this guide being this strongly dependent on the case for which this template is used.

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

provide guidance on how to determine the relevancy 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 multilinguistic 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 for 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 see link to eHDSI) use a business to business exchange infrastructure based on a network of countries’ gateways that hide the national infrastructures; the eHDSI Patient Summary (eHDSI PS) is used as a “pivot” document for the cross-country exchange: local data/document formats are in fact remapped into the eHDSI PS; the document exchanged is processed each time it passes through one of these a gateway applying the needed syntactical transformations; codes mapping; codes designations’ translation; 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 to extend the multi-linguistic support for the cross-border patient summaries to a wider set of potential consumers (EHR-Systems), without requiring specialized viewers as applied in the European services.

Concept code mapping

In several real world cases the records used as source for the Patient Summaries may use locally adopted terminologies that – when possible – are remapped into the reference value sets; or may be able in some cases to provide only uncoded information. This leads to a series of requirements for the IPS that will be discussed in the Design conventions and principles section.

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

Moreover it should be taken in account that:

The original record may support multiple coding, so that the IPS instance should be able to distinguish if the additional codes belong to the original content or they are the result of a coded concepts 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.
It may happen that distinct original and the reference coded concepts 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 of a format transformation (e.g. a CCD document is used as input for generating an IPS). Also for these cases the requirement of recording both coded concepts should be applied.

Note: in some jurisdiction (as the European Cross-border services) some of these should may be turned into a shall.

Multilinguistic support

The debate on the multi linguistic support for the IPS could be split in two distinct subjects:

The translation of coded concept designations (displayName)
The translation of the narrative

In both cases several options may be identified depending also on the use cases considered:

The translation in the receiving country language: an IPS is prepared before a planned travel; a foreign provider retrieves a translated copy of the IPS from the patient country of affiliation;…
The translation into a commonly agreed language: an English version of the IPS is prepared;..
The predefined set of translations is included in the shared IPS.

Is out of the scope of this guide to suggest any of these solutions, all of them should be supported by this standard.

Designations’ Translation

Basically, the requirements related to the translation of the designations derive from the European Cross-border services imposing as functional requirements that for “safety and liability reasons” that all the terms (designations, displayName) associated to the original codes in the original language shall be recorded in the exchanged documents; together with the English and the receiving country language terms (designations, displayName) associated to the reference codes. The designations translated in the receiving country language are used for generating the human readable content shown to the receiving provider. No free text translation is applied in this case. In order to accomplish this need, the IPS should have the capability of recording one or more designations, possibly indicating the language used.

Narrative Translation

With the term narrative translation two different concepts are covered:

The translation of the original narrative text. This can be in principle:
- Human curated
- Automatically performed (e.g. using specialized or generic translation services)
The creation of a new translated narrative based on the coded entries.

Different levels of quality and liability can be obtained depending on the solution adopted and on the translation service used. It is out of the scope of this guide to suggest any of these solutions, in all the cases however:

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

Reading Guide

Responsible: Kai Heitmann

Description of formalisms used, symbols, icons, how to read ART-DECOR artefacts

CDA Document Level Templates

International Patient Summary

Id

2.16.840.1.113883.10.22.1.1

Effective Date

2020‑07‑14 16:08:21

Other versions this id:

HL7-IPS as of 2024‑08‑02 13:02:39
HL7-IPS as of 2020‑05‑08 12:30:59
HL7-IPS as of 2017‑04‑11

Status Draft Version Label 2021

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)

Uses

Uses 21 templates

Used by	as	Name	Version
hl7ips-transaction-2	Transaction	IPS Created (2020)	2017‑04‑07 11:10:54
Uses	as	Name	Version
2.16.840.1.113883.10.22.2.1	Include	IPS CDA recordTarget (2021)	DYNAMIC
2.16.840.1.113883.10.22.2.2	Include	IPS CDA author (STU1)	DYNAMIC
2.16.840.1.113883.10.22.2.3	Include	IPS CDA custodian (2021)	DYNAMIC
2.16.840.1.113883.10.22.2.4	Include	IPS CDA legalAuthenticator (STU1)	DYNAMIC
2.16.840.1.113883.10.22.2.5	Include	IPS Patient Contacts (STU1)	DYNAMIC
2.16.840.1.113883.10.22.2.6	Include	IPS CDA documentationOf (STU1)	DYNAMIC
2.16.840.1.113883.10.22.2.7	Include	IPS CDA relatedDocument (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.1	Containment	IPS Medication Summary Section (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.2	Containment	IPS Allergies and Intolerances Section (STU2)	DYNAMIC
2.16.840.1.113883.10.22.3.3	Containment	IPS Problems Section (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.4	Containment	IPS History of Procedures Section (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.5	Containment	IPS Immunizations Section (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.6	Containment	IPS Medical Devices Section (2021)	DYNAMIC
2.16.840.1.113883.10.22.3.14	Containment	IPS Results Section (STU1)	DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2	Containment	IHE Coded Vital Signs Section (2014)	DYNAMIC
2.16.840.1.113883.10.22.3.7	Containment	IPS History of Past Illness Section (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.8	Containment	IPS Functional Status Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.9	Containment	IPS Plan of Care Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.10	Containment	IPS Social History Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.11	Containment	IPS History of Pregnancy Section (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.12	Containment	IPS Advance Directives Section (TI-2020)	DYNAMIC

Relationship

Version: 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

<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"/>  
  
  
  
  
  
  
  <component>
    <structuredBody classCode="DOCBODY">
      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>    </structuredBody>  </component></ClinicalDocument>

Item DT Card Conf Description Label

hl7:ClinicalDocument

R

CDA header

(HL7-IPS)

hl7:realmCode

CS

0 … 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 (LOINC)

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:languageCode

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 2.16.840.1.113883.4.642.3.21 All Languages (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 language code; CC is ISO country 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

@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"/> 

</patient> </patientRole></recordTarget>

hl7:patientRole

1 … 1

M

(HL7-IPS)


	hl7ips-dataelement-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-dataelement-202	Healthcare related Identifiers	CEN/TC 251 prEN 17269
hl7ips-dataelement-7	Insurance identifier	CEN/TC 251 prEN 17269

hl7:addr

AD.IPS

1 … *

R

The patient address.

(HL7-IPS)


	hl7ips-dataelement-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-dataelement-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

@determinerCode

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-dataelement-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:administrativeGenderCode

CE.IPS

1 … 1

R

Patient's Gender

(HL7-IPS)


	hl7ips-dataelement-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 Administrative Gender (HL7 V3) (DYNAMIC)

Example <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
<translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>

hl7:birthTime

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-dataelement-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:guardianPerson

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:languageCommunication

0 … *

R

(HL7-IPS)

hl7:languageCode

CS

1 … 1

R

Patient’s language

(HL7-IPS)


	hl7ips-dataelement-135	Patient’s preferred language	CEN/TC 251 prEN 17269

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 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)

Example

British English

Example

Amurdak (Australia)

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 language code; CC is ISO country 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

@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>

</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

url

0 … 1

Example <telecom use="WP" value="tel:+39-051-34343434"/>

Example <telecom nullFlavor="NI"/>

Choice

1 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(HL7-IPS)

@classCode

cs

0 … 1

F

PSN

@determinerCode

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:assignedAuthoringDevice

0 … 1

C

(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)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(HL7-IPS)

hl7:manufacturerModelName

SC

0 … 1

(HL7-IPS)

hl7:softwareName

SC

0 … 1

(HL7-IPS)

hl7:representedOrganization

0 … 1

R

(HL7-IPS)

Included from 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)

@classCode

cs

1 … 1

F

ORG

@determinerCode

cs

1 … 1

F

INSTANCE

hl7:id

II

1 … *

R

(HL7-IPS)

@nullFlavor

cs

0 … 1

hl7:name

ON

1 … 1

R

(HL7-IPS)

@nullFlavor

cs

0 … 1

hl7:telecom

TEL

1 … *

R

(HL7-IPS)

@use

set_cs

1 … 1

R

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

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:addr

AD.IPS

1 … 1

R

(HL7-IPS)

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.

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">

</representedCustodianOrganization> </assignedCustodian></custodian>

hl7:assignedCustodian

1 … 1

R

(HL7-IPS)

@classCode

cs

0 … 1

F

ASSIGNED

hl7:representedCustodianOrganization

1 … 1

R

(HL7-IPS)

@classCode

cs

0 … 1

F

ORG

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:id

II

1 … *

R

(HL7-IPS)

@nullFlavor

cs

0 … 1

hl7:name

ON

1 … 1

R

(HL7-IPS)

@nullFlavor

cs

0 … 1

hl7:telecom

TEL

1 … 1

R

(HL7-IPS)

@use

set_cs

1 … 1

R

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

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:addr

AD.IPS

1 … 1

R

(HL7-IPS)

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.

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:assignedPerson

1 … 1

R

(HL7-IPS)

@classCode

cs

0 … 1

F

PSN

@determinerCode

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: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 (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-dataelement-154	Patient’s Address Book	CEN/TC 251 prEN 17269
hl7ips-dataelement-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:associatedEntity

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-dataelement-169	Telecoms	CEN/TC 251 prEN 17269
hl7ips-dataelement-174	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:associatedPerson
hl7:scopingOrganization

hl7:associatedPerson

0 … 1

C

Or the associatedPerson, or the scopingOrganization, or both elements shall be provided

(HL7-IPS)


	hl7ips-dataelement-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-dataelement-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:scopingOrganization

0 … 1

C

Or the associatedPerson, or the scopingOrganization, or both elements shall be provided

(HL7-IPS)


	hl7ips-dataelement-166	Healthcare Provider (organisation)	CEN/TC 251 prEN 17269

hl7:name

ON

1 … *

R

Organization's Name

(HL7-IPS)


	hl7ips-dataelement-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">

</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:assignedPerson

0 … 1

(HL7-IPS)

Included from 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

(HL7-IPS)

hl7:representedOrganization

0 … 1

Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)

(HL7-IPS)

Included 0 … 2 R from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)

Constraint

A conformant CDA document can have:

a single relatedDocument with typeCode "APND"; OR
a single relatedDocument with typeCode "RPLC"; OR
a single relatedDocument with typeCode "XFRM"; OR
a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; OR
a combination of two relatedDocuments with typeCodes "XFRM" and "APND".

No other combinations are allowed.

hl7:relatedDocument

0 … 2

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 (LOINC)

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)

hl7:component

1 … 1

M

Contains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC)

(HL7-IPS)

hl7:component

1 … 1

M

Contains 2.16.840.1.113883.10.22.3.3 IPS Problems Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

R

Contains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

R

Contains 2.16.840.1.113883.10.22.3.5 IPS Immunizations Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

R

Contains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

R

Contains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

R

Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 IHE Coded Vital Signs Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

Contains 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC)

(HL7-IPS)

hl7:component

0 … 1

Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC)

(HL7-IPS)

CDA Header Level Templates

IPS CDA author

Id

2.16.840.1.113883.10.22.2.2

Effective Date

2017‑04‑11

Status

Under pre-publication review

Version Label

STU1

Name

IPSCDAauthor

Display Name

IPS 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).

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 2 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.9.2	Include	IPS CDA Device (STU1)	DYNAMIC
2.16.840.1.113883.10.22.9.1	Include	IPS CDA Organization (STU1)	DYNAMIC

Relationship

Adaptation: 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>
      
    </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>

Item

DT

Card

Conf

Description

Label

hl7:author

1 … *

R

(IPS...hor)

@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>
    
  </representedOrganization></author>

hl7:functionCode

CE.IPS

0 … 1

R

(IPS...hor)

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.

(IPS...hor)

Example

hl7:assignedAuthor

1 … 1

R

(IPS...hor)

@classCode

cs

0 … 1

F

ASSIGNED

hl7:id

II

1 … *

R

Author Identifier(s)

(IPS...hor)

@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.

(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

hl7:addr

AD.IPS

1 … *

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>

hl7:telecom

TEL.IPS

1 … *

R

(IPS...hor)

@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

url

0 … 1

Example

Example

Choice

1 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...hor)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...hor)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...hor)

hl7:given

1 … *

R

(IPS...hor)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...hor)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...hor)

hl7:manufacturerModelName

SC

0 … 1

(IPS...hor)

hl7:softwareName

SC

0 … 1

(IPS...hor)

hl7:representedOrganization

0 … 1

R

(IPS...hor)

Included

from 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)

@classCode

cs

1 … 1

F

ORG

@determinerCode

cs

1 … 1

F

INSTANCE

hl7:id

II

1 … *

R

(IPS...hor)

@nullFlavor

cs

0 … 1

hl7:name

ON

1 … 1

R

(IPS...hor)

@nullFlavor

cs

0 … 1

hl7:telecom

TEL

1 … *

R

(IPS...hor)

@use

set_cs

1 … 1

R

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

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:addr

AD.IPS

1 … 1

R

(IPS...hor)

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

(IPS...hor)

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

(IPS...hor)

hl7:postalCode

ADXP

0 … 1

C

Subject's or Organization's Postal Code

(IPS...hor)

hl7:state

ADXP

0 … 1

C

Subject's or Organization's State or Province

(IPS...hor)

hl7:country

ADXP

0 … 1

C

Subject's Country.

(IPS...hor)

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.

IPS CDA custodian

Id

2.16.840.1.113883.10.22.2.3

Effective Date

2021‑08‑04 12:13:07

Other versions this id:

IPSCDAcustodian as of 2017‑04‑11

Status

Draft

Version Label

2021

Name

IPSCDAcustodian

Display Name

IPS 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.

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.11	Include	IPS Address (STU1)	DYNAMIC

Relationship

Version: 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

Item

DT

Card

Conf

Description

Label

hl7:custodian

1 … 1

R

(IPS...ian)

@typeCode

cs

0 … 1

F

CST

Example

hl7:assignedCustodian

1 … 1

R

(IPS...ian)

@classCode

cs

0 … 1

F

ASSIGNED

hl7:representedCustodianOrganization

1 … 1

R

(IPS...ian)

@classCode

cs

0 … 1

F

ORG

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:id

II

1 … *

R

(IPS...ian)

@nullFlavor

cs

0 … 1

hl7:name

ON

1 … 1

R

(IPS...ian)

@nullFlavor

cs

0 … 1

hl7:telecom

TEL

1 … 1

R

(IPS...ian)

@use

set_cs

1 … 1

R

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

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:addr

AD.IPS

1 … 1

R

(IPS...ian)

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

(IPS...ian)

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

(IPS...ian)

hl7:postalCode

ADXP

0 … 1

C

Subject's or Organization's Postal Code

(IPS...ian)

hl7:state

ADXP

0 … 1

C

Subject's or Organization's State or Province

(IPS...ian)

hl7:country

ADXP

0 … 1

C

Subject's Country.

(IPS...ian)

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.

IPS CDA documentationOf

Id

2.16.840.1.113883.10.22.2.6

Effective Date

2017‑04‑12

Status

Under pre-publication review

Version Label

STU1

Name

IPSdocumentationOfPCPR

Display Name

IPS 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.

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 2 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.9.3	Include	IPS CDA Person (STU1)	DYNAMIC
2.16.840.1.113883.10.22.9.1	Containment	IPS CDA Organization (STU1)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.12.110 CDA documentationOf (2005‑09‑07)

ref

ad1bbr-

Example

Item

DT

Card

Conf

Description

Label

hl7:documentationOf

0 … *

R

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.

(IPS...CPR)

@typeCode

cs

0 … 1

F

DOC

Example

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.

(IPS...CPR)

@classCode

cs

1 … 1

F

PCPR

@moodCode

cs

1 … 1

F

EVN

hl7:id

II

0 … *

R

(IPS...CPR)

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...CPR)

hl7:low

TS

1 … 1

R

(IPS...CPR)

hl7:high

TS

1 … 1

R

(IPS...CPR)

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

(IPS...CPR)

@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

(IPS...CPR)

hl7:time

IVL_TS.IPS.TZ

0 … 1

R

(IPS...CPR)

hl7:assignedEntity

1 … 1

M

(IPS...CPR)

hl7:id

II

1 … *

R

Healthcare provider ID number

(IPS...CPR)

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.

(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)

hl7:addr

AD.IPS

1 … *

R

(IPS...CPR)

hl7:telecom

TEL.IPS

1 … *

R

(IPS...CPR)

hl7:assignedPerson

0 … 1

(IPS...CPR)

Included

from 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

(IPS...CPR)

hl7:representedOrganization

0 … 1

Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)

(IPS...CPR)

IPS CDA legalAuthenticator

Id

2.16.840.1.113883.10.22.2.4

Effective Date

2017‑04‑11

Status

Under pre-publication review

Version Label

STU1

Name

IPSCDAlegalAuthenticator

Display Name

IPS 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.

