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draft Template  Medication Card document

Id 2.16.756.5.30.1.1.10.1.3 Effective Date 2016‑05‑13
Status draft Draft Version Label 2020
Name MedicationCardDocument Display Name Medication Card document
Description
The Medication Card document (IPAG:eCurrentMedication, different view) describes the current medication of a patient, medications (*) that have been or will be taken by the patient.

Relation to IHE Pharmacy
The Medication Card document it derived from the IHE Pharmacy PML Supplement (Pharmacy Medication List) and the IHE Pharmacy MTP Supplement (Medication Treatment Plan). The planned medication entries in the eCurrentMedication follow the contraints of the IHE MTP entries.
Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 3 concepts
Id Name Data Set
cdachemed-dataelement-151 draft Arzneimittel draft Dataset 1
cdachemed-dataelement-45 draft Medication Card document draft Dataset 1
cdachemed-dataelement-146 draft Allgemeine Bemerkungen * draft Dataset 1
Used by / Uses
Used by 0 transactions and 0 templates, Uses 6 templates
Uses as Name Version
2.16.756.5.30.1.1.10.2.25 Include active Document Realm (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.18 Include active Document Template Ids CDA-CH v2.0 - structuredBody (2020) DYNAMIC
2.16.756.5.30.1.1.10.9.42 Include pending Header Template Compilation Medication Card document (2019) DYNAMIC
2.16.756.5.30.1.1.10.3.9 Containment pending Medication Card Section Content Module (2021) DYNAMIC
2.16.756.5.30.1.1.10.3.2 Containment active Remarks Section - coded (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.45 Containment draft Original Representation Section - coded (2017) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.1.9 CDA-CH v2.1 - structuredBody (DYNAMIC)
ref
hl7chcda-

Specialization: template 1.3.6.1.4.1.19376.1.9.1.1.5 IHE Pharmacy Medication List (DYNAMIC)
ref
ch-pharm-
Example
header
<hl7:ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 ../../../../schemas/PHARM/schemas/cda/extendedschemas/CDA_extended_pharmacy.xsd">
  <hl7:realmCode code="CHE"/>  <hl7:typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <!-- CDA-CH V2 specification (optional, but informative template id). -->
  <hl7:templateId root="2.16.756.5.30.1.1.1.1.4"/>  <!-- HL7 CDA R2 (2005) having a structuredBody. -->
  <hl7:templateId root="2.16.840.1.113883.10.12.2"/>  <!-- HL7 CDA R2 (2005). -->
  <hl7:templateId root="2.16.840.1.113883.10.12.1"/>  <!-- Exchange format according to the Swiss EPR -->
  <hl7:templateId root="2.16.756.5.30.1.127.1.4"/>  <!-- IHE PCC -->
  <hl7:templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>  <!-- IHE PHARM PML -->
  <hl7:templateId root="1.3.6.1.4.1.19376.1.9.1.1.5"/>  <!-- CDA-CH-EMED Medication Card -->
  <hl7:templateId root="2.16.756.5.30.1.1.10.1.3"/>  <!-- id of this Medication List -->
  <hl7:id root="6B6ED376-A7DA-44CB-92D1-E75CE1AE73B0"/>  <!-- IHE PHARM PML -->
  <hl7:code code="56445-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication summary">
    <hl7:translation code="721912009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Medication summary document (record artifact)"/>  </hl7:code>
  <hl7:title>Medikationsplan</hl7:title>  <hl7:effectiveTime value="20120204140500+0100"/>  <hl7:confidentialityCode code="1051000195109" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Normal"/>  <hl7:languageCode code="de-CH"/>  <!-- Document setId and versionNumber according to CDA-CH v2.0. -->
  <hl7:setId root="6B6ED376-A7DA-44CB-92D1-E75CE1AE73B0"/>  <hl7:versionNumber value="1"/>  <!-- snip -->
</hl7:ClinicalDocument>
XML overview
XML overview
Scenario doublearrow Transaction Transaction
draft Medication draft Use Case draft arrowright Medication Card document
Item DT Card Conf Description Label
hl7:ClinicalDocument
(Meddotsent)
 
