2.16.840.1.113883.3.1937.777.11.10.102

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Template epSOSCDAauthor

Description

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

A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).

For definition “The author element represents the creator of the clinical document. If the role of the actor is the entry of information from his or her own knowledge or application of skills, that actor is the author. If one actor provides information to another actor who filters, reasons, or algorithmically creates new information, then that second actor is also an author, having created information from his or her own knowledge or skills. [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March 2009].

According to this definition, not any device that generates the electronic document has to be considered as an author:

  • a spider collecting and filtering information from different repositories, according to defined rules and policies, for the scope of creating a Patient Summary is definitely a document author (and maybe the only one for this document);
  • an application that transforms a prescription record into a epSOS eP CDA may not be an author instead;
  • The NCP that modifies the concepts conveyed, should appear as one of the authors.
  • The author of the parent document is often also an author of the document generated through a transformation process (in that case also the author time should be the same).

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

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

The CDA provides a mechanism to better specify who authored what within the document, allowing the specification of authorship at the whole document level, at the section level and finally at the entry level. In any case is not required to repeat this information for each level, taking advantage of the context conduction propriety. Infact “context that is specified on an outer tag holds true for all nested tags, unless overridden on a nested tag. Context specified on a tag within the CDA body always overrides context propagated from an outer tag. For instance, the specification of authorship at a document section level overrides all authorship propagated from outer tags.” (HL7 CDA R2 Standard).


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

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

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

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

ClinicalDocument/author/assignedAuthor/representedOrganization

Actual version

Id2.16.840.1.113883.3.1937.777.11.10.102Effective Date valid from 2013‑12‑20
StatusKyellow.png DraftVersion Label
NameepSOSCDAauthorDisplay NameepSOS CDA author
Description
<p>A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).</p>

<p>For definition “The <code>author</code> element represents the creator of the clinical document. If the role of the actor is the <b>entry of information from his or her own knowledge or application of skills</b>, that actor is the author. If one actor provides information to another actor <b>who filters, reasons, or algorithmically creates new information</b>, then that second actor <b>is also an author, <u>having created information from his or her own knowledge or skills.</u>”</b> [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March

                   2009].</p>

<p>According to this definition, not any device that generates the electronic document has to be considered as an author:</p> <ul>

   <li>a spider collecting and filtering information from different repositories, according to defined rules and policies, for the scope of creating a Patient Summary is definitely a document author (and maybe the only one for this document);</li>
   <li>an application that transforms a prescription record into a epSOS eP CDA may not be an author instead;</li>
   <li>The NCP that modifies the concepts conveyed, should appear as one of the authors.</li>
   <li>The author of the parent document is often also an author of the document generated through a transformation process (in that case also the author time should be the same).</li>

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

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

</ul> <p>The CDA provides a mechanism to better specify who authored what within the document, allowing the specification of authorship at the whole document level, at the section level and finally at the entry level. In any case is not required to repeat this information for each level, taking advantage of the context conduction propriety. Infact “context that is specified on an outer tag holds true for all nested tags, unless overridden on a nested tag. Context specified on a tag within the CDA body always overrides context propagated from an outer tag. For instance, the

                   specification of authorship at a document section level overrides all authorship propagated from outer tags.” (HL7 CDA R2 Standard).</p>

<hr/> <p>/ClinicalDocument/author/assignedAuthor<br/>/ClinicalDocument/documentationOf/serviceEvent/performer (this applies to the prescriber and the dispenser).</p> <p>The template ID referenced here refers to HP information in the /ClinicalDocument/documentationOf/serviceEvent/performer structure. In this document, the same requriements apply to the person author of the document (if there is one), and to the prescrober and dispenser (see body).</p> <p>When there is no HP but we have the method of assembly of data by a device, such as the “spider” method, we have the following expression; ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice.</p> <p>When the data is collected from different sources &amp; pre-existing documents that are part of a bigger system. In that case the organization responsible of that collection “signed” the PS as responsible.</p>