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.9.1	Containment	IPS CDA Organization (STU1)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (2005‑09‑07)

ref

ad1bbr-

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>

Item

DT

Card

Conf

Description

Label

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>

hl7:time

TS.IPS.TZ

1 … 1

M

Time of signing the document

(IPS...tor)

hl7:signatureCode

CS

0 … 1

R

Signature code

(IPS...tor)

@code

CONF

0 … 1

F

S

hl7:assignedEntity

0 … 1

R

The entity that is responsible for the legal authentication of the CDA document

(IPS...tor)

hl7:id

1 … *

R

Unique identification of legal authenticator

(IPS...tor)

hl7:addr

AD.IPS

1 … *

R

(IPS...tor)

hl7:telecom

TEL.IPS

1 … *

R

(IPS...tor)

hl7:assignedPerson

1 … 1

R

(IPS...tor)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the legal authenticator

(IPS...tor)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

HP Family Name/Surname

(IPS...tor)

hl7:given

1 … *

R

HP Given Name

(IPS...tor)

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)

(IPS...tor)

IPS CDA Organization

Id

2.16.840.1.113883.10.22.9.1

Effective Date

2017‑04‑11

Status

Under pre-publication review

Version Label

STU1

Name

IPSCDAOrganization

Display Name

IPS CDA Organization

Description

This is a reusable template providing essential information for describing / identifying an organization.

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.11	Include	IPS Address (STU1)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (2013‑12‑20)

ref

epsos-

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>

Item

DT

Card

Conf

Description

Label

@classCode

cs

1 … 1

F

ORG

@determinerCode

cs

1 … 1

F

INSTANCE

hl7:id

II

1 … *

R

(IPS...ion)

@nullFlavor

cs

0 … 1

hl7:name

ON

1 … 1

R

(IPS...ion)

@nullFlavor

cs

0 … 1

hl7:telecom

TEL

1 … *

R

(IPS...ion)

@use

set_cs

1 … 1

R

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

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:addr

AD.IPS

1 … 1

R

(IPS...ion)

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

(IPS...ion)

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

(IPS...ion)

hl7:postalCode

ADXP

0 … 1

C

Subject's or Organization's Postal Code

(IPS...ion)

hl7:state

ADXP

0 … 1

C

Subject's or Organization's State or Province

(IPS...ion)

hl7:country

ADXP

0 … 1

C

Subject's Country.

(IPS...ion)

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.

IPS CDA Person

Id

2.16.840.1.113883.10.22.9.3

Effective Date

2017‑04‑12

Status

Under pre-publication review

Version Label

STU1

Name

IPSCDAPerson

Display Name

IPS CDA Person

Description

Person name

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: template 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)

ref

ad1bbr-

Item

DT

Card

Conf

Description

Label

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

(IPS...son)

IPS CDA recordTarget

Id

2.16.840.1.113883.10.22.2.1

Effective Date

2021‑09‑02 12:10:24

Other versions this id:

IPSCDArecordTarget as of 2020‑07‑14 16:56:08
IPSCDArecordTarget as of 2017‑04‑11

Status Draft Version Label 2021

Name IPSCDArecordTarget Display Name IPS 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.

Classification CDA Header Level Template

Open/Closed Open (other than defined elements are allowed)

Associated with

Associated with 9 concepts

Id	Name	Data Set
hl7ips-dataelement-100	Telecoms	CEN/TC 251 prEN 17269
hl7ips-dataelement-135	Patient’s preferred language	CEN/TC 251 prEN 17269
hl7ips-dataelement-162	Address	CEN/TC 251 prEN 17269
hl7ips-dataelement-2.1	Patient Attributes	CEN/TC 251 prEN 17269
hl7ips-dataelement-202	Healthcare related Identifiers	CEN/TC 251 prEN 17269
hl7ips-dataelement-3	Patient's name	CEN/TC 251 prEN 17269
hl7ips-dataelement-4	Administrative gender	CEN/TC 251 prEN 17269
hl7ips-dataelement-5	Date of birth	CEN/TC 251 prEN 17269
hl7ips-dataelement-7	Insurance identifier	CEN/TC 251 prEN 17269

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.11	Include	IPS Address (STU1)	DYNAMIC

Relationship

Version: 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

<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"/>      
      
    </patient>  </patientRole></recordTarget>

Item DT Card Conf Description Label

hl7:recordTarget

1 … *

R

(IPS...get)

@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"/> 

</patient> </patientRole></recordTarget>

hl7:patientRole

1 … 1

M

(IPS...get)


	hl7ips-dataelement-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)

(IPS...get)


hl7ips-dataelement-202	Healthcare related Identifiers	CEN/TC 251 prEN 17269
hl7ips-dataelement-7	Insurance identifier	CEN/TC 251 prEN 17269

hl7:addr

AD.IPS

1 … *

R

The patient address.

(IPS...get)


	hl7ips-dataelement-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

(IPS...get)

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

(IPS...get)

hl7:postalCode

ADXP

0 … 1

C

Subject's or Organization's Postal Code

(IPS...get)

hl7:state

ADXP

0 … 1

C

Subject's or Organization's State or Province

(IPS...get)

hl7:country

ADXP

0 … 1

C

Subject's Country.

(IPS...get)

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.

(IPS...get)


	hl7ips-dataelement-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

(IPS...get)

@classCode

cs

0 … 1

F

PSN

@determinerCode

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

(IPS...get)


	hl7ips-dataelement-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

(IPS...get)

hl7:given

1 … *

R

Patient's Given Name

(IPS...get)

hl7:administrativeGenderCode

CE.IPS

1 … 1

R

Patient's Gender

(IPS...get)


	hl7ips-dataelement-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 Administrative Gender (HL7 V3) (DYNAMIC)

Example <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
<translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>

hl7:birthTime

TS

1 … 1

R

Patient's Date of Birth. The patient date of birth may be a partial date such as only the year.

(IPS...get)


	hl7ips-dataelement-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.

(IPS...get)

@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.

(IPS...get)

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

(IPS...get)

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

(IPS...get)

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

(IPS...get)

hl7:postalCode

ADXP

0 … 1

C

Subject's or Organization's Postal Code

(IPS...get)

hl7:state

ADXP

0 … 1

C

Subject's or Organization's State or Province

(IPS...get)

hl7:country

ADXP

0 … 1

C

Subject's Country.

(IPS...get)

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.

(IPS...get)

@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:guardianPerson

1 … 1

R

(IPS...get)

hl7:name

PN

1 … *

R

Patient Guardian's Name

(IPS...get)

hl7:family

ENXP

1 … *

R

Patient Guardian's Family Name/Surname

(IPS...get)

hl7:given

ENXP

1 … *

R

Patient Guardian's Given Name

(IPS...get)

hl7:languageCommunication

0 … *

R

(IPS...get)

hl7:languageCode

CS

1 … 1

R

Patient’s language

(IPS...get)


	hl7ips-dataelement-135	Patient’s preferred language	CEN/TC 251 prEN 17269

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 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)

Example

British English

Example

Amurdak (Australia)

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 language code; CC is ISO country code)

IPS CDA relatedDocument

Id

2.16.840.1.113883.10.22.2.7

Effective Date

2017‑04‑12

Status

Under pre-publication review

Version Label

STU1

Name

IPSCDArelatedDocument

Display Name

IPS 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.”

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: 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

Example

Reference to the local PS and to supporting documentation

<relatedDocument typeCode="XFRM">
  
  <parentDocument>
    <id root="aa-bb-cc"/>  </parentDocument></relatedDocument><relatedDocument typeCode="APND">
  
  <parentDocument>
    <id root="aa1-bb1-cc1"/>  </parentDocument></relatedDocument>

Item

DT

Card

Conf

Description

Label

hl7:relatedDocument

0 … *

R

(IPS...ent)

@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

(IPS...ent)

@classCode

cs

0 … 1

F

DOCCLIN

@moodCode

cs

0 … 1

F

EVN

hl7:id

II

1 … *

R

(IPS...ent)

hl7:code

CD.IPS

0 … 1

R

(IPS...ent)

@codeSystem

CONF

0 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:text

ED

0 … 1

R

(IPS...ent)

hl7:setId

II

0 … 1

R

(IPS...ent)

hl7:versionNumber

INT

0 … 1

R

(IPS...ent)

IPS Patient Contacts

Id

2.16.840.1.113883.10.22.2.5

Effective Date

2017‑04‑12

Status

Under pre-publication review

Version Label

STU1

Name

IPSCDAContacts

Display Name

IPS 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.

Classification

CDA Header Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 8 concepts

Id	Name	Data Set
hl7ips-dataelement-121	Name	CEN/TC 251 prEN 17269
hl7ips-dataelement-154	Patient’s Address Book	CEN/TC 251 prEN 17269
hl7ips-dataelement-163	Preferred Healthcare providers	CEN/TC 251 prEN 17269
hl7ips-dataelement-165	Healthcare Provider (person)	CEN/TC 251 prEN 17269
hl7ips-dataelement-166	Healthcare Provider (organisation)	CEN/TC 251 prEN 17269
hl7ips-dataelement-169	Telecoms	CEN/TC 251 prEN 17269
hl7ips-dataelement-172	Organisation’s Name	CEN/TC 251 prEN 17269
hl7ips-dataelement-174	Telecoms	CEN/TC 251 prEN 17269

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.11	Include	IPS Address (STU1)	DYNAMIC

Relationship

Adaptation: 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>

Item

DT

Card

Conf

Description

Label

hl7:participant

R

Patient 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']


hl7ips-dataelement-154	Patient’s Address Book	CEN/TC 251 prEN 17269
hl7ips-dataelement-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

(IPS...cts)

@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>

(IPS...cts)

@code

CONF

0 … 1

F

PCP

@codeSystem

0 … 1

F

2.16.840.1.113883.5.88 (Participation Function)

hl7:associatedEntity

R

The <associatedEntity> element identifies the type of contact. </associatedEntity>

(IPS...cts)

@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.

(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

hl7:addr

AD.IPS

1 … *

R

Patient Contact's / Preferred HP's Address

(IPS...cts)

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

(IPS...cts)

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

(IPS...cts)

hl7:postalCode

ADXP

0 … 1

C

Subject's or Organization's Postal Code

(IPS...cts)

hl7:state

ADXP

0 … 1

C

Subject's or Organization's State or Province

(IPS...cts)

hl7:country

ADXP

0 … 1

C

Subject's Country.

(IPS...cts)

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>

(IPS...cts)


hl7ips-dataelement-169	Telecoms	CEN/TC 251 prEN 17269
hl7ips-dataelement-174	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

Choice

1 … 2

Elements to choose from:

hl7:associatedPerson
hl7:scopingOrganization

hl7:associatedPerson

0 … 1

C

Or the associatedPerson, or the scopingOrganization, or both elements shall be provided

(IPS...cts)


	hl7ips-dataelement-165	Healthcare Provider (person)	CEN/TC 251 prEN 17269

hl7:name

PN

1 … *

R

Patient Contact's Name / Preferred HP's Name

(IPS...cts)


	hl7ips-dataelement-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

(IPS...cts)

hl7:given

1 … *

R

Patient Contact's Given Name / Preferred HP's Given Name

(IPS...cts)

hl7:scopingOrganization

0 … 1

C

Or the associatedPerson, or the scopingOrganization, or both elements shall be provided

(IPS...cts)


	hl7ips-dataelement-166	Healthcare Provider (organisation)	CEN/TC 251 prEN 17269

hl7:name

ON

1 … *

R

Organization's Name

(IPS...cts)


	hl7ips-dataelement-172	Organisation’s Name	CEN/TC 251 prEN 17269

CDA Section Level Templates

IPS Advance Directives Section

Id

2.16.840.1.113883.10.22.3.12

Effective Date

2020‑05‑08 16:38:49

Other versions this id:

IPSAdvanceDirectivesSection as of 2017‑04‑13

Status

Under pre-publication review

Version Label

TI-2020

Name

IPSAdvanceDirectivesSection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.12

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 2 concepts

Id	Name	Data Set
hl7ips-dataelement-26	Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-8	Advance Directives	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.46	Containment	IPS Advance Directive Organizer (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: 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

<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>
    
  </hl7:author>  <hl7:informant>
    
  </hl7:informant>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:component>
    
  </hl7:component></cda:section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-8	Advance Directives	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.12

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

42348-3

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

Advance directives

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-26	Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.46 IPS Advance Directive Organizer (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Allergies and Intolerances Section

Id

2.16.840.1.113883.10.22.3.2

Effective Date

2024‑08‑04 10:07:36

Other versions this id:

IPSSectionAllergiesOrIntolerances as of 2016‑11‑11

Status

Draft

Version Label

STU2

Name

IPSSectionAllergiesOrIntolerances

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.2

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-183	Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-28	Allergy or Intolerance list	CEN/TC 251 prEN 17269
hl7ips-dataelement-9	Allergies and Intolerances	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.5	Containment	IPS Allergy and Intolerance Concern (STU2)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Specialization: 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

<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>
      
    </text>    <author>
      
    </author>    <informant>
      
    </informant>    <entry typeCode="COMP" contextConductionInd="true">
      
    </entry>    <component>
      
    </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>
    
  </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>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

R

(IPS...ces)


	hl7ips-dataelement-9	Allergies and Intolerances	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ces)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.2

hl7:id

II

0 … *

R

(IPS...ces)

hl7:code

CE.IPS

1 … 1

M

(IPS...ces)

@code

CONF

1 … 1

F

48765-2

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

(IPS...ces)

hl7:text

SD.TEXT

1 … 1

M

Section text

(IPS...ces)


	hl7ips-dataelement-183	Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ces)

hl7:templateId

II

1 … 1

M

(IPS...ces)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ces)

hl7:assignedAuthor

1 … 1

M

(IPS...ces)

hl7:id

II

1 … *

R

(IPS...ces)

hl7:code

0 … 1

R

(IPS...ces)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ces)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ces)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ces)

hl7:given

1 … *

R

(IPS...ces)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ces)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ces)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ces)

hl7:softwareName

SC

0 … 1

(IPS...ces)

hl7:representedOrganization

0 … 1

(IPS...ces)

hl7:id

II

0 … *

(IPS...ces)

hl7:name

0 … *

(IPS...ces)

hl7:telecom

TEL

0 … *

(IPS...ces)

hl7:addr

AD

0 … *

(IPS...ces)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ces)

hl7:entry

1 … *

M

Contains 2.16.840.1.113883.10.22.4.5 IPS Allergy and Intolerance Concern (DYNAMIC)

(IPS...ces)


	hl7ips-dataelement-28	Allergy or Intolerance list	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ces)

IPS Functional Status Section

Id

2.16.840.1.113883.10.22.3.8

Effective Date

2020‑05‑08 19:17:37

Other versions this id:

IPSFunctionalStatusSection as of 2017‑04‑13

Status

Under pre-publication review

Version Label

TI-2020

Name

IPSFunctionalStatusSection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.8

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-10	Functional Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-137	Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-197	Description	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.42	Containment	IPS Survey Panel (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: 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

<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>
    
  </hl7:author>  <hl7:informant>
    
  </hl7:informant>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:component>
    
  </hl7:component></cda:section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-10	Functional Status	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.8

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

47420-5

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

Functional Status Assessment

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)


hl7ips-dataelement-137	Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-197	Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.42 IPS Survey Panel (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS History of Past Illness Section

Id

2.16.840.1.113883.10.22.3.7

Effective Date

2017‑04‑12

Status

Under pre-publication review

Version Label

STU1

Name

IPSHistoryOfPastIllnessSection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.7

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-11	History of Past Illness	CEN/TC 251 prEN 17269
hl7ips-dataelement-31	Past health conditions and problems list	CEN/TC 251 prEN 17269
hl7ips-dataelement-35	Description	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.7	Containment	IPS Problem Concern Entry (2021)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)

ref

ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.8 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

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-11	History of Past Illness	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.7

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

11348-0

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

History of Past Illness

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-35	Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

1 … *

R

Contains 2.16.840.1.113883.10.22.4.7 IPS Problem Concern Entry (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-31	Past health conditions and problems list	CEN/TC 251 prEN 17269

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS History of Pregnancy Section

Id

2.16.840.1.113883.10.22.3.11

Effective Date

2020‑05‑07 18:46:08

Other versions this id:

IPSHistoryofpregnancysection as of 2018‑09‑06 09:46:57
IPSHistoryofpregnancysection as of 2017‑04‑13

Status

Under pre-publication review

Version Label

TI-2020

Name

IPSHistoryofpregnancysection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.11

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 5 concepts

Id	Name	Data Set
hl7ips-dataelement-12	History of Pregnancy	CEN/TC 251 prEN 17269
hl7ips-dataelement-225	Pregnancy Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-37	Status of pregnancy	CEN/TC 251 prEN 17269
hl7ips-dataelement-38	Previous Pregnancies	CEN/TC 251 prEN 17269
hl7ips-dataelement-39	Previous Pregnancies Description	CEN/TC 251 prEN 17269