target
cdachemed-dataelement-45 draft Medication Card document draft Dataset 1
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.25 Document Realm (DYNAMIC)
hl7:realmCode
CS 1 … 1 M Swiss Realm (CHE) of HL7 CDA. CDA‑CH V2
@code
CONF 1 … 1 F CHE
hl7:typeId
II 1 … 1 M HL7 CDA R2, 2005 (Meddotsent)
@root
uid 1 … 1 F 2.16.840.1.113883.1.3
@extension
st 1 … 1 F POCD_HD000040
Included from 2.16.756.5.30.1.1.10.2.18 Document Template Ids CDA-CH v2.0 - structuredBody (DYNAMIC)
hl7:templateId
II 0 … 1 CDA-CH v2.0 specification. This is an informational reference, only. CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.1.1.4
hl7:templateId
II 1 … 1 M CDA-CH v2.0 structuredBody CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.1.9
hl7:templateId
II 1 … 1 M HL7 CDA R2 (2005); contains ClinicalDocument.component as structuredBody. CDA‑CH V2
@root
uid 1 … 1 F 2.16.840.1.113883.10.12.2
hl7:templateId
II 1 … 1 M HL7 CDA R2 (2005). CDA‑CH V2
@root
uid 1 … 1 F 2.16.840.1.113883.10.12.1
hl7:templateId
II 1 … 1 M Exchange format according to the Swiss EPR (Meddotsent)
@root
uid 1 … 1 F 2.16.756.5.30.1.127.1.4
hl7:templateId
II 1 … 1 M IHE PCC (Meddotsent)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.1
hl7:templateId
II 1 … 1 M IHE PHARM PML (Meddotsent)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.9.1.1.5
hl7:templateId
II 1 … 1 M CDA-CH-EMED Medication Card document (Meddotsent)
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.1.3
Included from 2.16.756.5.30.1.1.10.9.42 Header Template Compilation Medication Card document (DYNAMIC)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.23 Document Id (DYNAMIC)
hl7:id
II 1 … 1 M A unique identifier for each CDA document instance. CDA‑CH V2
 
target
cdachemed-dataelement-141 draft Identification number of the document draft Dataset 1
cdachemed-dataelement-63 draft Identification number of the document draft Dataset 1
cdachemed-dataelement-139 draft Identification number of the document draft Dataset 1
cdachemed-dataelement-140 draft Identification number of the document draft Dataset 1
cdachemed-dataelement-76 draft Identification number of the document draft Dataset 1
cdachemed-dataelement-24 draft Identification number of the document draft Dataset 1
@root
uid 1 … 1 R The document's id as Globally Unique Identifier (GUID).
@extension
st 0 NP NP/not present
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.50 Document Code Medication List (DYNAMIC)
hl7:code
CE 1 … 1 M IHE PHARM PML document code (Meddotsent)
@code
CONF 1 … 1 F 56445-0
@codeSystem
1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@codeSystemName
1 … 1 F LOINC
@displayName
1 … 1 F Medication summary
hl7:translation
CD 1 … 1 M Translation to the Swiss EPR XDS.b metadata. (Meddotsent)
 
target
cdachemed-dataelement-136 draft Document type draft Dataset 1
@code
CONF 1 … 1 F 721912009
@codeSystem
1 … 1 F 2.16.840.1.113883.6.96 (Snomed-CT)
@codeSystemName
1 … 1 F SNOMED CT
@displayName
1 … 1 F Medication summary document (record artifact)
hl7:title
ST 1 … 1 M Title of the document according to the document language (Meddotsent)
 
target
cdachemed-dataelement-131 draft Title of the document draft Dataset 1
  CONF
element content shall be "Medikationsplan"
-or-
element content shall be "Plan de médication"
-or-
element content shall be "Piano farmacologico"
-or-
element content shall be "Medication Card"
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='de') or text()='Medikationsplan'  
  Message The German title SHALL be 'Medikationsplan'  
  Schematron assert role red error  
  test not($languageCode='fr') or text()='Plan de médication'  
  Message The French title SHALL be 'Plan de médication'  
  Schematron assert role red error  
  test not($languageCode='it') or text()='Piano farmacologico'  
  Message The Italian title SHALL be 'Piano farmacologico'  
  Schematron assert role red error  
  test not($languageCode='en') or text()='Medication Card'  
  Message The English title SHALL be 'Medication Card'  
hl7:effectiveTime
TS.CH.TZ 1 … 1 M The document's creation date and time. If this document replaces a previous version (linked via parentDocument), this is the date and time of the new version. (Meddotsent)
 
