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draft Template  Medication Prescription document

Id 2.16.756.5.30.1.1.10.1.4 Effective Date 2016‑05‑21
Status draft Draft Version Label 2017
Name MedicationPrescriptionDocument Display Name Medication Prescription document
Description
The Medication Prescription document (IPAG report: eRezept) describes the content and format of a Prescription document generated during the process in which a health care professional decides that the patient needs medication (*).
Relation to IHE Pharmacy
The Medication Prescription document is based on the IHE Pharmacy Technical Framework Supplement – Pharmacy Prescription (PRE).
Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 5 templates
Used by as Name Version
cdachemed-transaction-4 Transaction draft Medication Prescription document 2018‑04‑04 15:33:29
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 (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.45 Include draft Header Template Compilation Medication Prescription document (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.10 Containment draft Prescription Section Content Module (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.2 Containment pending Remarks Section - coded (2017) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.1.9 (2018‑04‑18)
Specialization: template 1.3.6.1.4.1.19376.1.9.1.1.1 (DYNAMIC)
Example
Example
<ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 ../../../../schemas/PHARM/schemas/cda/extendedschemas/CDA_extended_pharmacy.xsd">
  <realmCode code="CHE"/>  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <!-- CDA-CH V2 specification (optional, but informative template id). -->
  <templateId root="2.16.756.5.30.1.1.1.1.4"/>  <!-- HL7 CDA R2 (2005) having a structuredBody. -->
  <templateId root="2.16.840.1.113883.10.12.2"/>  <!-- HL7 CDA R2 (2005). -->
  <templateId root="2.16.840.1.113883.10.12.1"/>  <!-- Exchange format according to the Swiss EPR -->
  <templateId root="2.16.756.5.30.1.127.1.4"/>  <!-- IHE PCC -->
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>  <!-- IHE PRE -->
  <templateId root="1.3.6.1.4.1.19376.1.9.1.1.1"/>  <!-- CDA-CH-EMED Medication Treatment Plan document -->
  <templateId root="2.16.756.5.30.1.1.10.1.4"/>  <!-- id of this Prescription -->
  <id root="D41D72BA-2100-11E6-B67B-9E71128CAE77"/>  <!-- IHE PHARM PRE -->
  <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication">
    <!-- Mapping to the Swiss EPR XDS.b metadata according to the Value-Set
EprDocumentTypeCode (201704.1-beta; 2.16.756.5.30.1.127.3.10.1.27) -->
    <translation code="440545006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Drug prescription"/>  </code>
  <title>Rezept</title>  <effectiveTime value="20120204140000+0100"/>  <confidentialityCode code="1051000195109" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Normal"/>  <languageCode code="de-CH"/>  <!-- Document setId and versionNumber according to CDA-CH v2.0. -->
  <setId root="D41D72BA-2100-11E6-B67B-9E71128CAE77"/>  <versionNumber value="1"/>  <!-- snip -->
</ClinicalDocument>
Item DT Card Conf Description Label
hl7:ClinicalDocument
(Meddotsent)
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 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 CDA-CH-EMED Medication Prescription document (Meddotsent)
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.1.4
hl7:templateId
II 1 … 1 M IHE PHARM PRE (Meddotsent)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.9.1.1.1
Included from 2.16.756.5.30.1.1.10.9.45 Header Template Compilation Medication Prescription 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
@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 2.16.756.5.30.1.1.10.2.52 Document Code Medication Prescription (DYNAMIC)
hl7:code
CE 1 … 1 M IHE PHARM PRE document code (Meddotsent)
@code
CONF 1 … 1 F 57833-6
@codeSystem
1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
@codeSystemName
1 … 1 F LOINC
@displayName
1 … 1 F Prescription for medication
hl7:translation
CD 1 … 1 M Translation to the Swiss EPR XDS.b metadata. (Meddotsent)
@code
CONF 1 … 1 F 440545006
@codeSystem
1 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
@codeSystemName
1 … 1 F SNOMED CT
@displayName
1 … 1 F Drug prescription
hl7:title
ST 1 … 1 M (Meddotsent)
  CONF
element content shall be "Rezept"
-or-
element content shall be "Ordonnance"
-or-
element content shall be "Ricetta"
-or-
element content shall be "Prescription"
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='de') or text()='Rezept'  
  Message The German title SHALL be 'Rezept'  
  Schematron assert role red error  
  test not($languageCode='fr') or text()='Ordonnance'  
  Message The French title SHALL be 'Ordonnance'  
  Schematron assert role red error  
  test not($languageCode='it') or text()='Ricetta'  
  Message The Italian title SHALL be 'Ricetta'  
  Schematron assert role red error  
  test not($languageCode='en') or text()='Prescription'  
  Message The English title SHALL be 'Prescription'  
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)
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
@code
cs 1 … 1 R The value of @code MUST be drawn from value set EprDocumentConfidentialityCode (2.16.756.5.30.1.127.3.10.1.5)
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 R The value of @displayName MUST be drawn from value set EprDocumentConfidentialityCode (2.16.756.5.30.1.127.3.10.1.5)
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.5 EprDocumentConfidentialityCode (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 RFC 1766 (ISO-639-1 and ISO 3166) based language in which the narrative texts in this CDA document instance are written. CDA‑CH V2
  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
@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
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
@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
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
treeblank treeblank treeblank where [hl7:administrativeGenderCode [@codeSystem='2.16.840.1.113883.5.1' or concat(@code,@codeSystem)=doc('include/voc-2.16.756.5.30.1.127.3.10.1.25-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code,@codeSystem)]]
hl7:administrativeGenderCode
CE 1 … 1 R The patient's gender according to the Swiss EPR XDS.b metadata. CDA‑CH V2
@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
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.25 EprGender (DYNAMIC)
hl7:birthTime
TS.CH.TZ 1 … 1 R The patient's birthdate. CDA‑CH V2
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
treeblank treeblank treeblank where [hl7:id [@root='2.51.1.3']]
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
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 1 … 1 R