Uses

Uses 6 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.27	Containment	IPS Pregnancy Status Observation (2021)	DYNAMIC
2.16.840.1.113883.10.22.4.28	Containment	IPS Pregnancy Outcome Observation (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.36	Containment	IPS Pregnancy Observation (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Version: 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

<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>
    
  </hl7:author>  <hl7:informant>
    
  </hl7:informant>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:component>
    
  </hl7:component></cda:section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-12	History of Pregnancy	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.11

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

10162-6

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

History of pregnancies

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)


hl7ips-dataelement-225	Pregnancy Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-39	Previous Pregnancies Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

0 … 1

R

Contains 2.16.840.1.113883.10.22.4.27 IPS Pregnancy Status Observation (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-37	Status of pregnancy	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

R

Contains 2.16.840.1.113883.10.22.4.28 IPS Pregnancy Outcome Observation (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-38	Previous Pregnancies	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.36 IPS Pregnancy Observation (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS History of Procedures Section

Id

2.16.840.1.113883.10.22.3.4

Effective Date

2017‑03‑27

Status

Under pre-publication review

Version Label

STU1

Name

IPSHistoryofProceduresSection

Display Name

IPS 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:

Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)
Therapeutic procedure: e.g. dialysis;
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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.4

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-13	History of Procedures	CEN/TC 251 prEN 17269
hl7ips-dataelement-43	Procedure list	CEN/TC 251 prEN 17269
hl7ips-dataelement-51	Procedure description	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.17	Containment	IPS Procedure Entry (STU2)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)

ref

ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.2 IHE History of Surgical Procedures Section (2017‑03‑24 14:43:08)

ref

IHE-PCC-

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>
    
  </author>  <informant>
    
  </informant>  <entry typeCode="COMP" contextConductionInd="true">
    
  </entry>  <component>
    
  </component></section>

Item

DT

Card

Conf

Description

Label

hl7:section

(IPS...ion)


	hl7ips-dataelement-13	History of Procedures	CEN/TC 251 prEN 17269

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.4

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

47519-4

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

History of procedures

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

R

(IPS...ion)


	hl7ips-dataelement-51	Procedure description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

1 … *

R

Contains 2.16.840.1.113883.10.22.4.17 IPS Procedure Entry (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-43	Procedure list	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Immunizations Section

Id

2.16.840.1.113883.10.22.3.5

Effective Date

2017‑04‑05

Status

Under pre-publication review

Version Label

STU1

Name

IPSImmunizationsSection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.5

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 2 concepts

Id	Name	Data Set
hl7ips-dataelement-14	Immunizations	CEN/TC 251 prEN 17269
hl7ips-dataelement-50	Immunizations list	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.15	Containment	IPS Immunization (STU2)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)

ref

ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.2.2.1 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

<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>
    
  </author>  <informant>
    
  </informant>  <entry typeCode="COMP" contextConductionInd="true">
    
  </entry>  <component>
    
  </component></section>

Item

DT

Card

Conf

Description

Label

hl7:section

(IPS...ion)


	hl7ips-dataelement-14	Immunizations	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.5

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

11369-6

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

1 … *

M

Contains 2.16.840.1.113883.10.22.4.15 IPS Immunization (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-50	Immunizations list	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Medical Devices Section

Id

2.16.840.1.113883.10.22.3.6

Effective Date

2021‑10‑20 17:11:42

Other versions this id:

IPSMedicalDevicesSection as of 2017‑04‑11

Status

Draft

Version Label

2021

Name

IPSMedicalDevicesSection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.6

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 2 concepts

Id	Name	Data Set
hl7ips-dataelement-15	Medical Devices	CEN/TC 251 prEN 17269
hl7ips-dataelement-219	Device List	CEN/TC 251 prEN 17269

Uses

Uses 5 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.26	Containment	IPS Medical Device (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.17	Containment	IPS Procedure Entry (STU2)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Version: 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

<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>
    
  </author>  <informant>
    
  </informant>  <entry typeCode="COMP" contextConductionInd="true">
    
  </entry>  <component>
    
  </component></section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-15	Medical Devices	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.6

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

46264-8

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

Medical Devices

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

1 … *

R

Contains 2.16.840.1.113883.10.22.4.26 IPS Medical Device (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-219	Device List	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.17 IPS Procedure Entry (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Medication Summary Section

Id

2.16.840.1.113883.10.22.3.1

Effective Date

2016‑11‑11

Status

Under pre-publication review

Version Label

STU1

Name

IPSMedicationSummarySection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.1

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 2 concepts

Id	Name	Data Set
hl7ips-dataelement-16	Medication Summary	CEN/TC 251 prEN 17269
hl7ips-dataelement-61	List of medication	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.4	Containment	IPS Medication Statement (STU2)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)

ref

ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.1.8 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

<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>
    
  </author>  <informant>
    
  </informant>  <entry typeCode="COMP" contextConductionInd="true">
    
  </entry>  <component>
    
  </component></section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-16	Medication Summary	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.1

hl7:id

II

0 … *

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

History of medication use

(IPS...ion)

@code

CONF

1 … 1

F

10160-0

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

Medication Summary

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

Section text

(IPS...ion)

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

1 … *

R

Contains 2.16.840.1.113883.10.22.4.4 IPS Medication Statement (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-61	List of medication	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Plan of Care Section

Id

2.16.840.1.113883.10.22.3.9

Effective Date

2020‑05‑08 18:28:38

Other versions this id:

IPSPlanofCareSection as of 2017‑04‑13

Status

Under pre-publication review

Version Label

TI-2020

Name

IPSPlanofCareSection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.9

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 2 concepts

Id	Name	Data Set
hl7ips-dataelement-110	Plan Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-17	Plan Of Care	CEN/TC 251 prEN 17269

Uses

Uses 8 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.41	Containment	IPS Planned Observation (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.4.38	Containment	IPS Planned Procedure (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.4.40	Containment	IPS Planned Encounter (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.4.47	Containment	IPS Planned Immunization (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.4.39	Containment	IPS Planned Act (2022)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: 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

<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>
    
  </hl7:author>  <hl7:informant>
    
  </hl7:informant>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:entry typeCode="COMP" contextConductionInd="true">
    
  </hl7:entry>  <hl7:component>
    
  </hl7:component></cda:section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-17	Plan Of Care	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.9

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

18776-5

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

Plan of Care

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-110	Plan Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.41 IPS Planned Observation (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.38 IPS Planned Procedure (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.40 IPS Planned Encounter (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.47 IPS Planned Immunization (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.39 IPS Planned Act (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Problems Section

Id

2.16.840.1.113883.10.22.3.3

Effective Date

2017‑02‑15

Status

Under pre-publication review

Version Label

STU1

Name

IPSProblemList

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.3

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-130	Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-139	Problem list	CEN/TC 251 prEN 17269
hl7ips-dataelement-18	Problems	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.7	Containment	IPS Problem Concern Entry (2021)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Specialization: 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

<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>
    
  </author>  <informant>
    
  </informant>  <entry typeCode="COMP" contextConductionInd="true">
    
  </entry>  <component>
    
  </component></section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ist)


	hl7ips-dataelement-18	Problems	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ist)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.3

hl7:id

II

0 … *

R

(IPS...ist)

hl7:code

CE.IPS

1 … 1

M

(IPS...ist)

@code

CONF

1 … 1

F

11450-4

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

(IPS...ist)

hl7:text

SD.TEXT

1 … 1

M

Section text

(IPS...ist)


	hl7ips-dataelement-130	Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ist)

hl7:templateId

II

1 … 1

M

(IPS...ist)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ist)

hl7:assignedAuthor

1 … 1

M

(IPS...ist)

hl7:id

II

1 … *

R

(IPS...ist)

hl7:code

0 … 1

R

(IPS...ist)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ist)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ist)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ist)

hl7:given

1 … *

R

(IPS...ist)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ist)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ist)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ist)

hl7:softwareName

SC

0 … 1

(IPS...ist)

hl7:representedOrganization

0 … 1

(IPS...ist)

hl7:id

II

0 … *

(IPS...ist)

hl7:name

0 … *

(IPS...ist)

hl7:telecom

TEL

0 … *

(IPS...ist)

hl7:addr

AD

0 … *

(IPS...ist)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ist)

hl7:entry

1 … *

R

Contains 2.16.840.1.113883.10.22.4.7 IPS Problem Concern Entry (DYNAMIC)

(IPS...ist)


	hl7ips-dataelement-139	Problem list	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ist)

IPS Results Section

Id

2.16.840.1.113883.10.22.3.14

Effective Date

2017‑04‑30

Status

Under pre-publication review

Version Label

STU1

Name

IPSResultsSection

Display Name

IPS 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).

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.14

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-126	Observations results list	CEN/TC 251 prEN 17269
hl7ips-dataelement-142	Result Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-19	Results	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.9	Containment	IPS Result Organizer (STU1)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)

ref

ad1bbr-

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>
    
  </text>  <author>
    
  </author>  <author>
    
  </author>  <entry typeCode="COMP" contextConductionInd="true">
    
    <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>
        
      </author>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </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>
        
      </author>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </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>
        
      </author>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>      <component>
        
      </component>    </organizer>  </entry></section>

Item

DT

Card

Conf

Description

Label

hl7:section

(IPS...ion)


	hl7ips-dataelement-19	Results	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

@moodCode

cs

0 … 1

F

EVN

hl7:templateId

II

1 … 1

R

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.14

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

30954-2

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-142	Result Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

1 … *

M

Contains 2.16.840.1.113883.10.22.4.9 IPS Result Organizer (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-126	Observations results list	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Social History Section

Id

2.16.840.1.113883.10.22.3.10

Effective Date

2020‑05‑10 18:52:32

Other versions this id:

IPSSocialHistorySection as of 2020‑05‑10 18:52:19
IPSSocialHistorySection as of 2017‑04‑13

Status

Under pre-publication review

Version Label

TI-2020

Name

IPSSocialHistorySection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.3.10

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-147	Life Style Factor list	CEN/TC 251 prEN 17269
hl7ips-dataelement-149	Description	CEN/TC 251 prEN 17269
hl7ips-dataelement-20	Social History	CEN/TC 251 prEN 17269

Uses

Uses 6 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.12.319	Containment	CDA Informant (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.34	Containment	IPS Social History Tobacco Use (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.35	Containment	IPS Social History Alcohol Use (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.48	Containment	IPS Social History Observation (TI-2020)	DYNAMIC
2.16.840.1.113883.10.22.3.15	Containment	IPS Translation Section (2021)	DYNAMIC

Relationship

Version: 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

<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>
    
  </author>  <informant>
    
  </informant>  <entry typeCode="COMP" contextConductionInd="true">
    
  </entry>  <entry typeCode="COMP" contextConductionInd="true">
    
  </entry>  <component>
    
  </component></section>

Item

DT

Card

Conf

Description

Label

hl7:section

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-20	Social History	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.3.10

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CE.IPS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

29762-2

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:title

ST

1 … 1

M

Social History

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-149	Description	CEN/TC 251 prEN 17269

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:informant

0 … *

Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)

(IPS...ion)

hl7:entry

0 … 1

Contains 2.16.840.1.113883.10.22.4.34 IPS Social History Tobacco Use (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-147	Life Style Factor list	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … 1

Contains 2.16.840.1.113883.10.22.4.35 IPS Social History Alcohol Use (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-147	Life Style Factor list	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:entry

0 … *

Contains 2.16.840.1.113883.10.22.4.48 IPS Social History Observation (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)

(IPS...ion)

IPS Translation Section

Id

2.16.840.1.113883.10.22.3.15

Effective Date

2021‑09‑02 12:04:41

Other versions this id:

IPSTranslationSection as of 2017‑07‑12

Status

Draft

Version Label

2021

Name

IPSTranslationSection

Display Name

IPS Translation Section

Description

Template CDA Section to carry the translations of a Parent Section

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Version: 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

<section>
<title>Translated title</title> 
<text>This is an English text</text> <languageCode code="en-US"/></section>

Item

DT

Card

Conf

Description

Label

hl7:section

(IPS...ion)

hl7:id

II

0 … *

R

(IPS...ion)

hl7:title

ST

1 … 1

R

(IPS...ion)

hl7:text

SD.TEXT

1 … 1

R

(IPS...ion)

hl7:languageCode

CS

1 … 1

R

(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

Id

2.16.840.1.113883.10.22.4.5

Effective Date

2024‑08‑04 10:09:24

Other versions this id:

IPSAllergyAndIntoleranceConcern as of 2016‑11‑11

Status

Draft

Version Label

STU2

Name

IPSAllergyAndIntoleranceConcern

Display Name

IPS 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"

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.5

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.1	Containment	IPS Allergy or Intolerance (STU2)	DYNAMIC

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:act

0 … *

R

(IPS...ern)

@classCode

cs

1 … 1

F

ACT

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ern)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.5

hl7:id

II

0 … *

R

(IPS...ern)

hl7:code

CD

1 … 1

M

(IPS...ern)

@code

CONF

1 … 1

F

CONC

@codeSystem

1 … 1

F

2.16.840.1.113883.5.6 (HL7ActClass)

hl7:statusCode

CS

1 … 1

R

As 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)

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...ern)

hl7:low

IVXB_TS

1 … 1

R

This 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)

hl7:high

IVXB_TS

0 … 1

C

This element asserts when the clinician deemed there is no longer any need to track the underlying conditions.

(IPS...ern)

Constraint

If statusCode/@code="completed" Completed, then effectiveTime *SHALL* contain [1..1] high

Schematron assert

role

error

test

not(../hl7:statusCode[@code='completed']) or hl7:high

Message

If statusCode/@code="completed" Completed, then effectiveTime *SHALL* contain [1..1] high

hl7:entryRelationship

1 … *

R

Contains 2.16.840.1.113883.10.22.4.1 IPS Allergy or Intolerance (DYNAMIC)

(IPS...ern)

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

0 … 1

F

false

IPS Allergy Certainty Observation

IPS Allergy or Intolerance

Id

2.16.840.1.113883.10.22.4.1

Effective Date

2024‑08‑04 09:48:50

Other versions this id:

IPSEntryAllergyOrIntolerance as of 2016‑11‑10

Status

Draft

Version Label

STU2

Name

IPSEntryAllergyOrIntolerance

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.1

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 12 concepts

Id	Name	Data Set
hl7ips-dataelement-173	Agent	CEN/TC 251 prEN 17269
hl7ips-dataelement-182	Allergies/Intolerances Content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-184	Allergy/Intolerance	CEN/TC 251 prEN 17269
hl7ips-dataelement-185	Diagnosis	CEN/TC 251 prEN 17269
hl7ips-dataelement-186	Clinical Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-187	Onset date	CEN/TC 251 prEN 17269
hl7ips-dataelement-188	End Date	CEN/TC 251 prEN 17269
hl7ips-dataelement-189	Criticality	CEN/TC 251 prEN 17269
hl7ips-dataelement-190	Certainty	CEN/TC 251 prEN 17269
hl7ips-dataelement-191	Type of propensity	CEN/TC 251 prEN 17269
hl7ips-dataelement-192	Reaction	CEN/TC 251 prEN 17269
hl7ips-dataelement-196	Agent code	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.6	Containment	IPS Reaction Manifestation (STU2)	DYNAMIC
2.16.840.1.113883.10.22.4.18	Containment	IPS Criticality Observation (STU1)	DYNAMIC
2.16.840.1.113883.10.22.10	Containment	IPS Allergy Certainty Observation (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.21	Containment	IPS Allergy Status Observation (STU1)	DYNAMIC

Relationship

Specialization: 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

No Known Allergies

Example

No Information available about allergies or intolerances

Example

Minimum Set (active propensity; agent known)

Item

DT

Card

Conf

Description

Label

hl7:observation

R

(IPS...nce)


	hl7ips-dataelement-184	Allergy/Intolerance	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...nce)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.1

hl7:id

II

0 … *

R

(IPS...nce)

hl7:code

CD.IPS

1 … 1

M

This 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)


	hl7ips-dataelement-191	Type of propensity	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)

hl7:text

ED

0 … 1

R

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.</reference>

(IPS...nce)

hl7:reference

TEL

1 … 1

M

(IPS...nce)

@value

url

1 … 1

R

When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS

1 … 1

M

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'.</statusCode>

(IPS...nce)

@code

cs

1 … 1

F

completed

hl7:effectiveTime

IVL_TS

1 … 1

M

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)

hl7:low

IVXB_TS

1 … 1

R

The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active.