target
cdachemed-dataelement-128 draft Creation Date draft Dataset 1
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.19 Document Confidentiality Code (DYNAMIC)
hl7:confidentialityCode
CE (required) 1 … 1 M Swiss Realm of Confidentiality Code according to the Swiss EPR regulation. CDA‑CH V2
 
target
cdachemed-dataelement-125 draft Confidentiality level draft Dataset 1
cdachemed-dataelement-126 draft Confidentiality level draft Dataset 1
cdachemed-dataelement-29 draft Confidentiality level draft Dataset 1
cdachemed-dataelement-124 draft Confidentiality level draft Dataset 1
cdachemed-dataelement-81 draft Confidentiality level draft Dataset 1
cdachemed-dataelement-68 draft Confidentiality level draft Dataset 1
@code
cs 1 … 1 R The value of @code MUST be drawn from value set DocumentEntry.confidentialityCode
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R The value of @displayName MUST be drawn from value set DocumentEntry.confidentialityCode
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.5 DocumentEntry.confidentialityCode (DYNAMIC)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.22 Document Language (DYNAMIC)
hl7:languageCode
CS 1 … 1 M The RFC5646 based language in which the narrative texts in this CDA document instance are written. CDA‑CH V2
 
target
cdachemed-dataelement-26 draft Language of the document draft Dataset 1
cdachemed-dataelement-135 draft Language of the document draft Dataset 1
cdachemed-dataelement-134 draft Language of the document draft Dataset 1
cdachemed-dataelement-65 draft Language of the document draft Dataset 1
cdachemed-dataelement-78 draft Language of the document draft Dataset 1
cdachemed-dataelement-133 draft Language of the document draft Dataset 1
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Included from 2.16.756.5.30.1.1.10.2.20 Document Set Id and Version Number (DYNAMIC)
hl7:setId
II 1 … 1 R The setId element MUST match the document id of the very first version of that document. It MUST remain the same for all document versions. CDA‑CH V2
 
target
cdachemed-dataelement-118 draft Set ID draft Dataset 1
cdachemed-dataelement-70 draft Set ID draft Dataset 1
cdachemed-dataelement-119 draft Set ID draft Dataset 1
cdachemed-dataelement-120 draft Set ID draft Dataset 1
cdachemed-dataelement-83 draft Set ID draft Dataset 1
cdachemed-dataelement-41 draft Set ID draft Dataset 1
@root
uid 1 … 1 R The root attribute MUST contain the setId as Globally Unique Identifier (GUID).
@extension
st 0 NP NP/not present
  Schematron assert role red error  
  test (parent::*/hl7:versionNumber[@value='1'] and @root=parent::*/hl7:id/@root and (@extension=parent::*/hl7:id/@extension or (not(@extension) and not(parent::*/hl7:id/@extension)))) or (parent::*/hl7:versionNumber[not(@value ='1')] and ((@root=parent::*/hl7:id/@root and @extension and not(@extension=parent::*/hl7:id/@extension)) or(not(@root=parent::*/hl7:id/@root))))  
  Message The setId MUST be equal with the document id for version 1 and it MUST differ for all other versions.  
hl7:versionNumber
INT.NONNEG 1 … 1 R The versionNumber element MUST contain the value 1 for the very first version of that document. For later versions, the version number MUST be increased by 1 each. CDA‑CH V2
 
target
cdachemed-dataelement-121 draft Version draft Dataset 1
cdachemed-dataelement-122 draft Version draft Dataset 1
cdachemed-dataelement-82 draft Version draft Dataset 1
cdachemed-dataelement-69 draft Version draft Dataset 1
cdachemed-dataelement-30 draft Version draft Dataset 1
cdachemed-dataelement-123 draft Version draft Dataset 1
Included 1 … 1 R from 2.16.756.5.30.1.1.10.2.1 Patient - recordTarget (DYNAMIC)
hl7:recordTarget
1 … 1 R A human patient for whom this CDA document instance was created.
  • Target patient
    The HL7 CDA R2 (2005) standard allows multiple patients.
    In order to ensure that the information in a CDA document is unambiguously assigned to one and only patient, a CDA-CH V2 based document MUST contain exactly one patient.
    Special cases: In exceptional cases (e.g., new-born twins, both having jaundice), multiple documents MUST be created (all of the same content, but each with a unique patient).

