2.16.840.1.113883.10.22.2.2/static-2017-04-11T000000

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>       <!-- template 'IPS CDA Organization' (dynamic) -->     </representedOrganization>  </assignedAuthor></author>
Example	Device Author <author>   <time value="201212290600+0100"/>  <assignedAuthor>     <id root="1.2.3.999" extension="__example only__"/>    <addr use="WP">       <state>Castilla-La Mancha</state>      <city>Toledo</city>      <precinct>Toledo</precinct>      <country>ES</country>      <postalCode>45071</postalCode>      <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>    </addr>    <telecom nullFlavor="NI"/>    <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">       <softwareName displayName="Turriano"/>    </assignedAuthoringDevice>    <representedOrganization classCode="ORG" determinerCode="INSTANCE">       <id root="1.2.3.999" extension="__example only__"/>      <name>SESCAM</name>      <telecom use="WP" value="tel:+34925274100"/>      <addr use="WP">         <state>Castilla-La Mancha</state>        <city>Toledo</city>        <precinct>Toledo</precinct>        <country>ES</country>        <postalCode>45071</postalCode>        <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>      </addr>    </representedOrganization>  </assignedAuthor></author>
Item DT Card Conf Description Label hl7:author 1 … * R (IPS...hor) @typeCode cs 0 … 1 F AUT @context​Control​Code cs 0 … 1 F OP   Example <author>   <time value="201212290600+0100"/>  <assignedAuthor>     <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr use="WP">       <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>       <name>         <given>Paolo</given>        <family>Rossi</family>      </name>    </assignedPerson>  </assignedAuthor>  <representedOrganization>     <!-- template 'IPS CDA Organization' (dynamic) -->   </representedOrganization></author> hl7:functionCode CE.IPS 0 … 1 R (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 <time value="201212290600+0100"/> 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 <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 (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 <telecom use="WP" value="tel:+39-051-34343434"/>   Example <telecom nullFlavor="NI"/> Choice 1 … 1 Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C (IPS...hor) @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 1 … * R Name of the person (e.g. the Healthcare Professional)  authoring this document (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:assigned​Authoring​Device 0 … 1 C (IPS...hor)   Example <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">   <softwareName displayName="Turriano"/></assignedAuthoringDevice> Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:code CE 0 … 1 (IPS...hor) hl7:manufacturer​Model​Name SC 0 … 1 (IPS...hor) hl7:softwareName SC 0 … 1 (IPS...hor) hl7:represented​Organization 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 @determiner​Code 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.