(IPS...nce)


	hl7ips-dataelement-187	Onset date	CEN/TC 251 prEN 17269

hl7:high

IVXB_TS

0 … 1

C

The 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)


	hl7ips-dataelement-188	End Date	CEN/TC 251 prEN 17269

Constraint

If this condition is known to be resolved, then the effectiveTime/high would be present.

hl7:value

CD.IPS (preferred)

0 … 1

(IPS...nce)


	hl7ips-dataelement-185	Diagnosis	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)

hl7:participant

0 … 1

C

The 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)


	hl7ips-dataelement-173	Agent	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

CSM

Constraint

IF 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.

hl7:participantRole

1 … 1

R

(IPS...nce)

@classCode

cs

1 … 1

F

MANU

hl7:playingEntity

1 … 1

R

(IPS...nce)

@classCode

cs

1 … 1

F

MMAT

hl7:code

CD.IPS (preferred)

1 … 1

R

Code for the substance causing the allergy or intolerance.

(IPS...nce)


	hl7ips-dataelement-196	Agent code	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)

hl7:entryRelationship

0 … *

R

The 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)


	hl7ips-dataelement-192	Reaction	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

MFST

@inversionInd

bl

1 … 1

F

true

hl7:entryRelationship

0 … 1

R

Criticality
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)


	hl7ips-dataelement-189	Criticality	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

1 … 1

F

true

hl7:entryRelationship

0 … 1

R

Certainty 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)


	hl7ips-dataelement-190	Certainty	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

1 … 1

F

true

hl7:entryRelationship

0 … 1

R

Status 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)


	hl7ips-dataelement-186	Clinical Status	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

REFR

@inversionInd

bl

1 … 1

F

false

IPS Allergy Status Observation

Id

2.16.840.1.113883.10.22.4.21

Effective Date

2017‑05‑24

Status

Under pre-publication review

Version Label

STU1

Name

IPSAllergyStatusObservation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.21

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 1 concept

Id	Name	Data Set
hl7ips-dataelement-186	Clinical Status	CEN/TC 251 prEN 17269

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)

@classCode

cs

0 … 1

F

OBS

@moodCode

cs

0 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.21

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.20

hl7:code

CD

1 … 1

R

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

(IPS...ion)

@code

CONF

0 … 1

F

33999-4

@codeSystem

0 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:text

ED

0 … 1

R

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)

hl7:reference

TEL

1 … 1

M

(IPS...ion)

@value

url

1 … 1

R

Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS

1 … 1

M

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)

@code

CONF

1 … 1

F

completed

hl7:value

CE.IPS

1 … 1

R

The value element contains the clinical status.

(IPS...ion)


	hl7ips-dataelement-186	Clinical Status	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

Id

2.16.840.1.113883.10.22.4.14

Effective Date

2017‑03‑02

Status

Under pre-publication review

Version Label

STU1

Name

IPSBodyAuthor

Display Name

IPS 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.

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.9.2	Include	IPS CDA Device (STU1)	DYNAMIC

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:author

0 … 1

(IPS...hor)

hl7:templateId

II

1 … 1

M

(IPS...hor)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...hor)

hl7:assignedAuthor

1 … 1

M

(IPS...hor)

hl7:id

II

1 … *

R

(IPS...hor)

hl7:code

0 … 1

R

(IPS...hor)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...hor)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...hor)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...hor)

hl7:given

1 … *

R

(IPS...hor)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...hor)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...hor)

hl7:manufacturerModelName

SC

0 … 1

(IPS...hor)

hl7:softwareName

SC

0 … 1

(IPS...hor)

hl7:representedOrganization

0 … 1

(IPS...hor)

hl7:id

II

0 … *

(IPS...hor)

hl7:name

0 … *

(IPS...hor)

hl7:telecom

TEL

0 … *

(IPS...hor)

hl7:addr

AD

0 … *

(IPS...hor)

IPS CDA Device

Id

2.16.840.1.113883.10.22.9.2

Effective Date

2017‑04‑12

Status

Under pre-publication review

Version Label

STU1

Name

IPSCDADevice

Display Name

IPS CDA Device

Description

This template provides basic information about a device

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: template 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)

ref

ad1bbr-

Item

DT

Card

Conf

Description

Label

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ice)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ice)

hl7:softwareName

SC

0 … 1

(IPS...ice)

IPS Certainty Observation

Id

2.16.840.1.113883.10.22.4.19

Effective Date

2024‑06‑10 09:59:19

Other versions this id:

IPSCertaintyObservation as of 2017‑03‑29

Status

Draft

Version Label

STU1

Name

IPSCertaintyObservation

Display Name

IPS Certainty Observation

Description

This observation represents the verification status to support the clinical status of the condition.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.19

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.19

hl7:code

CD

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

66455-7

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:statusCode

CS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

completed

hl7:value

CD.IPS (required)

1 … 1

M

(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

Id

2.16.840.1.113883.10.22.4.22

Effective Date

2017‑04‑05

Status

Under pre-publication review

Version Label

STU1

Name

IPSCommentActivity

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.22

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:act

(IPS...ity)

@classCode

cs

1 … 1

F

ACT

@moodCode

cs

1 … 1

F

EVN

Constraint

Data elements defined elsewhere in the specification SHALL NOT be recorded using the Comment Activity

hl7:templateId

II

1 … 1

M

(IPS...ity)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.22

hl7:code

CD.IPS

1 … 1

M

(IPS...ity)

@code

CONF

1 … 1

F

48767-8

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:text

ED

1 … 1

M

(IPS...ity)

hl7:reference

TEL

1 … 1

M

(IPS...ity)

@value

url

1 … 1

R

Schematron assert

role

error

test

not(@value) or starts-with(@value, '#')

Message

This 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)

hl7:author

0 … 1

(IPS...ity)

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ity)

hl7:assignedAuthor

1 … 1

M

(IPS...ity)

Constraint

The author, if present, SHALL include assignedPerson/name or representedOrganization/name

hl7:id

II

1 … 1

R

(IPS...ity)

hl7:addr

AD

1 … *

M

(IPS...ity)

Choice

1 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ity)

hl7:name

0 … *

R

(IPS...ity)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ity)

hl7:softwareName

0 … 1

R

(IPS...ity)

IPS Criticality Observation

Id

2.16.840.1.113883.10.22.4.18

Effective Date

2017‑03‑27

Status

Under pre-publication review

Version Label

STU1

Name

IPSCriticalityObservation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.18

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 1 concept

Id	Name	Data Set
hl7ips-dataelement-189	Criticality	CEN/TC 251 prEN 17269

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.18

hl7:code

CD

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

82606-5

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:statusCode

CS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

completed

hl7:value

CD.IPS (required)

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-189	Criticality	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

Id

2.16.840.1.113883.10.22.4.15

Effective Date

2024‑08‑04 21:20:24

Other versions this id:

IPSImmunization as of 2017‑03‑08

Status

Draft

Version Label

STU2

Name

IPSImmunization

Display Name

IPS Immunization

Description

An Immunization entry describes immunization substance administrations that have actually occurred.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.15

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-215	Product Administration Process	CEN/TC 251 prEN 17269
hl7ips-dataelement-45	Immunization	CEN/TC 251 prEN 17269
hl7ips-dataelement-53	Date of Immunization	CEN/TC 251 prEN 17269

Uses

Uses 3 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.16	Include	IPS Immunization Medication Information (STU2)	DYNAMIC
2.16.840.1.113883.10.12.318	Containment	CDA Author (Body)	DYNAMIC
2.16.840.1.113883.10.21.4.6	Containment	UV Subordinate Substance Administration (2023)	DYNAMIC

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:substanceAdministration

(IPS...ion)


hl7ips-dataelement-215	Product Administration Process	CEN/TC 251 prEN 17269
hl7ips-dataelement-45	Immunization	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

SBADM

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.15

hl7:id

II

0 … *

(IPS...ion)

hl7:code

CV.IPS

1 … 1

M

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19709 ActSubstanceAdministrationImmunizationCode (DYNAMIC)

hl7:statusCode

CS

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

completed

hl7:effectiveTime

TS

1 … 1

R

(IPS...ion)


	hl7ips-dataelement-53	Date of Immunization	CEN/TC 251 prEN 17269

Example

hl7:consumable

1 … 1

M

(IPS...ion)

Included

from 2.16.840.1.113883.10.22.4.16 IPS Immunization Medication Information (DYNAMIC)

hl7:manufacturedProduct

(IPS...ion)


	hl7ips-dataelement-54	Product Administered	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

MANU

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.16

hl7:manufacturedMaterial

1 … 1

M

(IPS...ion)

hl7:code

CD.IPS (preferred)

1 … 1

R

(IPS...ion)


hl7ips-dataelement-46	Immunizations Content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-52	Vaccine for type of disease	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)

hl7:translation

CE

0 … *

(IPS...ion)

CONF

shall be drawn from concept domain "Product Code"

hl7:translation

CE

0 … 1

candidate: 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)

hl7:lotNumberText

ST

0 … 1

(IPS...ion)

hl7:manufacturerOrganization

0 … 1

R

Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)

(IPS...ion)

hl7:author

0 … *

R

Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)

(IPS...ion)

hl7:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

F

RSON

IPS Immunization Medication Information

Id

2.16.840.1.113883.10.22.4.16

Effective Date

2024‑08‑04 21:16:00

Other versions this id:

IPSImmunizationMedicationInformation as of 2017‑03‑08

Status

Draft

Version Label

STU2

Name

IPSImmunizationMedicationInformation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.16

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-46	Immunizations Content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-52	Vaccine for type of disease	CEN/TC 251 prEN 17269
hl7ips-dataelement-54	Product Administered	CEN/TC 251 prEN 17269

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.9.1	Containment	IPS CDA Organization (STU1)	DYNAMIC

Relationship

Specialization: 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

Example

MMR Vaccine

Item

DT

Card

Conf

Description

Label

hl7:manufacturedProduct

(IPS...ion)


	hl7ips-dataelement-54	Product Administered	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

MANU

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.16

hl7:manufacturedMaterial

1 … 1

M

(IPS...ion)

hl7:code

CD.IPS (preferred)

1 … 1

R

(IPS...ion)


hl7ips-dataelement-46	Immunizations Content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-52	Vaccine for type of disease	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)

hl7:translation

CE

0 … *

(IPS...ion)

CONF

shall be drawn from concept domain "Product Code"

hl7:translation

CE

0 … 1

candidate: 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)

hl7:lotNumberText

ST

0 … 1

(IPS...ion)

hl7:manufacturerOrganization

0 … 1

R

Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)

(IPS...ion)

IPS Internal Reference

Id

2.16.840.1.113883.10.22.4.31

Effective Date

2017‑05‑02

Status

Under pre-publication review

Version Label

STU1

Name

IPSEntryInternalReference

Display Name

IPS Internal Reference

Description

This template is used to reference (point to) information contained in other entries within the same document.

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:act

R

(IPS...nce)

@classCode

cs

1 … 1

F

ACT

@moodCode

cs

1 … 1

R

The @moodCode of the reference SHALL match the @moodCode of the referenced element

Variable let

Name

refMoodCode

Value

@moodCode

Variable let

Name

refID

Value

concat(hl7:id[1]/@root,'#',hl7:id[1]/@extension)

Variable let

Name

refCode

Value

concat(hl7:code[1]/@code,'#',hl7:code[1]/@codeSystem)

Variable let

Name

reffedObject

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 assert

role

error

test

not(exists($reffedObject)) or $reffedObject[@moodCode=$refMoodCode]

Message

The @moodCode of the reference SHALL match the @moodCode of the referenced element

Schematron assert

role

error

test

exists($reffedObject)

Message

The root and extension attributes SHALL identify an element defined elsewhere in the same document.

Schematron assert

role

error

test

not(exists($reffedObject)) or ($reffedObject[not(*:code/@code)] and hl7:code[@nullFlavor='NA']) or $reffedObject/*:code[concat(@code,'#',@codeSystem)=$refCode]

Message

The code of the reference SHALL match the code of the referenced element

hl7:templateId

II

1 … 1

M

(IPS...nce)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.31

hl7:id

II

1 … 1

R

This element shall be present. The root and extension attributes shall identify an element defined elsewhere in the same document.

(IPS...nce)

hl7:code

CD

1 … 1

R

This 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)

@nullFlavor

cs

0 … 1

F

NA

IPS Laboratory Result Observation

Id

2.16.840.1.113883.10.22.4.13

Effective Date

2024‑08‑04 11:10:20

Other versions this id:

IPSLaboratoryResultObservation as of 2017‑03‑21

Status

Draft

Version Label

STU2

Name

IPSLaboratoryResultObservation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.13

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 2 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.22	Containment	IPS Comment Activity (STU1)	DYNAMIC

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.13

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CD.IPS

1 … 1

M

(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)

hl7:statusCode

CS

1 … 1

M

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...ion)

Choice

1 … 1

Elements 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']

hl7:value

CE.IPS (extensible)

0 … 1

R

(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

Example

Germ susceptible to antimicrobial agent from HL7 vocabulary

hl7:value

PQ

0 … 1

R

(IPS...ion)

where [@xsi:type='PQ']

Constraint

If 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

hl7:value

IVL_PQ

0 … 1

R

(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

hl7:value

ST

0 … 1

R

(IPS...ion)

where [@xsi:type='ST']

Example

Result free text (data type ST)

<value xsi:type="ST">slight macrocytosis, check on alcohol consumption</value>

hl7:value

TS

0 … 1

R

(IPS...ion)

where [@xsi:type='TS']

Example

Result time stamp (data type TS): 6-Aug-2014

hl7:value

RTO_QTY_QTY

0 … 1

R

(IPS...ion)

where [@xsi:type='RTO_QTY_QTY']

Example

Result ratio (data type RTO_QTY_QTY): 1/179

hl7:interpretationCode

CE.IPS

0 … 1

R

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)

Included

0 … *

R

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

R

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:referenceRange

0 … 1

R

The referenceRange is constrained to represent the normal range for this observation and this patient.

(IPS...ion)

hl7:observationRange

1 … 1

M

(IPS...ion)

hl7:code

CD

NP

(IPS...ion)

hl7:value

ANY

1 … 1

M

(IPS...ion)

hl7:interpretationCode

CE.IPS

0 … 1

(IPS...ion)

@code

CONF

0 … 1

F

N

@codeSystem

0 … 1

F

2.16.840.1.113883.5.83 (Observation Interpretation)

hl7:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

F

COMP

IPS Manufactured Material

Id

2.16.840.1.113883.10.22.4.3

Effective Date

2024‑08‑04 10:47:30

Other versions this id:

IPSMedMaterial as of 2021‑08‑02 16:52:27
IPSMedMaterial as of 2016‑11‑10

Status

Draft

Version Label

STU2

Name

IPSMedMaterial

Display Name

IPS 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.

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 4 concepts

Id	Name	Data Set
hl7ips-dataelement-105	Product Code	CEN/TC 251 prEN 17269
hl7ips-dataelement-117	Brand Name	CEN/TC 251 prEN 17269
hl7ips-dataelement-171	Product Common Name (and Strength)	CEN/TC 251 prEN 17269
hl7ips-dataelement-227	Pharmaceutical dose form	CEN/TC 251 prEN 17269

Relationship

Specialization: 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

<manufacturedMaterial>
  
  <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>
      
      <containerPackagedProduct>
        
        <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">
      
      <generalizedMaterialKind classCode="MMAT">
        
        <code code=" " codeSystem="2.16.840.1.113883.6.73" displayName=" " codeSystemName="WHO ATC"/>      </generalizedMaterialKind>    </asSpecializedKind>    <asSpecializedKind>
      
      <generalizedMaterialKind classCode="MMAT">
        <code code="PhPID" codeSystem=" " displayName=" " codeSystemName="PhP EMA">
          <name>....</name>        </code>      </generalizedMaterialKind>    </asSpecializedKind>    
    <ingredient classCode="ACTI" determinerCode="KIND">
      <quantity>
        
        <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

Item

DT

Card

Conf

Description

Label

hl7:manufacturedMaterial

0 … *

R

(IPS...ial)

@classCode

cs

0 … 1

F

MMAT

@determinerCode

cs

0 … 1

F

KIND

hl7:templateId

II

1 … 1

M

(IPS...ial)

@root

oid

1 … 1

F

2.16.840.1.113883.10.22.4.3

Choice

0 … 1

Elements to choose from:

hl7:code
hl7:code[@codeSystem='2.16.840.1.113883.6.96']

hl7:code

CE.IPS

0 … 1

R

This 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)


	hl7ips-dataelement-105	Product Code	CEN/TC 251 prEN 17269

hl7:code

CE.IPS

0 … 1

R

Non 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)

hl7:name

EN

0 … 1

R

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)


hl7ips-dataelement-117	Brand Name	CEN/TC 251 prEN 17269
hl7ips-dataelement-171	Product Common Name (and Strength)	CEN/TC 251 prEN 17269

pharm:formCode

CE.IPS

0 … 1

R

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)


	hl7ips-dataelement-227	Pharmaceutical dose form	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

pharm: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:capacityQuantity> 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)

@classCode

cs

1 … 1

F

CONT

Example

Packaged Medicinal Product with multiple layers packaging

Example

Packaged Medicinal Product with formCode

<asContent>
  <containerPackagedProduct>
    
    <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>

pharm:quantity

PQ

0 … 1

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ial)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

It represents the most inner Package Item or the Packaged Medicinal Product.