  • Patient identifiers
    Multiple ids (patient identification number) MAY be declared.
    If multiple ids are known, it is highly recommended to declare all known ids. Especially in cases where the CDA document instance is kind of an answer to a preceding order (independent of its data format), all ids specified by the ordering system SHALL be declared in the CDA document instance. This allows the receiver to assign its internal patient identification.
    The patient identification number MUST be grouped with the OID of its assigning system. The patient identification number MUST be unique within the system identified by the OID.
    The declared OID MUST be found in one of the public OID registries, such as oid.refdata.ch (preferred), oid-info.com, hl7.org/oid, www.dimdi.de/static/de/klassi/oid/, gesundheit.gv.at/OID_Frontend/ etc.
    OIDs that can't be found in a public OID registry are NOT ALLOWED.

  • Pseudonymizing
    In special cases, the demographic data of the patient are not allowed to be transmitted or they have to be pseudonymized.
    While HL7 CDA or its derivatives like CDA-CH or Swiss exchange formats nevertheless require these elements in the XML structure, the affected values MUST be replaced by a nullFlavor of type "MSK" (masked), in order to support the required data format structure and simultaneously to shield the real data.

CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.1
hl7:patientRole
1 … 1 R CDA‑CH V2
hl7:id
II 1 … * R The patient's id. CDA‑CH V2
 
target
cdachemed-dataelement-13 draft Identification number draft Dataset 1
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   The id itself. It MUST be unique within the issuing system.
hl7:addr
AD 0 … * The patient's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
 
target
cdachemed-dataelement-14 draft Address (es) draft Dataset 1
hl7:telecom
TEL 0 … * The patient's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:patient
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) CDA‑CH V2
 
target
cdachemed-dataelement-9 draft Names draft Dataset 1
cdachemed-dataelement-5 draft Patient/Patientin draft Dataset 1
cdachemed-dataelement-10 draft First names draft Dataset 1
hl7:administrativeGenderCode
CE 1 … 1 R The patient's gender CDA‑CH V2
 
target
cdachemed-dataelement-12 draft Gender draft Dataset 1
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.5.1
@codeSystemName
st 1 … 1 F HL7 AdministrativeGender
@displayName
st 1 … 1 R
hl7:birthTime
TS.CH.TZ 1 … 1 R The patient's birthdate. CDA‑CH V2
 
target
cdachemed-dataelement-11 draft Date of birth draft Dataset 1
hl7:maritalStatusCode
CE 0 … 1 The patient's marital status. CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.1.11.12212
@codeSystemName
st 1 … 1 F HL7 MaritalStatus
@displayName
st 1 … 1 R
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12212 MaritalStatus (DYNAMIC)
hl7:translation
0 … * A translation of the code to another coding system CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:religiousAffiliationCode
CE 0 … 1 The patient's religion. CDA‑CH V2
@nullFlavor
cs 0 … 1 F NAV
@code
cs 0 … 1  
@codeSystem
oid 0 … 1  
@codeSystemName
st 0 … 1  
@displayName
st 0 … 1  
Included 0 … 1 C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:originalText
ED 0 … 1 C CDA‑CH V2
hl7:reference
TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
  Schematron assert role red error  
  test parent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text()  
  Message The originalText content MUST be identical to the narrative text for this reference.  
  Schematron assert role red error  
  test (@nullFlavor='NAV' and originalText and not(@codeSystem or @codeSystemName or @code or @displayName)) or (@codeSystem and @codeSystemName and @code and @displayName)  
  Message Either a code described by code, codeSystem, codeSystemName and displayName or originalText and nullFlavor="NAV" is REQUIRED.  
hl7:guardian
0 … * The patient's guardian. CDA‑CH V2
hl7:id
II 0 … * The guardian's id. CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   The id itself. It MUST be unique within the issuing system.
hl7:code
CE 0 … 1 The guardian's role. CDA‑CH V2
@nullFlavor
cs 0 … 1  
@code
cs 0 … 1  
@codeSystem
oid 0 … 1 F 2.16.840.1.113883.5.111
@codeSystemName
st 0 … 1 F HL7RoleCode
@displayName
st 0 … 1  
  Schematron assert role red error  
  test (not(@nullFlavor) and @displayName and @code and @codeSystem and @codeSystemName) or (@nullFlavor and not(@displayName or @code or @codeSystem or @codeSystemName))  
  Message Either nullFlavor or a valid code is required.  
hl7:addr
AD 0 … * The guardian's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
hl7:telecom
TEL 0 … * The guardian's means of communication (phone, eMail, ...). CDA‑CH V2
Choice 1 … 1 Elements to choose from:
hl7:guardianPerson
The guardian's as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:guardianOrganization
The guardian's as an organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
hl7:birthplace
0 … 1 The patient's birthplace. CDA‑CH V2
hl7:place
1 … 1 CDA‑CH V2
hl7:name
EN 0 … 1 The patient's birthplace name. CDA‑CH V2
hl7:addr
AD 1 … 1 R The patient's birthplace address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
hl7:languageCommunication
0 … * The patient's language skills. CDA‑CH V2
hl7:languageCode
CS 1 … 1 CDA‑CH V2
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:modeCode
CE 0 … 1 CDA‑CH V2
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
hl7:proficiencyLevelCode
CE 0 … 1 CDA‑CH V2
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
hl7:preferenceInd
BL 0 … 1 In case of @value=true it is the patient's correspondence language. CDA‑CH V2
hl7:providerOrganization
0 … 1 The organization who took care of the patient in the same context with the current CDA document. E.g. entry of the Medreg, FMH Index or the Health Organisation Index (HOI) of the Swiss EPR.
Contains 2.16.756.5.30.1.1.10.9.30 Organization Compilation with GLN and name (DYNAMIC)
CDA‑CH V2
Included 1 … * M from 2.16.756.5.30.1.1.10.9.23 Author (DYNAMIC)
hl7:author
1 … * M Information about the author of a CDA document, section or entry. An author MAY be a person or a device. CDA‑CH V2
 