<p>ClinicalDocument/author/assignedAuthor/representedOrganization</p>
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 9 concepts
IdNameData Set
epsos-data​element-19Author Full NameepSOS Data Set
epsos-data​element-21Family Name/SurnameepSOS Data Set
epsos-data​element-273PrefixepSOS Data Set
epsos-data​element-274SuffixepSOS Data Set
epsos-data​element-23Author Healthcare FacilityepSOS Data Set
epsos-data​element-67AuthorepSOS Data Set
epsos-data​element-22Author IdentificationepSOS Data Set
epsos-data​element-20Given NameepSOS Data Set
epsos-data​element-180Author RoleepSOS Data Set
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.777.13.10.28IncludeKpurple.png IPS Entry Comment (0)2017‑04‑07 10:00:14
Uses as NameVersion
2.16.840.1.113883.3.1937.777.11.10.129ContainmentKyellow.png CDA Device ()DYNAMIC
2.16.840.1.113883.3.1937.777.11.10.111ContainmentKyellow.png epSOS CDA Organization ()DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.102 CDA author (2005‑09‑07)
ref
(from repository: ad1bbr-)
Example
Example
<author>
  <time value="20121229"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr>
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:(+39)051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
1 … *RepSO...thor
 
Target.pngepsos-data​element-67AuthorepSOS Data Set
Treetree.png@typeCode
cs0 … 1FAUT
Treetree.png@context​Control​Code
cs0 … 1FOP
Treetree.pnghl7:functionCode
CE.EPSOS0 … 1RR1.10.6
 
Target.pngepsos-data​element-180Author RoleepSOS Data Set
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.1 epSOSHealthcareProfessionalRoles (DYNAMIC)
Treetree.pnghl7:time
TS.EPSOS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. The author/time element SHALL be present.epSO...thor
Treetree.pnghl7:assignedAuthor
1 … 1RepSO...thor
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:assigned​Person or hl7:assigned​Authoring​Device 
 MessageIf assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for "ClinicalDocument/author/assignedAuthor/id/@nullFlavor" SHALL be "NA" "Not applicable" 2.16.840.1.113883.5.1008 NullFlavor STATIC. 
Treeblank.pngTreetree.pnghl7:id
II.EPSOS1 … *RHP ID numberR1.10.5
 
Target.pngepsos-data​element-22Author IdentificationepSOS Data Set
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNA
Treeblank.pngTreetree.pnghl7:code
CE.EPSOS0 … 1RHP SpecialtyR1.10.7
Treeblank.pngTreetree.pnghl7:addr
AD.EPSOS1 … *RIHE PCC
Treeblank.pngTreetree.pnghl7:telecom
TEL.EPSOS1 … *RAttribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLSchemeIHE PCC / R1.10.8 / R1.10.8.1 / R1.10.8.2
Treeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.40 epSOSTelecomAddress (DYNAMIC)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device containing template 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
RepSO...thor
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … 1RHP NameIHE PCC
 
Target.pngepsos-data​element-19Author Full NameepSOS Data Set
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *MHP Family Name/SurnameR1.10.1
 
Target.pngepsos-data​element-21Family Name/SurnameepSOS Data Set
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *MHP Given NameR1.10.2
 
Target.pngepsos-data​element-20Given NameepSOS Data Set
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:prefix
0 … *RHP PrefixR1.10.3
 
Target.pngepsos-data​element-273PrefixepSOS Data Set
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:suffix
0 … *RHP SuffixR1.10.4
 
Target.pngepsos-data​element-274SuffixepSOS Data Set
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
RContains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC)epSO...thor
Treeblank.pngTreetree.pnghl7:represented​Organization
1 … 1RContains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC)R1.10.9
 
Target.pngepsos-data​element-23Author Healthcare FacilityepSOS Data Set

List of all versions of this template