(IPS...ial)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm: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)

pharm:name

ST

0 … 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>

pharm:formCode

CE.IPS

0 … 1

R

This 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

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...ial)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm: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)

@classCode

cs

1 … 1

F

CONT

pharm:quantity

PQ

0 … 1

R

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ial)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

It represents the intermediate Package Item or the Packaged Medicinal Product

(IPS...ial)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS

0 … 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)

pharm:name

ST

0 … 1

R

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

pharm:formCode

CE.IPS

1 … 1

R

This 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)

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...ial)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm: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)

@classCode

cs

1 … 1

F

CONT

pharm:quantity

PQ

0 … 1

R

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ial)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

When present, it represents the Packaged Medicinal Product

(IPS...ial)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS

0 … 1

When 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)

pharm:name

ST

0 … 1

R

When present, it can be used for the representing the brand name.

(IPS...ial)

pharm:formCode

CE.IPS

1 … 1

R

When 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)

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...ial)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm:asSpecializedKind

0 … 1

R

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']

@classCode

cs

1 … 1

F

GRIC

Example

pharm:generalizedMaterialKind

1 … 1

M

(IPS...ial)

@classCode

cs

1 … 1

F

MMAT

pharm:code

CD.IPS

1 … 1

R

The <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

pharm:name

0 … *

(IPS...ial)

pharm:asSpecializedKind

0 … *

R

The 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)

@classCode

cs

1 … 1

F

GRIC

Example

pharm:generalizedMaterialKind

R

(IPS...ial)

@classCode

cs

1 … 1

F

MMAT

pharm:code

CD.IPS

1 … 1

R

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)

pharm:name

0 … *

R

(IPS...ial)

pharm: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)

@classCode

cs

1 … 1

R

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC)

pharm:quantity

1 … 1

M

The 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

hl7:numerator

PQ

1 … 1

R

(IPS...ial)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.30 Medicine Strength Numerator (DYNAMIC)

@value

1 … 1

R

hl7:denominator

PQ

1 … 1

R

(IPS...ial)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.31 Medicine Strength Denominator (DYNAMIC)

@value

1 … 1

R

pharm:ingredientSubstance

1 … 1

R

(IPS...ial)

@classCode

cs

1 … 1

F

MMAT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS (extensible)

0 … 1

C

The 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)

hl7:originalText

ED

0 … *

(IPS...ial)

hl7:reference

TEL

0 … *

(IPS...ial)

hl7:translation

CD

0 … *

This element can be used to provide alternative identifications for the described substance.

(IPS...ial)

pharm:name

0 … 1

C

Name of the substance

(IPS...ial)

Schematron assert

role

error

test

pharm:code or pharm:name

Message

Either the name or the code of the substance (or both) shall be provided

IPS Medical Device

Id

2.16.840.1.113883.10.22.4.26

Effective Date

2017‑04‑11

Status

Under pre-publication review

Version Label

STU1

Name

IPSMedicalDevice

Display Name

IPS Medical Device

Description

The medical devices entry content module describes the kind of device that is, or has been used by the patient

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.26

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 6 concepts

Id	Name	Data Set
hl7ips-dataelement-150	Use end date	CEN/TC 251 prEN 17269
hl7ips-dataelement-218	Device content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-57	Device	CEN/TC 251 prEN 17269
hl7ips-dataelement-58	Device Type	CEN/TC 251 prEN 17269
hl7ips-dataelement-59	Use start date	CEN/TC 251 prEN 17269
hl7ips-dataelement-60	Device Identifier	CEN/TC 251 prEN 17269

Relationship

Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.3.5 Medical Devices (2013‑12‑20)

ref

epsos-

Example

Item

DT

Card

Conf

Description

Label

hl7:supply

R

The <supply> element shall be present. The moodCode attribute shall be EVN to reflect that a medical device has been provided.</supply>

(IPS...ice)

@classCode

cs

1 … 1

F

SPLY

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ice)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.26

hl7:id

II

0 … *

R

This optional element identifies the provision of the device (e.g. implant procedure)

(IPS...ice)

hl7:text

ED

0 … 1

R

(IPS...ice)

hl7:reference

TEL

1 … 1

M

(IPS...ice)

@value

url

1 … 1

R

Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:effectiveTime

IVL_TS

1 … 1

R

This element provides the interval of time corresponding to the device usage by/presence in the patient.

(IPS...ice)

@xsi:type

st

1 … 1

F

IVL_TS

hl7:low

TS

1 … 1

R

The lower bound of the interval represents the start date/time.

(IPS...ice)


	hl7ips-dataelement-59	Use start date	CEN/TC 251 prEN 17269

hl7:high

TS

0 … 1

C

The 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)


	hl7ips-dataelement-150	Use end date	CEN/TC 251 prEN 17269

hl7:participant

1 … *

R

The device is represented as a participant in the supply structure. The following descriptions apply to the device structure.

(IPS...ice)


	hl7ips-dataelement-57	Device	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

DEV

Example

Example

Presence of implanted device not known (situation)

Example

No implant in situ (situation)

hl7:participantRole

1 … 1

R

(IPS...ice)

@classCode

cs

1 … 1

F

MANU

hl7:id

II

0 … *

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)


	hl7ips-dataelement-60	Device Identifier	CEN/TC 251 prEN 17269

Example

UDI GS1: DeviceIdentifier 00844588003288, Serial# 10987654d321, Lot# 7654321D

Example

UDI ICCBBA: DeviceIdentifier 00844588003288

Example

UDI HIBCC: Serial# XYZ456789012345678, Lot# LOT123456789012345

hl7:playingDevice

1 … 1

R

The playingDevice element describes the device instance.

(IPS...ice)

@classCode

cs

1 … 1

F

DEV

@determinerCode

cs

1 … 1

F

INSTANCE

hl7:code

CE.IPS (preferred)

1 … 1

R

The device code describes the type of device (e.g. arm prosthesis, arterial stent).

(IPS...ice)


hl7ips-dataelement-218	Device content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-58	Device Type	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)

Id

2.16.840.1.113883.10.22.4.2

Effective Date

2024‑08‑04 10:45:46

Other versions this id:

IPSManufacturedProduct as of 2016‑11‑10

Status

Draft

Version Label

STU2

Name

IPSManufacturedProduct

Display Name

IPS Medication Information (detail)

Description

This entry describes the consumable subject of the medication statement.
All the information about the medication is provided in the included IPS Manufactured Material template.

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 1 concept

Id	Name	Data Set
hl7ips-dataelement-2	Medicinal Product	CEN/TC 251 prEN 17269

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.3	Include	IPS Manufactured Material (STU2)	DYNAMIC

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:manufacturedProduct

0 … *

R

(IPS...uct)


	hl7ips-dataelement-2	Medicinal Product	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

MANU

hl7:templateId

II

1 … 1

M

(IPS...uct)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.2

Included

1 … 1

R

from 2.16.840.1.113883.10.22.4.3 IPS Manufactured Material (DYNAMIC)

hl7:manufacturedMaterial

1 … 1

R

(IPS...uct)

@classCode

cs

0 … 1

F

MMAT

@determinerCode

cs

0 … 1

F

KIND

hl7:templateId

II

1 … 1

M

(IPS...uct)

@root

oid

1 … 1

F

2.16.840.1.113883.10.22.4.3

Choice

0 … 1

Elements to choose from:

hl7:code
hl7:code[@codeSystem='2.16.840.1.113883.6.96']

hl7:code

CE.IPS

0 … 1

R

This 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)


	hl7ips-dataelement-105	Product Code	CEN/TC 251 prEN 17269

hl7:code

CE.IPS

0 … 1

R

Non 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)

hl7:name

EN

0 … 1

R

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)


hl7ips-dataelement-117	Brand Name	CEN/TC 251 prEN 17269
hl7ips-dataelement-171	Product Common Name (and Strength)	CEN/TC 251 prEN 17269

pharm:formCode

CE.IPS

0 … 1

R

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)


	hl7ips-dataelement-227	Pharmaceutical dose form	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

pharm: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:capacityQuantity> 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)

@classCode

cs

1 … 1

F

CONT

Example

Packaged Medicinal Product with multiple layers packaging

Example

Packaged Medicinal Product with formCode

<asContent>
  <containerPackagedProduct>
    
    <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>

pharm:quantity

PQ

0 … 1

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...uct)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

It represents the most inner Package Item or the Packaged Medicinal Product.

(IPS...uct)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm: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)

pharm:name

ST

0 … 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>

pharm:formCode

CE.IPS

0 … 1

R

This 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

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...uct)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm: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)

@classCode

cs

1 … 1

F

CONT

pharm:quantity

PQ

0 … 1

R

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...uct)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

It represents the intermediate Package Item or the Packaged Medicinal Product

(IPS...uct)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS

0 … 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)

pharm:name

ST

0 … 1

R

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

pharm:formCode

CE.IPS

1 … 1

R

This 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)

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...uct)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm: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)

@classCode

cs

1 … 1

F

CONT

pharm:quantity

PQ

0 … 1

R

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...uct)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

When present, it represents the Packaged Medicinal Product

(IPS...uct)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS

0 … 1

When 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)

pharm:name

ST

0 … 1

R

When present, it can be used for the representing the brand name.

(IPS...uct)

pharm:formCode

CE.IPS

1 … 1

R

When 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)

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...uct)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm:asSpecializedKind

0 … 1

R

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']

@classCode

cs

1 … 1

F

GRIC

Example

pharm:generalizedMaterialKind

1 … 1

M

(IPS...uct)

@classCode

cs

1 … 1

F

MMAT

pharm:code

CD.IPS

1 … 1

R

The <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

pharm:name

0 … *

(IPS...uct)

pharm:asSpecializedKind

0 … *

R

The 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)

@classCode

cs

1 … 1

F

GRIC

Example

pharm:generalizedMaterialKind

R

(IPS...uct)

@classCode

cs

1 … 1

F

MMAT

pharm:code

CD.IPS

1 … 1

R

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)

pharm:name

0 … *

R

(IPS...uct)

pharm: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)

@classCode

cs

1 … 1

R

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC)

pharm:quantity

1 … 1

M

The 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

hl7:numerator

PQ

1 … 1

R

(IPS...uct)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.30 Medicine Strength Numerator (DYNAMIC)

@value

1 … 1

R

hl7:denominator

PQ

1 … 1

R

(IPS...uct)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.31 Medicine Strength Denominator (DYNAMIC)

@value

1 … 1

R

pharm:ingredientSubstance

1 … 1

R

(IPS...uct)

@classCode

cs

1 … 1

F

MMAT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS (extensible)

0 … 1

C

The 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)

hl7:originalText

ED

0 … *

(IPS...uct)

hl7:reference

TEL

0 … *

(IPS...uct)

hl7:translation

CD

0 … *

This element can be used to provide alternative identifications for the described substance.

(IPS...uct)

pharm:name

0 … 1

C

Name of the substance

(IPS...uct)

Schematron assert

role

error

test

pharm:code or pharm:name

Message

Either the name or the code of the substance (or both) shall be provided

IPS Medication Statement

Id

2.16.840.1.113883.10.22.4.4

Effective Date

2024‑08‑04 10:41:54

Other versions this id:

IPSMedicationStatement as of 2021‑09‑02 12:17:54
IPSMedicationStatement as of 2016‑11‑11

Status

Draft

Version Label

STU2

Name

IPSMedicationStatement

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.4

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-102	Route of administration	CEN/TC 251 prEN 17269
hl7ips-dataelement-104	Medication	CEN/TC 251 prEN 17269
hl7ips-dataelement-220	Medication Summary content status	CEN/TC 251 prEN 17269

Uses

Uses 4 templates

Uses	as	Name	Version
2.16.840.1.113883.10.21.9.1	Include	UV Use Period (2023)	DYNAMIC
2.16.840.1.113883.10.22.4.2	Include	IPS Medication Information (detail) (STU2)	DYNAMIC
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.21.4.6	Containment	UV Subordinate Substance Administration (2023)	DYNAMIC

Relationship

Specialization: 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

No medication infos

Item

DT

Card

Conf

Description

Label

hl7:substanceAdministration

R

(IPS...ent)


	hl7ips-dataelement-104	Medication	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

SBADM

@moodCode

cs

1 … 1

R

If 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)

hl7:templateId

II

1 … 1

M

(IPS...ent)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.4

hl7:id

II

0 … *

R

(IPS...ent)

hl7:code

CD.IPS

1 … 1

R

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)


	hl7ips-dataelement-220	Medication Summary content status	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)

hl7:text

ED

0 … 1

R

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)

hl7:reference

TEL

1 … 1

M

(IPS...ent)

@value

url

1 … 1

R

Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS

1 … 1

M

(IPS...ent)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.12 ActStatusActiveCompletedAbortedSuspended (DYNAMIC)

Example

Included

1 … 1

R

from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC)

Choice

1 … 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)]

hl7:effectiveTime

IVL_TS

0 … 1

C

Case 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)]

@nullFlavor

cs

0 … 1

Example

Known Interval

Example

Information not available about the period

Example

Unknown end date

Example

continous therapy

hl7:low

IVXB_TS

1 … 1

R

(IPS...ent)

hl7:high

IVXB_TS

0 … 1

R

(IPS...ent)

hl7:effectiveTime

IVL_TS

0 … 1

C

Case 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

hl7:low

NP

(IPS...ent)

hl7:high

NP

(IPS...ent)

hl7:center

NP

(IPS...ent)

hl7:width

PQ

1 … 1

R

(IPS...ent)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)

hl7:effectiveTime

IVL_TS

0 … 1

C

Case 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

hl7:low

IVXB_TS

0 … 1

C

(IPS...ent)

hl7:width

PQ

1 … 1

R

(IPS...ent)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)

hl7:routeCode

CE.IPS

0 … 1

R

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)


	hl7ips-dataelement-102	Route of administration	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)

hl7:doseQuantity

IVL_PQ

NP

(IPS...ent)

hl7:rateQuantity

IVL_PQ

NP

(IPS...ent)

hl7:administrationUnitCode

CE

NP

(IPS...ent)

hl7:consumable

1 … 1

M

(IPS...ent)

@typeCode

cs

1 … 1

F

CSM

Included

from 2.16.840.1.113883.10.22.4.2 IPS Medication Information (detail) (DYNAMIC)

hl7:manufacturedProduct

0 … *

R

(IPS...ent)


	hl7ips-dataelement-2	Medicinal Product	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

MANU

hl7:templateId

II

1 … 1

M

(IPS...ent)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.2

Included

1 … 1

R

from 2.16.840.1.113883.10.22.4.3 IPS Manufactured Material (DYNAMIC)

hl7:manufacturedMaterial

1 … 1

R

(IPS...ent)

@classCode

cs

0 … 1

F

MMAT

@determinerCode

cs

0 … 1

F

KIND

hl7:templateId

II

1 … 1

M

(IPS...ent)

@root

oid

1 … 1

F

2.16.840.1.113883.10.22.4.3

Choice

0 … 1

Elements to choose from:

hl7:code
hl7:code[@codeSystem='2.16.840.1.113883.6.96']

hl7:code

CE.IPS

0 … 1

R

This 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)


	hl7ips-dataelement-105	Product Code	CEN/TC 251 prEN 17269

hl7:code

CE.IPS

0 … 1

R

Non 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)

hl7:name

EN

0 … 1

R

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)


hl7ips-dataelement-117	Brand Name	CEN/TC 251 prEN 17269
hl7ips-dataelement-171	Product Common Name (and Strength)	CEN/TC 251 prEN 17269

pharm:formCode

CE.IPS

0 … 1

R

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)


	hl7ips-dataelement-227	Pharmaceutical dose form	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

pharm: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:capacityQuantity> 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)

@classCode

cs

1 … 1

F

CONT

Example

Packaged Medicinal Product with multiple layers packaging

Example

Packaged Medicinal Product with formCode

<asContent>
  <containerPackagedProduct>
    
    <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>

pharm:quantity

PQ

0 … 1

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ent)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

It represents the most inner Package Item or the Packaged Medicinal Product.

(IPS...ent)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm: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)

pharm:name

ST

0 … 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>

pharm:formCode

CE.IPS

0 … 1

R

This 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

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...ent)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm: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)

@classCode

cs

1 … 1

F

CONT

pharm:quantity

PQ

0 … 1

R

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ent)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

It represents the intermediate Package Item or the Packaged Medicinal Product

(IPS...ent)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS

0 … 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)

pharm:name

ST

0 … 1

R

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

pharm:formCode

CE.IPS

1 … 1

R

This 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)

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...ent)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm: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)

@classCode

cs

1 … 1

F

CONT

pharm:quantity

PQ

0 … 1

R

The quantity which specified how many inner packaged content entities are in an outer packaging container entity.