target
cdachemed-dataelement-2 draft Autorin/Autor draft Dataset 1
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.9.23
hl7:functionCode
CE 0 … 1 CDA‑CH V2
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
TS.CH.TZ 1 … 1 R Timestamp of the authorship. CDA‑CH V2
 
target
cdachemed-dataelement-117 draft Timestamp Authorship draft Dataset 1
cdachemed-dataelement-84 draft Timestamp Authorship draft Dataset 1
cdachemed-dataelement-115 draft Timestamp Authorship draft Dataset 1
cdachemed-dataelement-42 draft Timestamp Authorship draft Dataset 1
cdachemed-dataelement-116 draft Timestamp Authorship draft Dataset 1
cdachemed-dataelement-71 draft Timestamp Authorship draft Dataset 1
cdachemed-dataelement-108 draft Abgabedatum * (Medication Dispense) in section.author.time draft Dataset 1
hl7:assignedAuthor
1 … 1 R CDA‑CH V2
  Schematron assert role red error  
  test not(assignedAuthoringDevice/softwareName) or (representedOrganization)  
  Message For device authors the element representedOrganization is REQUIRED.  
hl7:id
II 1 … 1 R The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared.
CDA‑CH V2
 
target
cdachemed-dataelement-7 draft Identifier draft Dataset 1
@nullFlavor
cs 0 … 1 F NAV
  Temporarily unknown, will be filled later.
@root
cs 0 … 1 F 2.51.1.3
  OID for GS1 GLN.
@extension
st 0 … 1   The GS1 GLN.
  Schematron assert role red error  
  test (@root='2.51.1.3' and @extension) or (@nullFlavor='NAV')  
  Message Either the GS1 GLN or nullFlavor='NAV' is REQUIRED  
hl7:id
II 0 … * Other ids are allowed. CDA‑CH V2
@root
cs 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:addr
AD 0 … * The author's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
hl7:telecom
TEL 0 … * The author's means of communication (phone, eMail, ...). CDA‑CH V2
Choice 1 … 1 Elements to choose from:
hl7:assignedPerson
0 … 1 The author as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
 
target
cdachemed-dataelement-3 draft Name draft Dataset 1
cdachemed-dataelement-6 draft First names draft Dataset 1
hl7:assignedAuthoringDevice
0 … 1 The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
CDA‑CH V2
hl7:representedOrganization
0 … 1 The author's organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
 