The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.

If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, nullFlavor='NAV' MUST be used. In this case, the originalText element MUST contain the description of the role.

Translations to other vocabularies are allowed.

CDA‑CH V2
@nullFlavor
st 0 … 1 F NAV
@code
cs 0 … 1  
@codeSystem
oid 0 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 0 … 1 F SNOMED CT
@displayName
st 0 … 1  
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 EprAuthorRole (DYNAMIC)
  Example
Patient
<functionCode code="116154003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Patient"/>
  Example
Nurse
<functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
  Example
Home helper
<functionCode nullFlavor="NAV">
  <originalText>Home helper</originalText></functionCode>
  Example
Laboratory technician
<functionCode nullFlavor="NAV">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
  Schematron assert role red error  
  test (@code and @codeSystem) or (@nullFlavor='NAV')  
  Message Either a code with its code system or nullFlavor='NAV' is required.  
  Schematron assert role red error  
  test not(@nullFlavor) or (hl7:originalText)  
  Message Other Caregivers description MUST be declared in the originalText element in case of nullFlavor.  
hl7:translation
0 … * A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7) CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:time
TS.CH.TZ 1 … 1 R Timestamp of the authorship. CDA‑CH V2
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
@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
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
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
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 … * The custodian's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:addr
AD 0 … * 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:functionCode
CE 1 … 1 R The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.
If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, the code 133932002 (Other Caregiver) MUST be used. In this case, the originalText element MUST contain the description of the role.
Translations to other vocabularies are allowed.
CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 R
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 EprAuthorRole (DYNAMIC)
  Example <functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
  Example <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
  <originalText>Home helper</originalText></functionCode>
  Example <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
  Schematron assert role red error  
  test not(@code='133932002') or (hl7:originalText/text())  
  Message Other Caregivers description MUST be declared in the originalText element.  
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.  
hl7:translation
0 … * A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7) CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
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
hl7:documentationOf
0 … 1 Validity of document 6.3.2.1
hl7:serviceEvent
1 … 1 R 6.3.2.1
hl7:effectiveTime
IVL_TS 1 … 1 R Validity of prescription 6.3.2.1
hl7:low
TS 1 … 1 R Start of validity of the prescription 6.3.2.1
hl7:high
TS 1 … 1 R End of validity of the prescription 6.3.2.1
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:id/@root) and not(@extension) and not(/hl7:ClinicalDocument/hl7:id/@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 @value > /hl7:ClinicalDocument/hl7:versionNumber/@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)
@codeSystem
CONF 0 … 1 F 2.16.840.1.113883.5.4 (Act Code)
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 2.16.756.5.30.1.1.10.3.10 Prescription Section Content Module (DYNAMIC) (Meddotsent)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.9.1.2.1'] and hl7:templateId [@root='2.16.756.5.30.1.1.10.3.10']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.2 Remarks Section - coded (DYNAMIC) (Meddotsent)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.2']]]