(IPS...ent)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

Example

Example

pharm:containerPackagedProduct

1 … 1

R

When present, it represents the Packaged Medicinal Product

(IPS...ent)

@classCode

cs

1 … 1

F

CONT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS

0 … 1

When 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)

pharm:name

ST

0 … 1

R

When present, it can be used for the representing the brand name.

(IPS...ent)

pharm:formCode

CE.IPS

1 … 1

R

When 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)

pharm:capacityQuantity

PQ

0 … 1

It represents the functional capacity of the container: e.g. bottle containing up to 20 tablets or ampule of 10 ml.

(IPS...ent)

@unit

cs

0 … 1

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.28 Quantity Units (DYNAMIC)

@value

1 … 1

R

pharm:asSpecializedKind

0 … 1

R

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']

@classCode

cs

1 … 1

F

GRIC

Example

pharm:generalizedMaterialKind

1 … 1

M

(IPS...ent)

@classCode

cs

1 … 1

F

MMAT

pharm:code

CD.IPS

1 … 1

R

The <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

pharm:name

0 … *

(IPS...ent)

pharm:asSpecializedKind

0 … *

R

The 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)

@classCode

cs

1 … 1

F

GRIC

Example

pharm:generalizedMaterialKind

R

(IPS...ent)

@classCode

cs

1 … 1

F

MMAT

pharm:code

CD.IPS

1 … 1

R

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)

pharm:name

0 … *

R

(IPS...ent)

pharm: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)

@classCode

cs

1 … 1

R

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC)

pharm:quantity

1 … 1

M

The 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

hl7:numerator

PQ

1 … 1

R

(IPS...ent)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.30 Medicine Strength Numerator (DYNAMIC)

@value

1 … 1

R

hl7:denominator

PQ

1 … 1

R

(IPS...ent)

@unit

cs

1 … 1

R

CONF

The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.31 Medicine Strength Denominator (DYNAMIC)

@value

1 … 1

R

pharm:ingredientSubstance

1 … 1

R

(IPS...ent)

@classCode

cs

1 … 1

F

MMAT

@determinerCode

cs

1 … 1

F

KIND

pharm:code

CD.IPS (extensible)

0 … 1

C

The 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)

hl7:originalText

ED

0 … *

(IPS...ent)

hl7:reference

TEL

0 … *

(IPS...ent)

hl7:translation

CD

0 … *

This element can be used to provide alternative identifications for the described substance.

(IPS...ent)

pharm:name

0 … 1

C

Name of the substance

(IPS...ent)

Schematron assert

role

error

test

pharm:code or pharm:name

Message

Either the name or the code of the substance (or both) shall be provided

Included

0 … *

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

(IPS...ent)

hl7:templateId

II

1 … 1

M

(IPS...ent)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ent)

hl7:assignedAuthor

1 … 1

M

(IPS...ent)

hl7:id

II

1 … *

R

(IPS...ent)

hl7:code

0 … 1

R

(IPS...ent)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ent)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ent)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ent)

hl7:given

1 … *

R

(IPS...ent)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ent)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ent)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ent)

hl7:softwareName

SC

0 … 1

(IPS...ent)

hl7:representedOrganization

0 … 1

(IPS...ent)

hl7:id

II

0 … *

(IPS...ent)

hl7:name

0 … *

(IPS...ent)

hl7:telecom

TEL

0 … *

(IPS...ent)

hl7:addr

AD

0 … *

(IPS...ent)

hl7: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)

@typeCode

cs

1 … 1

F

COMP

Constraint

At least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent. </substanceAdministration>

Example

<hl7:entryRelationship typeCode="COMP">
  
  <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>

hl7:sequenceNumber

INT

0 … 1

Sequence number of the Subordinate Substance Administration

(IPS...ent)

IPS ObservationMedia

Id

2.16.840.1.113883.10.22.4.23

Effective Date

2021‑09‑02 12:02:16

Other versions this id:

IPSObservationMedia as of 2017‑04‑06

Status

Draft

Version Label

2021

Name

IPSObservationMedia

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.23

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 2 templates

Uses	as	Name	Version
2.16.840.1.113883.10.12.323	Containment	CDA Performer (Body)	DYNAMIC
2.16.840.1.113883.10.12.318	Containment	CDA Author (Body)	DYNAMIC

Relationship

Version: 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

<observationMedia ID="Unique_String" moodCode="EVN" classCode="OBS">
  
  <templateId root="2.16.840.1.113883.10.22.4.23"/>  <value mediaType="image/png" representation="B64">content encoded in Base 64</value>  <performer>
    
  </performer>  <author>
    
  </author></observationMedia>

Item

DT

Card

Conf

Description

Label

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)

@classCode

cs

0 … 1

F

OBS

@moodCode

cs

0 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...dia)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.23

hl7:languageCode

CS

0 … 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)

hl7:value

ED

1 … 1

M

(IPS...dia)

@representation

cs

1 … 1

R

@mediaType

cs

1 … 1

R

hl7:performer

0 … 1

Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC)

(IPS...dia)

hl7:author

0 … *

Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)

(IPS...dia)

IPS Pathology Result Observation

Id

2.16.840.1.113883.10.22.4.11

Effective Date

2024‑08‑04 11:10:42

Other versions this id:

IPSPathologyResultObservation as of 2017‑03‑21

Status

Draft

Version Label

STU2

Name

IPSPathologyResultObservation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.11

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 2 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.22	Containment	IPS Comment Activity (STU1)	DYNAMIC

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.11

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CD.IPS

1 … 1

M

(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)

hl7:statusCode

CS

1 … 1

M

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...ion)

Choice

1 … 1

Elements 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']

hl7:value

CE.IPS (extensible)

0 … 1

R

(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

Example

Result code: code 'POS' from code system 2.16.840.1.113883.5.83

hl7:value

PQ

0 … 1

R

(IPS...ion)

where [@xsi:type='PQ']

Constraint

If 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

hl7:value

IVL_PQ

0 … 1

R

(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

hl7:value

ST

0 … 1

R

(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>

hl7:value

TS

0 … 1

R

(IPS...ion)

where [@xsi:type='TS']

Example

Result time stamp (data type TS): 6-Aug-2014

hl7:value

RTO_QTY_QTY

0 … 1

R

(IPS...ion)

where [@xsi:type='RTO_QTY_QTY']

Example

Result ratio (data type RTO_QTY_QTY): 1/179

hl7:interpretationCode

CE.IPS

0 … 1

R

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)

Included

0 … *

R

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

R

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:referenceRange

0 … *

R

(IPS...ion)

hl7:observationRange

1 … 1

M

(IPS...ion)

hl7:code

CD

NP

(IPS...ion)

hl7:value

ANY

1 … 1

M

(IPS...ion)

hl7:interpretationCode

CE

0 … 1

(IPS...ion)

@code

CONF

0 … 1

F

N

@codeSystem

0 … 1

F

2.16.840.1.113883.5.83 (Observation Interpretation)

hl7:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

F

COMP

IPS Pregnancy Expected Delivery Date Observation

Id

2.16.840.1.113883.10.22.4.29

Effective Date

2024‑08‑04 11:02:42

Other versions this id:

IPSPregnancyExpectedDeliveryDateObservation as of 2017‑04‑13

Status

Draft

Version Label

STU2

Name

IPSPregnancyExpectedDeliveryDateObservation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.29

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 1 concept

Id	Name	Data Set
hl7ips-dataelement-213	Expected delivery date	CEN/TC 251 prEN 17269

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

R

(IPSPregnancyExpectedDeliveryDateObservation )

hl7:templateId

II

1 … 1

M

(IPSPregnancyExpectedDeliveryDateObservation )

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.29

hl7:code

CD.IPS

1 … 1

M

(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)

hl7:statusCode

CS

1 … 1

R

(IPSPregnancyExpectedDeliveryDateObservation )

@code

CONF

0 … 1

F

completed

hl7:effectiveTime

IVL_TS

0 … 1

R

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 )

hl7:value

TS

1 … 1

R

(IPSPregnancyExpectedDeliveryDateObservation )


	hl7ips-dataelement-213	Expected delivery date	CEN/TC 251 prEN 17269

IPS Pregnancy Outcome Observation

Id

2.16.840.1.113883.10.22.4.28

Effective Date

2017‑04‑13

Status

Under pre-publication review

Version Label

STU1

Name

IPSPregnancyOutcomeObservation

Display Name

IPS Pregnancy Outcome Observation

Description

A pregnancy outcome observation records a summary over all pregnancies.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.28

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 1 concept

Id	Name	Data Set
hl7ips-dataelement-214	Summary Metric	CEN/TC 251 prEN 17269

Relationship

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

Item

DT

Card

Conf

Description

Label

hl7:observation

R

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.28

hl7:code

CD.IPS

1 … 1

M

(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)

hl7:statusCode

CS

1 … 1

R

(IPS...ion)

@code

CONF

0 … 1

F

completed

hl7:value

INT

1 … 1

R

(IPS...ion)


	hl7ips-dataelement-214	Summary Metric	CEN/TC 251 prEN 17269

IPS Pregnancy Status Observation

Id

2.16.840.1.113883.10.22.4.27

Effective Date

2020‑07‑14 16:31:53

Other versions this id:

IPSPregnancyStatusObservation as of 2020‑07‑14 16:31:28
IPSPregnancyStatusObservation as of 2020‑05‑07 19:22:01
IPSPregnancyStatusObservation as of 2017‑04‑13

Status

Draft

Version Label

2021

Name

IPSPregnancyStatusObservation

Display Name

IPS Pregnancy Status Observation

Description

A 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.27

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-211	Date of Observation	CEN/TC 251 prEN 17269
hl7ips-dataelement-212	Pregnancy State	CEN/TC 251 prEN 17269
hl7ips-dataelement-213	Expected delivery date	CEN/TC 251 prEN 17269

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.29	Containment	IPS Pregnancy Expected Delivery Date Observation (STU2)	DYNAMIC

Relationship

Version: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

R

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.27

hl7:code

CD.IPS (extensible)

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

82810-3

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:statusCode

CS

1 … 1

R

(IPS...ion)

@code

CONF

0 … 1

F

completed

hl7:effectiveTime

IVL_TS

1 … 1

R

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)


	hl7ips-dataelement-211	Date of Observation	CEN/TC 251 prEN 17269

hl7:value

CE.IPS (required)

1 … 1

R

(IPS...ion)


	hl7ips-dataelement-212	Pregnancy State	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)

hl7:entryRelationship

0 … 1

R

Contains 2.16.840.1.113883.10.22.4.29 IPS Pregnancy Expected Delivery Date Observation (DYNAMIC)

(IPS...ion)


	hl7ips-dataelement-213	Expected delivery date	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

COMP

IPS Problem Concern Entry

Id

2.16.840.1.113883.10.22.4.7

Effective Date

2021‑08‑04 08:49:27

Other versions this id:

IPSProblemConcernEntry as of 2017‑02‑15

Status

Draft

Version Label

2021

Name

IPSProblemConcernEntry

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.7

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.8	Containment	IPS Problem Entry (2021)	DYNAMIC

Relationship

Version: 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

Example

Concern no longer tracked

Item

DT

Card

Conf

Description

Label

hl7:act

R

(IPS...try)

@classCode

cs

1 … 1

F

ACT

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...try)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.7

hl7:id

II

0 … *

R

(IPS...try)

hl7:code

CD

1 … 1

M

(IPS...try)

@code

1 … 1

F

CONC

@codeSystem

1 … 1

F

2.16.840.1.113883.5.6

hl7:statusCode

CS

1 … 1

R

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”.

(IPS...try)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)

hl7:effectiveTime

IVL_TS

1 … 1

M

(IPS...try)

hl7:low

IVXB_TS

1 … 1

R

This 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)

hl7:high

IVXB_TS

0 … 1

C

This element asserts when the clinician deemed there is no longer any need to track the underlying conditions.

(IPS...try)

Constraint

If the statusCode is completed this element is required

hl7:entryRelationship

1 … *

R

Contains 2.16.840.1.113883.10.22.4.8 IPS Problem Entry (DYNAMIC)

(IPS...try)

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

0 … 1

F

false

IPS Problem Entry

Id

2.16.840.1.113883.10.22.4.8

Effective Date

2024‑08‑04 11:06:03

Other versions this id:

IPSProblemEntry as of 2021‑08‑04 08:52:52
IPSProblemEntry as of 2017‑02‑15

Status

Draft

Version Label

2021

Name

IPSProblemEntry

Display Name

IPS 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".

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.8

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 12 concepts

Id	Name	Data Set
hl7ips-dataelement-101	Problem type	CEN/TC 251 prEN 17269
hl7ips-dataelement-115	Problem content status	CEN/TC 251 prEN 17269
hl7ips-dataelement-127	Onset date	CEN/TC 251 prEN 17269
hl7ips-dataelement-128	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-131	Diagnosis	CEN/TC 251 prEN 17269
hl7ips-dataelement-136	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-140	Problem	CEN/TC 251 prEN 17269
hl7ips-dataelement-209	Health condition / Problem	CEN/TC 251 prEN 17269
hl7ips-dataelement-210	Problem Type	CEN/TC 251 prEN 17269
hl7ips-dataelement-32	Onset Date	CEN/TC 251 prEN 17269
hl7ips-dataelement-34	Date resolved	CEN/TC 251 prEN 17269
hl7ips-dataelement-36	Diagnosis	CEN/TC 251 prEN 17269

Uses

Uses 3 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.25	Containment	IPS Severity Observation (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.19	Containment	IPS Certainty Observation (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.20	Containment	IPS Problem Status Observation (STU1)	2017‑03‑29

Relationship

Specialization: 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

Example

Closed Problem (resolution date known)

Example

Known absent problems

Item

DT

Card

Conf

Description

Label

hl7:observation

R

(IPS...try)


hl7ips-dataelement-140	Problem	CEN/TC 251 prEN 17269
hl7ips-dataelement-209	Health condition / Problem	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...try)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.8

hl7:id

II

0 … *

R

(IPS...try)

hl7:code

CD.IPS

1 … 1

R

This element describes the type of condition this observation is referring to.

(IPS...try)


hl7ips-dataelement-101	Problem type	CEN/TC 251 prEN 17269
hl7ips-dataelement-210	Problem Type	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

hl7:text

ED

0 … 1

R

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.</reference>

</text>

(IPS...try)

Example

hl7:reference

TEL

1 … 1

M

(IPS...try)

@value

url

1 … 1

R

When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS

1 … 1

M

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'.</statusCode>

(IPS...try)

@code

CONF

1 … 1

F

completed

hl7:effectiveTime

IVL_TS

1 … 1

M

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)

Example

Unknown onset date (active condition)

Example

Unknown resolution date

Example

Known resolution date

hl7:low

IVXB_TS

1 … 1

R

The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.