target
cdachemed-dataelement-8 draft Health facility draft Dataset 1
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.7 Data Enterer (DYNAMIC)
hl7:dataEnterer
0 … 1 Information about the person that entered information in this CDA document. It SHALL be declared, when data recorded in this document has been entered by a person other than the author but only when this is relevant for some reason. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.7
hl7:time
TS.CH.TZ 0 … 1 Timestamp of the data input. CDA‑CH V2
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) CDA‑CH V2
Included 0 … * from 2.16.840.1.113883.10.12.154 CDA Informant (DYNAMIC)
hl7:informant
0 … * (Meddotsent)
@typeCode
0 … 1 F INF
@contextControlCode
0 … 1 F OP
Choice 1 … 1 Elements to choose from:
hl7:assignedEntity
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Meddotsent)
hl7:relatedEntity
Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC) (Meddotsent)
Included 1 … 1 R from 2.16.756.5.30.1.1.10.2.3 Custodian (DYNAMIC)
hl7:custodian
1 … 1 R The organization in whose name this CDA document has been created (corresponds to the sender of a letter). CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.3
hl7:assignedCustodian
1 … 1 R CDA‑CH V2
hl7:representedCustodianOrganization
1 … 1 R CDA‑CH V2
 
target
cdachemed-dataelement-112 draft Custodian draft Dataset 1
cdachemed-dataelement-85 draft Custodian draft Dataset 1
cdachemed-dataelement-72 draft Custodian draft Dataset 1
cdachemed-dataelement-113 draft Custodian draft Dataset 1
cdachemed-dataelement-114 draft Custodian draft Dataset 1
cdachemed-dataelement-43 draft Custodian draft Dataset 1
hl7:id
II 1 … * M The custodian's id. CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:name
ON 1 … 1 R The custodian's name. CDA‑CH V2
hl7:telecom
TEL 0 … 1 The custodian's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:addr
AD 0 … 1 The custodian's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
Included 1 … * M from 2.16.756.5.30.1.1.10.2.4 Recipient - informationRecipient (DYNAMIC)
hl7:informationRecipient
1 … * M A recipient of this CDA document (corresponds to the addressee of a letter - person or organization).

Recipient types:
  • The main recipient of the document is indicated by typeCode 'PRCP' (primary recipient).
    Note: Since it makes no sense to create a CDA document without doing it for someone, in Switzerland at least one recipient MUST be declared. If the document is created for the user's own needs, the user itself or its organization will be the primary recipient.