(IPS...try)


hl7ips-dataelement-127	Onset date	CEN/TC 251 prEN 17269
hl7ips-dataelement-32	Onset Date	CEN/TC 251 prEN 17269

hl7:high

IVXB_TS

0 … 1

C

The 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)


	hl7ips-dataelement-34	Date resolved	CEN/TC 251 prEN 17269

Constraint

If this condition is known to be resolved, then the effectiveTime/high would be present.

hl7:value

CD.IPS (preferred)

1 … 1

M

The <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)


hl7ips-dataelement-115	Problem content status	CEN/TC 251 prEN 17269
hl7ips-dataelement-131	Diagnosis	CEN/TC 251 prEN 17269
hl7ips-dataelement-36	Diagnosis	CEN/TC 251 prEN 17269

@xsi:type

0 … 1

F

CD

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.73 IPS Problems (DYNAMIC)

Example

Multiple Coding

Example

Local code not mappable in the reference terminology

Example

Textual Information

Example

Known absent problems

hl7:originalText

ED

R

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)

hl7:reference

TEL

0 … 1

R

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

hl7:qualifier

CR

0 … *

(IPS...try)

hl7:translation

CD.IPS

0 … *

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)

hl7:entryRelationship

0 … 1

R

Severity
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)


hl7ips-dataelement-128	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-136	Severity	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

1 … 1

F

true

hl7:entryRelationship

0 … 1

R

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)

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

1 … 1

F

true

hl7:entryRelationship

0 … 1

R

Status 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)

@typeCode

cs

1 … 1

F

REFR

@inversionInd

bl

0 … 1

F

false

IPS Problem Status Observation

Id

2.16.840.1.113883.10.22.4.20

Effective Date

2021‑09‑02 11:41:28

Other versions this id:

IPSProblemStatusObservation as of 2017‑03‑29

Status

Draft

Version Label

2021

Name

IPSProblemStatusObservation

Display Name

IPS Problem Status Observation

Description

This 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.20

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Version: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)

@classCode

cs

0 … 1

F

OBS

@moodCode

cs

0 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.20

hl7:code

CD.IPS

1 … 1

R

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

(IPS...ion)

@code

CONF

0 … 1

F

33999-4

@codeSystem

0 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:text

ED

0 … 1

R

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)

hl7:reference

TEL

1 … 1

M

(IPS...ion)

@value

url

1 … 1

R

Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS

1 … 1

M

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)

@code

CONF

1 … 1

F

completed

hl7:value

CE.IPS

1 … 1

R

The 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

Id

2.16.840.1.113883.10.22.4.17

Effective Date

2024‑08‑04 11:08:35

Other versions this id:

IPSProcedureEntry as of 2020‑07‑14 16:35:58
IPSProcedureEntry as of 2017‑03‑27

Status

Draft

Version Label

STU2

Name

IPSProcedureEntry

Display Name

IPS Procedure Entry

Description

The procedure entry is used to record procedures that have occurred, or which are planned for in the future.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.17

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 5 concepts

Id	Name	Data Set
hl7ips-dataelement-216	Body site	CEN/TC 251 prEN 17269
hl7ips-dataelement-44	Procedures Content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-47	Procedure	CEN/TC 251 prEN 17269
hl7ips-dataelement-48	Procedure date	CEN/TC 251 prEN 17269
hl7ips-dataelement-49	Procedure code	CEN/TC 251 prEN 17269

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.31	Containment	IPS Internal Reference (STU1)	DYNAMIC

Relationship

Specialization: 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

<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">
    
  </hl7:entryRelationship></hl7:procedure>

Item

DT

Card

Conf

Description

Label

hl7:procedure

(IPS...try)


	hl7ips-dataelement-47	Procedure	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

PROC

@moodCode

cs

1 … 1

R

CONF

The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)

hl7:templateId

II

1 … 1

M

(IPS...try)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.17

hl7:id

II

0 … *

R

(IPS...try)

hl7:code

CD.IPS (preferred)

1 … 1

R

(IPS...try)


hl7ips-dataelement-44	Procedures Content Status	CEN/TC 251 prEN 17269
hl7ips-dataelement-49	Procedure code	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)

hl7:text

ED

0 … 1

R

The <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)

hl7:reference

TEL

1 … 1

M

(IPS...try)

@value

url

1 … 1

R

When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS

1 … 1

M

(IPS...try)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.22 ActStatusActiveCompletedAbortedCancelled (DYNAMIC)

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...try)


	hl7ips-dataelement-48	Procedure date	CEN/TC 251 prEN 17269

hl7:targetSiteCode

CD.IPS (preferred)

0 … *

(IPS...try)


	hl7ips-dataelement-216	Body site	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)

hl7:participant

1 … *

R

The device is represented as a participant in the procedure structure. The following descriptions apply to the device structure.

(IPS...try)

@typeCode

cs

1 … 1

F

DEV

Example

hl7:participantRole

1 … 1

R

(IPS...try)

@classCode

cs

1 … 1

F

MANU

hl7:id

II

0 … *

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

Example

UDI ICCBBA: DeviceIdentifier 00844588003288

Example

UDI HIBCC: Serial# XYZ456789012345678, Lot# LOT123456789012345

hl7:playingDevice

1 … 1

R

The playingDevice element describes the device instance.

(IPS...try)

@classCode

cs

1 … 1

F

DEV

@determinerCode

cs

1 … 1

F

INSTANCE

hl7:code

CE.IPS (preferred)

1 … 1

R

The 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)

hl7:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC)

(IPS...try)

@typeCode

cs

1 … 1

F

COMP

@inversionInd

bl

1 … 1

F

true

IPS Radiology Result Observation

Id

2.16.840.1.113883.10.22.4.12

Effective Date

2024‑08‑04 20:18:00

Other versions this id:

IPSRadiologyResultObservation as of 2017‑03‑21

Status

Draft

Version Label

STU2

Name

IPSRadiologyResultObservation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.12

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Uses

Uses 3 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.22.17	Containment	IPS Radiology Result Observation Component (STU2)	DYNAMIC
2.16.840.1.113883.10.22.4.22	Containment	IPS Comment Activity (STU1)	DYNAMIC

Relationship

Specialization: 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)

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.12

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CD.IPS (extensible)

1 … 1

M

(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)

hl7:statusCode

CS

1 … 1

M

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...ion)

hl7:value

ST

0 … 1

R

Actual result, free text (data type ST)

(IPS...ion)

hl7:interpretationCode

CE.IPS

0 … 1

R

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)

hl7:targetSiteCode

CD.IPS (preferred)

0 … 1

(IPS...ion)

Constraint

If 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)

hl7:qualifier

CR

0 … 1

Laterality

(IPS...ion)

Constraint

The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not pre-coordinated in the targetSiteCode

hl7:name

CV (preferred)

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

272741003

@codeSystem

1 … 1

F

2.16.840.1.113883.6.96 (SNOMED-CT)

hl7:value

CD.IPS (preferred)

1 … 1

M

(IPS...ion)

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.57 Laterality (qualifier) (DYNAMIC)

hl7:qualifier

CR

0 … 1

Topographical modifier

(IPS...ion)

hl7:name

CV (preferred)

1 … 1

M

(IPS...ion)

@code

CONF

1 … 1

F

106233006

@codeSystem

1 … 1

F

2.16.840.1.113883.6.96 (SNOMED-CT)

hl7:value

CD.IPS (preferred)

1 … 1

M

(IPS...ion)

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.58 Topographical modifier (qualifier) (DYNAMIC)

Included

0 … *

R

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

R

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:referenceRange

0 … *

R

(IPS...ion)

hl7:observationRange

1 … 1

M

(IPS...ion)

hl7:code

CD

NP

(IPS...ion)

hl7:value

ANY

1 … 1

M

(IPS...ion)

hl7:interpretationCode

CE

0 … 1

(IPS...ion)

@code

CONF

0 … 1

F

N

@codeSystem

0 … 1

F

2.16.840.1.113883.5.83 (Observation Interpretation)

hl7:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.22.17 IPS Radiology Result Observation Component (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

F

COMP

hl7:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

F

COMP

IPS Reaction Manifestation

Id

2.16.840.1.113883.10.22.4.6

Effective Date

2024‑08‑04 10:18:47

Other versions this id:

IPSAdverseReactionMFST as of 2016‑11‑15

Status

Draft

Version Label

STU2

Name

IPSAdverseReactionMFST

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.6

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 2 concepts

Id	Name	Data Set
hl7ips-dataelement-193	Manifestation of the reaction	CEN/TC 251 prEN 17269
hl7ips-dataelement-194	Severity	CEN/TC 251 prEN 17269

Uses

Uses 1 template

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.25	Containment	IPS Severity Observation (STU1)	DYNAMIC

Relationship

Specialization: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

R

(IPS...FST)

@classCode

cs

0 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...FST)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.6

hl7:id

II

0 … *

R

(IPS...FST)

hl7:code

CD.IPS

1 … 1

R

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)

hl7:text

ED

0 … 1

R

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)

hl7:reference

TEL

1 … 1

M

(IPS...FST)

@value

url

1 … 1

R

When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS (required)

0 … 1

R

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)

@code

CONF

0 … 1

F

completed

hl7:effectiveTime

IVL_TS

1 … 1

M

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)

hl7:low

IVXB_TS

1 … 1

R

The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.

(IPS...FST)

hl7:high

IVXB_TS

0 … 1

C

The 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.

hl7:value

CD.IPS (preferred)

1 … 1

R

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)


	hl7ips-dataelement-193	Manifestation of the reaction	CEN/TC 251 prEN 17269

@xsi:type

1 … 1

F

CD

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.3 IPS Allergy Reaction (DYNAMIC)

hl7:originalText

0 … 1

R

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)

hl7:reference

0 … 1

R

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

hl7:translation

CD

0 … *

(IPS...FST)

hl7:entryRelationship

0 … 1

R

Severity
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)


	hl7ips-dataelement-194	Severity	CEN/TC 251 prEN 17269

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

1 … 1

F

true

IPS Result Observation

Id

2.16.840.1.113883.10.22.4.10

Effective Date

2017‑03‑02

Status

Under pre-publication review

Version Label

STU1

Name

IPSResultObservation

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.10

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 4 concepts

Id	Name	Data Set
hl7ips-dataelement-106	Observation Result	CEN/TC 251 prEN 17269
hl7ips-dataelement-143	Date of observation	CEN/TC 251 prEN 17269
hl7ips-dataelement-144	Observation Type	CEN/TC 251 prEN 17269
hl7ips-dataelement-145	Value	CEN/TC 251 prEN 17269

Uses

Uses 2 templates

Uses	as	Name	Version
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.22	Containment	IPS Comment Activity (STU1)	DYNAMIC

Relationship

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-

Example

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...ion)


	hl7ips-dataelement-106	Observation Result	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.10

hl7:id

II

0 … *

R

(IPS...ion)

hl7:code

CD.IPS

1 … 1

M

(IPS...ion)


	hl7ips-dataelement-144	Observation Type	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)

hl7:statusCode

CS

1 … 1

M

(IPS...ion)

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...ion)


	hl7ips-dataelement-143	Date of observation	CEN/TC 251 prEN 17269

Choice

1 … 1

Elements 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']

hl7:value

CE.IPS

0 … 1

R

(IPS...ion)

where [@xsi:type='CE.IPS']


	hl7ips-dataelement-145	Value	CEN/TC 251 prEN 17269

Example

Result code: code '201' from code system 2.16.840.1.113883.2.4.4.30.1045

Example

Result code: code 'POS' from code system 2.16.840.1.113883.5.83

hl7:value

PQ

0 … 1

R

(IPS...ion)

where [@xsi:type='PQ']

Constraint

If 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

hl7:value

IVL_PQ

0 … 1

R

(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

hl7:value

ST

0 … 1

R

(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>

hl7:value

TS

0 … 1

R

(IPS...ion)

where [@xsi:type='TS']

Example

Result time stamp (data type TS): 6-Aug-2014

hl7:value

RTO_QTY_QTY

0 … 1

R

(IPS...ion)

where [@xsi:type='RTO_QTY_QTY']

Example

Result ratio (data type RTO_QTY_QTY): 1/179

hl7:interpretationCode

CE.IPS

0 … 1

R

(IPS...ion)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)

hl7:targetSiteCode

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)

Included

0 … *

R

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)

hl7:author

0 … *

R

(IPS...ion)

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...ion)

hl7:assignedAuthor

1 … 1

M

(IPS...ion)

hl7:id

II

1 … *

R

(IPS...ion)

hl7:code

0 … 1

R

(IPS...ion)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...ion)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...ion)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...ion)

hl7:given

1 … *

R

(IPS...ion)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...ion)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...ion)

hl7:manufacturerModelName

SC

0 … 1

(IPS...ion)

hl7:softwareName

SC

0 … 1

(IPS...ion)

hl7:representedOrganization

0 … 1

(IPS...ion)

hl7:id

II

0 … *

(IPS...ion)

hl7:name

0 … *

(IPS...ion)

hl7:telecom

TEL

0 … *

(IPS...ion)

hl7:addr

AD

0 … *

(IPS...ion)

hl7:referenceRange

0 … *

R

(IPS...ion)

hl7:observationRange

1 … 1

M

(IPS...ion)

hl7:code

CD

NP

(IPS...ion)

hl7:value

ANY

1 … 1

M

(IPS...ion)

hl7:interpretationCode

CE

0 … 1

(IPS...ion)

@code

CONF

0 … 1

F

N

@codeSystem

0 … 1

F

2.16.840.1.113883.5.83 (Observation Interpretation)

hl7:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)

(IPS...ion)

@typeCode

cs

1 … 1

F

COMP

IPS Result Organizer

Id

2.16.840.1.113883.10.22.4.9

Effective Date

2017‑03‑02

Status

Under pre-publication review

Version Label

STU1

Name

IPSResultOrganizer

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.9

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 6 concepts

Id	Name	Data Set
hl7ips-dataelement-106	Observation Result	CEN/TC 251 prEN 17269
hl7ips-dataelement-143	Date of observation	CEN/TC 251 prEN 17269
hl7ips-dataelement-144	Observation Type	CEN/TC 251 prEN 17269
hl7ips-dataelement-146	Performer	CEN/TC 251 prEN 17269
hl7ips-dataelement-177	Observer	CEN/TC 251 prEN 17269
hl7ips-dataelement-23	Observation Result	CEN/TC 251 prEN 17269

Uses

Uses 9 templates

Uses	as	Name	Version
2.16.840.1.113883.10.12.323	Containment	CDA Performer (Body)	DYNAMIC
2.16.840.1.113883.10.22.4.14	Include	IPS Body Author (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.13	Containment	IPS Laboratory Result Observation (STU2)	DYNAMIC
2.16.840.1.113883.10.22.4.12	Containment	IPS Radiology Result Observation (STU2)	DYNAMIC
2.16.840.1.113883.10.22.4.11	Containment	IPS Pathology Result Observation (STU2)	DYNAMIC
2.16.840.1.113883.10.22.4.10	Containment	IPS Result Observation (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.30	Containment	IPS Specimen Collection (STU2)	DYNAMIC
2.16.840.1.113883.10.22.4.22	Containment	IPS Comment Activity (STU1)	DYNAMIC
2.16.840.1.113883.10.22.4.23	Containment	IPS ObservationMedia (2021)	DYNAMIC

Relationship

Adaptation: 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

Example

Item

DT

Card

Conf

Description

Label

hl7:organizer

(IPS...zer)


	hl7ips-dataelement-106	Observation Result	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

R

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...zer)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.9

hl7:id

II

0 … *

(IPS...zer)

hl7:code

CD.IPS

1 … 1

R

(IPS...zer)


	hl7ips-dataelement-144	Observation Type	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)

hl7:statusCode

CS

1 … 1

M

(IPS...zer)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)

hl7:effectiveTime

IVL_TS

0 … 1

(IPS...zer)


	hl7ips-dataelement-143	Date of observation	CEN/TC 251 prEN 17269

hl7:low

IVXB_TS

0 … 1

(IPS...zer)

hl7:high

IVXB_TS

0 … 1

(IPS...zer)

hl7:performer

0 … *

R

When 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)


	hl7ips-dataelement-146	Performer	CEN/TC 251 prEN 17269

Included

0 … *

R

from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)


	hl7ips-dataelement-177	Observer	CEN/TC 251 prEN 17269

hl7:author

0 … *

R

(IPS...zer)

hl7:templateId

II

1 … 1

M

(IPS...zer)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.14

hl7:time

TS.IPS.TZ

1 … 1

R

(IPS...zer)

hl7:assignedAuthor

1 … 1

M

(IPS...zer)

hl7:id

II

1 … *

R

(IPS...zer)

hl7:code

0 … 1

R

(IPS...zer)

Choice

0 … 1

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

C

(IPS...zer)

@classCode

cs

0 … 1

F

PSN

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:name

PN

1 … *

R

Name of the person (e.g. the Healthcare Professional) authoring this document

(IPS...zer)

Example

<name>
<given>John</given> <family>Español Smith</family></name>

hl7:family

1 … *

R

(IPS...zer)

hl7:given

1 … *

R

(IPS...zer)

hl7:assignedAuthoringDevice

0 … 1

C

(IPS...zer)

Example

Included

from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:code

CE

0 … 1

(IPS...zer)

hl7:manufacturerModelName

SC

0 … 1

(IPS...zer)

hl7:softwareName

SC

0 … 1

(IPS...zer)

hl7:representedOrganization

0 … 1

(IPS...zer)

hl7:id

II

0 … *

(IPS...zer)

hl7:name

0 … *

(IPS...zer)

hl7:telecom

TEL

0 … *

(IPS...zer)

hl7:addr

AD

0 … *

(IPS...zer)

Choice

1 … *

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)

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.4.13 IPS Laboratory Result Observation (DYNAMIC)

(IPS...zer)

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.4.12 IPS Radiology Result Observation (DYNAMIC)

(IPS...zer)

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.4.11 IPS Pathology Result Observation (DYNAMIC)

(IPS...zer)

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.4.10 IPS Result Observation (DYNAMIC)

(IPS...zer)


	hl7ips-dataelement-23	Observation Result	CEN/TC 251 prEN 17269

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.4.30 IPS Specimen Collection (DYNAMIC)

(IPS...zer)

Constraint

An 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.

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)

(IPS...zer)

Constraint

An IPS Comment Activity SHALL contain a general comment applying to the whole set of observations present in the organizer

hl7:component

0 … *

Contains 2.16.840.1.113883.10.22.4.23 IPS ObservationMedia (DYNAMIC)

(IPS...zer)

IPS Severity Observation

Id

2.16.840.1.113883.10.22.4.25

Effective Date

2017‑04‑07

Status

Under pre-publication review

Version Label

STU1

Name

EntrySeverity

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.25

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-128	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-136	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-194	Severity	CEN/TC 251 prEN 17269

Relationship

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.1 eHDSI Severity (DYNAMIC)

ref

epsos-

Example

Item

DT

Card

Conf

Description

Label

hl7:observation

R

(Ent...ity)


hl7ips-dataelement-128	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-194	Severity	CEN/TC 251 prEN 17269

@classCode

cs

0 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(Ent...ity)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.25

hl7:id

II

0 … *

R

(Ent...ity)

hl7:code

CD

1 … 1

R

(Ent...ity)

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20386 SeverityObservationCode (DYNAMIC)

hl7:text

ED

0 … 1

R

If present, the <text> element shall contain a <reference> element pointing to the narrative where the severity is recorded</reference></text>

(Ent...ity)

hl7:reference

TEL

1 … 1

M

(Ent...ity)

@value

url

1 … 1

R

Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1

hl7:statusCode

CS

1 … 1

M

(Ent...ity)

@code

CONF

1 … 1

F

completed

hl7:value

CD.IPS (preferred)

1 … 1

R

The <value> element contains the level of severity.

(Ent...ity)


	hl7ips-dataelement-136	Severity	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

Id

2.16.840.1.113883.10.22.4.35

Effective Date

2017‑06‑29

Status

Under pre-publication review

Version Label

STU1

Name

IPSSocialHistoryObsAlcoholUse

Display Name

IPS Social History Alcohol Use

Description

This template is a specialization of the Social History Observation that may be used to represent alcohol consumption habits.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.35

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 2 concepts

Id	Name	Data Set
hl7ips-dataelement-151	Reference date range	CEN/TC 251 prEN 17269
hl7ips-dataelement-176	Life Style Factor	CEN/TC 251 prEN 17269

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...Use)


	hl7ips-dataelement-176	Life Style Factor	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...Use)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.35

hl7:id

II

0 … *

(IPS...Use)

hl7:code

CD.IPS (preferred)

1 … 1

R

(IPS...Use)

@code

CONF

0 … 1

F

74013-4

@codeSystem

0 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:translation

0 … *

R

(IPS...Use)

hl7:statusCode

CS

1 … 1

M

(IPS...Use)

@code

CONF

1 … 1

F

completed

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...Use)


	hl7ips-dataelement-151	Reference date range	CEN/TC 251 prEN 17269

hl7:value

PQ

1 … 1

R

(IPS...Use)

@xsi:type

cs

1 … 1

F

PQ

@unit

1 … 1

F

/d

IPS Social History Tobacco Use

Id

2.16.840.1.113883.10.22.4.34

Effective Date

2017‑06‑20

Status

Under pre-publication review

Version Label

STU1

Name

IPSSocialHistoryObsTobaccoUse

Display Name

IPS Social History Tobacco Use

Description

This template is a specialization of the Social History Observation that may be used to represent smoking or tobacco habits.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.34

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 1 concept

Id	Name	Data Set
hl7ips-dataelement-176	Life Style Factor	CEN/TC 251 prEN 17269

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:observation

(IPS...Use)


	hl7ips-dataelement-176	Life Style Factor	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...Use)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.34

hl7:id

II

0 … *

(IPS...Use)

hl7:code

CD.IPS

1 … 1

M

(IPS...Use)

@code

CONF

1 … 1

F

72166-2

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:translation

0 … *

R

(IPS...Use)

hl7:statusCode

CS

1 … 1

M

(IPS...Use)

@code

CONF

1 … 1

F

completed

hl7:effectiveTime

IVL_TS

1 … 1

R

(IPS...Use)

hl7:value

CD.IPS

1 … 1

R

(IPS...Use)

@xsi:type

cs

1 … 1

F

CD

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

Id

2.16.840.1.113883.10.22.4.30

Effective Date

2024‑08‑04 21:03:07

Other versions this id:

IPSSpecimenCollection as of 2017‑04‑14

Status

Draft

Version Label

STU2

Name

IPSSpecimenCollection

Display Name

IPS 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.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.30

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: 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

Item

DT

Card

Conf

Description

Label

hl7:procedure

(IPS...ion)

@classCode

cs

1 … 1

F

PROC

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

(IPS...ion)

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.30

hl7:code

CD.IPS

0 … 1

R

LOINC code representing the act of specimen collection

(IPS...ion)

@code

CONF

0 … 1

F

33882-2

@codeSystem

0 … 1

F

2.16.840.1.113883.6.1 (LOINC)

hl7:effectiveTime

IVL_TS

0 … 1

R

Date and time of specimen collection

(IPS...ion)

hl7:methodCode

CE.IPS

0 … 1

R

(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)

hl7:targetSiteCode

CE.IPS

0 … 1

R

(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)

hl7:participant

0 … 1

R

One 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)

@typeCode

cs

1 … 1

F

PRD

hl7:participantRole

1 … 1

M

(IPS...ion)

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

0 … 1

R

(IPS...ion)

hl7:playingEntity

1 … 1

R

(IPS...ion)

@determinerCode

cs

0 … 1

F

INSTANCE

@classCode

cs

0 … 1

F

ENT

hl7:code

CE (preferred)

1 … 1

M

(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

Id

2.16.840.1.113883.10.22.4.33

Effective Date

2017‑06‑15

Status

Under pre-publication review

Version Label

STU1

Name

IPSSubordinateSubstanceAdministration

Display Name

IPS Subordinate SubstanceAdministration

Description

This entry is used by a main substanceAdministration act to provide dosage information as the frequency of intakes or the amount of the medication given.

Context

Parent nodes of template element with id 2.16.840.1.113883.10.22.4.33

Label

IPSSubordSBADM

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 3 concepts

Id	Name	Data Set
hl7ips-dataelement-119	Dose Instruction	CEN/TC 251 prEN 17269
hl7ips-dataelement-223	Number of units per intake	CEN/TC 251 prEN 17269
hl7ips-dataelement-224	Frequency of intake	CEN/TC 251 prEN 17269

Relationship

Specialization: template 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC)

ref

pharmcda-

Example

<hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
  <hl7:templateId root="2.16.840.1.113883.10.22.4.33"/>  <hl7:statusCode code="active"/>  
  <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>

Item

DT

Card

Conf

Description

Label

hl7:substanceAdministration

IPSS...BADM


	hl7ips-dataelement-119	Dose Instruction	CEN/TC 251 prEN 17269

@classCode

cs

1 … 1

F

SBADM

@moodCode

cs

1 … 1

R

If 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)

Constraint

The moodCode of this subordinate <substanceAdministration> SHALL be the same of the parent <substanceAdministration> .

hl7:templateId

II

1 … 1

M

IPSS...BADM

@root

uid

1 … 1

F

2.16.840.1.113883.10.22.4.33

hl7:statusCode

CS

1 … 1

M

IPSS...BADM

Constraint

The 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

Choice

1 … 1

Elements 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']

hl7:effectiveTime

TS

0 … 1

C

This required element describes the frequency of intakes. If not known it shall be valued with the nullflavor "UNK"

IPSS...BADM

where [@value or @nullFlavor]


	hl7ips-dataelement-224	Frequency of intake	CEN/TC 251 prEN 17269

Example

Once (known date)

Example

Unknown

hl7:effectiveTime

PIVL_TS

0 … 1

C

IPSS...BADM

where [@xsi:type='PIVL_TS']


	hl7ips-dataelement-224	Frequency of intake	CEN/TC 251 prEN 17269

Example

Every 4 hours

Example

Twice a day

hl7:effectiveTime

EIVL_TS

0 … 1

C

IPSS...BADM

where [@xsi:type='EIVL_TS']


	hl7ips-dataelement-224	Frequency of intake	CEN/TC 251 prEN 17269

Example

After meal

Example

One hour before breakfast

hl7:event

EIVL.event

0 … 1

C

IPSS...BADM

@code

cs

0 … 1

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10706 TimingEvent (DYNAMIC)

hl7:effectiveTime

SXPR_TS

0 … 1

R

IPSS...BADM

where [@xsi:type='SXPR_TS']


	hl7ips-dataelement-224	Frequency of intake	CEN/TC 251 prEN 17269

hl7:doseQuantity

IVL_PQ

0 … 1

R

The <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


	hl7ips-dataelement-223	Number of units per intake	CEN/TC 251 prEN 17269

@unit

cs

0 … 1

Example

Not pre-coordinated consumable

Example

Pre-coordinated consumable - Dose Range

Example

Pre-coordinated consumable

Example

Pre-coordinated consumable with text reference

Example

Textual dosage

hl7:rateQuantity

IVL_PQ

0 … 1

IPSS...BADM

hl7:consumable

1 … 1

R

IPSS...BADM

hl7:manufacturedProduct

1 … 1

R

IPSS...BADM

hl7:manufacturedMaterial

1 … 1

R

IPSS...BADM

@nullFlavor

cs

1 … 1

F

NA

HL7 V2/V3 Datatype Level Template

IPS Address

Id

2.16.840.1.113883.10.22.11

Effective Date

2018‑04‑04 15:41:36

Other versions this id:

IPSAddress as of 2018‑04‑04 15:42:34
IPSAddress as of 2018‑04‑04 15:41:43

Status

Under pre-publication review

Version Label

STU1

Name

IPSAddress

Display Name

IPS Address

Description

Reusable address template

Classification

HL7 V2/V3 Datatype Level Template

Open/Closed

Open (other than defined elements are allowed)

Relationship

Adaptation: template 2.16.840.1.113883.10.20.22.5.2 US Realm Address (AD.US.FIELDED) (2015‑08‑13)

ref

ccda-

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

Item

DT

Card

Conf

Description

Label

@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

(IPS...ess)

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

(IPS...ess)

hl7:postalCode

ADXP

0 … 1

C

Subject's or Organization's Postal Code

(IPS...ess)

hl7:state

ADXP

0 … 1

C

Subject's or Organization's State or Province

(IPS...ess)

hl7:country

ADXP

0 … 1

C

Subject's Country.

(IPS...ess)

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.

Appendix

Responsible: NN

Acronyms and abbreviations

Glossary

Compliance: Compliance of one standard or specification is compliant with another standard or specification if all propositions 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 conformant implementations of the target are also conformant 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: 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: A process whereby a given implementation instance is evaluated to determine which f its various Conformance Assertions are valid implementations of a given specification’s Conformance Statements.

Conformance Statement : A 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: Conformance assertion is a testable, verifiable statement made about a specific implementation instance against a corresponding Conformance Statement.

Conformance points: Conformance points are the evaluation of conformance at specific points in the implementation or specification. See Conformance.

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)^[6] or info@ihtsdo.org
Logical Observation Identifiers Names & Codes (LOINC): Regenstrief Institute
International Classification of Diseases (ICD) codes: World Health Organization (WHO)

Integrated examples

Responsible: Kai Heitmann

links to example instances in the publication package

Validation artifacts

Responsible: Kai Heitmann

links to xsd
links to schematrons

Operational information

Responsible: Kai Heitmann

share the ips HL7 email list address
also offer info at international-patient-summary.net email address for inquiries regarding the specification
actual endpoints or user interfaces for testing/validation

FAQ’s

How to reuse this template

List of all artifacts used in this guide

Responsible: Autogenerated, assisted by Kai Heitmann

CDA Templates

2.16.840.1.113883.10.22.1.1 International Patient Summary
2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget
2.16.840.1.113883.10.22.2.2 IPS CDA author
2.16.840.1.113883.10.22.2.3 IPS CDA custodian
2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator
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 Treatment 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
2.16.840.1.113883.10.22.4.1 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

Value Sets

2.16.840.1.113883.11.22.2 Allergy or Intolerance Type
2.16.840.1.113883.11.22.3 Allergy Reaction
2.16.840.1.113883.11.22.4 ActStatusActiveCompleted
2.16.840.1.113883.11.22.5 CORE Problem List Disorders
2.16.840.1.113883.11.22.6 CORE Problem List Procedures
2.16.840.1.113883.11.22.7 CORE Problem List
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

System OIDs / IDs

Code systems

Datatypes

Responsible: Kai Heitmann

(This will be a list from ART-DECOR)

Examples (in progress)

( a set of link with explanations)

Responsible: Stephen Chu, Giorgio Cangioli (Translation), Kai Heitmann (Translation)

Plan:

Create one or more storyboards (Stephen?)
Turn the storyboards into real IPS example CDA instances
Allow for multilingual CDA (Italian, German)
Offer all XSD in the publication package
include schematrons (generated by ART-DECOR)

References

Literature

Links

↑ 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
↑ Transatlantic eHealth/health IT Cooperation Roadmap http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=12123
↑ HL7 Service-Aware Interoperability Framework: Canonical Definition Specification, Release 2 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=3
↑ CDA R2 Standard http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7
↑ 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
↑ Get SNOMED CT http://www.ihtsdo.org/snomed-ct/get-snomed-ct

Figures

↑ ^1.0 ^1.1 ^1.2 Standards in the HL7 SAIF Interoperability Matrix
↑ The IPS Principles
↑ ^3.0 ^3.1 The IPS meet-in-the-middle approach Cite error: Invalid <ref> tag; name "ipsmeetinthemiddle" defined multiple times with different content
↑ Representation of medicines in CDA
↑ ^5.0 ^5.1 CDA model has been enhanced with the Common Product Model
↑ ^6.0 ^6.1 The IPS World
↑ Examples of IPS usage

[1] 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

[2] Transatlantic eHealth/health IT Cooperation Roadmap http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=12123

[8] HL7 Service-Aware Interoperability Framework: Canonical Definition Specification, Release 2 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=3

[10] CDA R2 Standard http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7

[11] 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

[13] Get SNOMED CT http://www.ihtsdo.org/snomed-ct/get-snomed-ct

[saif-3] 1.0 ^1.1 ^1.2 Standards in the HL7 SAIF Interoperability Matrix

[ipsprinciples-4] The IPS Principles

[ipsmeetinthemiddle-5] 3.0 ^3.1 The IPS meet-in-the-middle approach Cite error: Invalid <ref> tag; name "ipsmeetinthemiddle" defined multiple times with different content

[6] Representation of medicines in CDA

[cdacpm-7] 5.0 ^5.1 CDA model has been enhanced with the Common Product Model

[ipsworld-9] 6.0 ^6.1 The IPS World

[12] Examples of IPS usage

[1]

[2]

[Figure 1]

[Figure 2]

[Figure 3]

[Figure 4]

[Figure 5]

[3]

[Figure 6]

[4]

[5]

[Figure 7]

[6]

International Patient Summary

Contents

Introduction

Purpose

Project Background

Scope

General Principles for this Specification

Structuring Choices

Ballot Status of the Document

Audience

Relationships with other projects and guidelines

How to read this document

Design conventions and principles

How to use terminologies (preferred binding)

Primary Code

Alternate Code

Original Text

Representing "known absent" and "not known"

Uncoded information

Unmapped Coded Concepts

Mapped coded concepts

Translation of designations

Narrative Translations

Medicinal Product Identifications

Medication Statement

Provenance

General Implementation Guidance

Conformance clause

Functional requirements and high-level use cases

Code mappings and multilinguistic support

Concept code mapping

Multilinguistic support

Designations’ Translation

Narrative Translation

Reading Guide

CDA Document Level Templates

International Patient Summary

CDA Header Level Templates

IPS CDA author

IPS CDA custodian

IPS CDA documentationOf

IPS CDA legalAuthenticator

IPS CDA recordTarget

IPS CDA relatedDocument

IPS Patient Contacts

CDA Section Level Templates

IPS Advance Directives Section

IPS Allergies and Intolerances Section

IPS Functional Status Section

IPS History of Past Illness Section

IPS History of Pregnancy Section

IPS History of Procedures Section

IPS Immunizations Section

IPS Medical Devices Section

IPS Medication Summary Section

IPS Plan of Care Section

IPS Problems Section

IPS Results Section

IPS Social History Section

IPS Translation Section

CDA Entry Level Templates

IPS Allergy and Intolerance Concern

IPS Allergy Certainty Observation

IPS Allergy or Intolerance

IPS Allergy Status Observation

IPS Body Author

IPS CDA Device

IPS Certainty Observation

IPS Comment Activity

IPS Criticality Observation

IPS Immunization

IPS Immunization Medication Information

IPS Internal Reference

IPS Laboratory Result Observation

IPS Manufactured Material

IPS Medical Device

IPS Medication Information (detail)

IPS Medication Statement

IPS ObservationMedia

IPS Pathology Result Observation