  • Other recipients (copy to; Cc) are indicated with typeCode, TRC '(secondary recipient).
CDA‑CH V2
@typeCode
cs 0 … 1   The main recipient of the document is indicated by typeCode 'PRCP' (primary recipient). This is the default value used when the attribute is not present.
Other recipients (copy to; Cc) are indicated with typeCode, TRC '(secondary recipient).
Note: Since it makes no sense to create a CDA document without doing it for someone, in Switzerland at least one recipient MUST be declared. If the document is created for the user's own needs, the user itself or its organization will be the primary recipient.
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.4
hl7:intendedRecipient
1 … 1 R CDA‑CH V2
hl7:id
II 0 … * R The recipient's identification(s). CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:addr
AD 0 … * The recipient's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
hl7:telecom
TEL 0 … * The recipient's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:informationRecipient
0 … 1 The addressee person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:receivedOrganization
0 … 1 The addressee organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.5 Legal Authenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1 Information about the legal authenticator of a CDA document. A legal authenticator MUST be a person. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.5
hl7:time
TS.CH.TZ 1 … 1 R Timestamp of the signature. CDA‑CH V2
hl7:signatureCode
CS 1 … 1 R CDA‑CH V2
@code
cs 1 … 1 F S
@codeSystem
oid 0 NP NP/not present
@codeSystemName
st 0 NP NP/not present
@displayName
st 0 NP NP/not present
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.2.6 Authenticator (DYNAMIC)
hl7:authenticator
0 … * Information about an authenticator of a CDA document. An authenticator MUST be a person. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.6
hl7:time
TS.CH.TZ 1 … 1 R Timestamp of the signature. CDA‑CH V2
hl7:signatureCode
CS 1 … 1 R CDA‑CH V2
@code
cs 1 … 1 F S
@codeSystem
oid 0 NP NP/not present
@codeSystemName
st 0 NP NP/not present
@displayName
st 0 NP NP/not present
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.2.43 Patient Contact - participant (DYNAMIC)
hl7:participant
0 … * Information on a patient contact. CDA‑CH V2
@typeCode
cs 1 … 1 F IND
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.43
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.4
hl7:time
IVL_TS.CH.TZ 0 … 1 Validity period of the participation. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of participation. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of participation. CDA‑CH V2
hl7:associatedEntity
1 … 1 R Either the contact person or the contact's organization SHALL be present. CDA‑CH V2
@classCode
cs 1 … 1 R The classCode attribute SHALL be present, and contains a value from the following set:
AGNT: agents of the patient
CAREGIVER: care givers
ECON: emergency contacts
NOK: next of kin
PRS: other relations
hl7:code
CE 1 … 1 R The contact's role. CDA‑CH V2
@nullFlavor
cs 0 … 1  
@code
cs 0 … 1  
@codeSystem
oid 0 … 1 F 2.16.840.1.113883.5.111
@codeSystemName
st 0 … 1 F HL7RoleCode
@displayName
st 0 … 1  
  Schematron assert role red error  
  test (not(@nullFlavor) and @displayName and @code and @codeSystem and @codeSystemName) or (@nullFlavor and not(@displayName or @code or @codeSystem or @codeSystemName))  
  Message Either nullFlavor or a valid code is required.  
hl7:addr
AD 0 … * The contact's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
hl7:telecom
TEL 0 … * The contact's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:associatedPerson
0 … 1 C The contact person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:scopingOrganization
0 … 1 C The contact's organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
  Schematron assert role red error  
  test @classCode=('AGNT','CAREGIVER','ECON','NOK','PRS')  
  Message The classCode attribute shall be present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or other relations respectively.  
Included 0 … * from 2.16.756.5.30.1.1.10.2.16 Order Reference - inFulfillmentOf (DYNAMIC)
hl7:inFulfillmentOf
0 … * Reference to one or more orders which led to the creation of this CDA document. It SHALL be declared, when the order reference is relevant for some reason. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.16
hl7:order
1 … 1 R CDA‑CH V2
hl7:id
II 1 … * R Order number. CDA‑CH V2
@root
uid 1 … 1 R Either the same GUID (order id) or the same OID (order issuing system) as the order itself.
@extension
st 0 … 1   Contains the order ID itself. The ID MUST be unique within the system that issued the ID.
Included 0 … * from 2.16.756.5.30.1.1.10.2.46 Health Service - documentationOf (DYNAMIC)
hl7:documentationOf
0 … * Information about a health service describing the context of this CDA document. CDA‑CH V2
@typeCode
cs 1 … 1 F DOC
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.46
hl7:serviceEvent
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F ACT
@moodCode
cs 1 … 1 F EVN
hl7:id
II 0 … * Health service identifiers such as case number ([ge]: Fallnummer; [fr]: Numéro de cas), consultation id, episode id, etc. CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   The id itself. It MUST be unique within the issuing system.
hl7:code
CE 1 … 1 R As long as the eventCodeList for the Swiss EPR metadata is not defined yet by the FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), the nullFlavor='NAV' MUST be used in this template. Other codes MAY be declared as translation. CDA‑CH V2
@nullFlavor
st 1 … 1 F NAV
@code
cs 0 NP NP/not present
@codeSystem
oid 0 NP NP/not present
@codeSystemName
st 0 NP NP/not present
@displayName
st 0 NP NP/not present
hl7:translation
0 … * A translation of the code to another coding system. CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:effectiveTime
IVL_TS.CH.TZ 1 … 1 R Duration of the health service. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the health service. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the health service. CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.9.31 Performer (DYNAMIC)
hl7:performer
0 … * Information about a healthcare provider who was the primary performer of the act. CDA‑CH V2
@typeCode
cs 1 … 1 F PRF
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.9.31
hl7:templateId
1 … 1 R CDA‑CH V2
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.24.3.5
hl7:templateId
1 … 1 R CDA‑CH V2
@root
uid 1 … 1 F 2.16.840.1.113883.10.12.323
hl7:time
IVL_TS.CH.TZ 0 … 1 Duration of the performance. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the performance. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the performance. CDA‑CH V2
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.32 Assigned Entity Compilation with id, name, addr, telecom, person and organization (DYNAMIC) CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.2.13 Document Replacement - relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … *

Relationship to another CDA-CH V2 based document that is replaced by the current one.

Notes: For correction of wrong information, a new document that replaces the earlier document MUST be created. The new document corrects previously incorrect information. This also applies to the case where information in the CDA header has been corrected (e.g., if the original document has been issued to the wrong patient). While processing the new document at the recipient, all values from the previous document MUST be interpreted as deprecated (deleted/marked as deleted/deprecated) and all values in the new document MUST be marked as valid:

  • Values that were only contained in the previous document have to be treated as deleted.
  • Values that are present in both documents are overwritten with the contents of the new document.
  • Values that are only contained in the new document are to be added.
CDA‑CH V2
@typeCode
cs 1 … 1 F RPLC
  Indicates that it is a relationship to another document that needs to be replaced.
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.13
hl7:parentDocument
1 … 1 R Relationship to the document that needs to be replaced. CDA‑CH V2
hl7:id
II 1 … 1 M The id of the document to be replaced MUST be declared. CDA‑CH V2
@root
uid 1 … 1 R The id (GUID) of the document to be replaced.
@extension
st 0 NP NP/not present
hl7:setId
II 1 … 1 M The setId of the document to be replaced MUST be declared. CDA‑CH V2
@extension
st 0 NP NP/not present
@root
uid 1 … 1 R The setId (GUID) of the document to be replaced and MUST be identical with the content of the setId of the current document.
  Schematron assert role red error  
  test (@root=/hl7:ClinicalDocument/hl7:setId/@root) and not(@extension) and not(/hl7:ClinicalDocument/hl7:setId/@extension)  
  Message ClinicalDocument/setId: MUST be identical to the one of the replaced document  
hl7:versionNumber
INT 1 … 1 M The version number of the document to be replaced. CDA‑CH V2
  Schematron assert role red error  
  test /hl7:ClinicalDocument/hl7:versionNumber/@value > @value  
  Message ClinicalDocument/versionNumber: MUST be higher than the one of the replaced document  
Included 0 … * from 2.16.840.1.113883.10.12.114 CDA Authorization (DYNAMIC)
hl7:authorization
0 … * (Meddotsent)
@typeCode
0 … 1 F AUTH
hl7:consent
1 … 1 (Meddotsent)
@classCode
0 … 1 F CONS
@moodCode
0 … 1 F EVN
hl7:id
II 0 … * (Meddotsent)
hl7:code
CE 0 … 1 (Meddotsent)
  CONF
shall be drawn from concept domain "ActCode"
hl7:statusCode
CS 1 … 1 R (Meddotsent)
@code
CONF 0 … 1 F completed
Included 0 … 1 from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC)
hl7:componentOf
0 … 1 (Meddotsent)
@typeCode
0 … 1 F COMP
hl7:encompassingEncounter
1 … 1 (Meddotsent)
@classCode
0 … 1 F ENC
@moodCode
0 … 1 F EVN
hl7:id
II 0 … * (Meddotsent)
hl7:code
CE 0 … 1 (Meddotsent)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
hl7:effectiveTime
IVL_TS 1 … 1 R (Meddotsent)
hl7:dischargeDispositionCode
CE 0 … 1 (Meddotsent)
  CONF
shall be drawn from concept domain "EncounterDischargeDisposition"
hl7:responsibleParty
0 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Meddotsent)
@typeCode
0 … 1 F RESP
hl7:encounterParticipant
0 … * (Meddotsent)
@typeCode
cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
hl7:time
IVL_TS 0 … 1 (Meddotsent)
hl7:assignedEntity
1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (Meddotsent)
hl7:location
0 … 1 (Meddotsent)
@typeCode
0 … 1 F LOC
hl7:healthCareFacility
1 … 1 (Meddotsent)
@classCode
0 … 1 F SDLOC
hl7:id
II 0 … * (Meddotsent)
hl7:code
CE 0 … 1 (Meddotsent)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
hl7:location
0 … 1 Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) (Meddotsent)
hl7:serviceProviderOrganization
0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) (Meddotsent)
hl7:component
1 … 1 R (Meddotsent)
@contextConductionInd
bl 1 … 1 R
hl7:structuredBody
1 … 1 M (Meddotsent)
hl7:component
1 … 1 M Contains 2.16.756.5.30.1.1.10.3.9 Medication Card Section Content Module (DYNAMIC) (Meddotsent)
 
target
cdachemed-dataelement-151 draft Arzneimittel draft Dataset 1
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.2 Remarks Section - coded (DYNAMIC) (Meddotsent)
 
target
cdachemed-dataelement-146 draft Allgemeine Bemerkungen * draft Dataset 1
hl7:component
1 … 1 M Contains 2.16.756.5.30.1.1.10.3.45 Original Representation Section - coded (DYNAMIC) (Meddotsent)