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retired Template  Patient - recordTarget

Id 2.16.756.5.30.1.1.10.2.1
ref
hl7chcda-
 		Effective Date 2018‑04‑18
Other versions this id:
Status retired Retired Version Label 2017
Name cdach_header_Patient Display Name Patient - recordTarget
Description A human patient for whom this CDA document instance was created. All CDA-CH V2 derivatives, i.e. Swiss exchange formats MUST use this template by either reference or specialisation.
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.2.1
Label CDA‑CH V2
Classification CDA Header Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 7 concepts
Id Name Data Set
cdachemed-dataelement-12 draft Gender draft Dataset 1
cdachemed-dataelement-9 draft Names draft Dataset 1
cdachemed-dataelement-13 draft Identification number draft Dataset 1
cdachemed-dataelement-11 draft Date of birth draft Dataset 1
cdachemed-dataelement-10 draft First names draft Dataset 1
cdachemed-dataelement-5 draft Patient/Patientin draft Dataset 1
cdachemed-dataelement-14 draft Address (es) draft Dataset 1
Used by / Uses
Used by 0 transactions and 0 templates, Uses 5 templates
Uses as Name Version
2.16.756.5.30.1.1.10.9.35 Containment active Address Information Compilation - eCH-0010 (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.34 Containment active Person Name Information Compilation - eCH-0011 (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.49 Include active Original Text Reference (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.24 Containment active Organization Compilation with name (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.30 Containment active Organization Compilation with GLN and name (2017) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.101 CDA recordTarget (2005‑09‑07)
ref
ad1bbr-
Example
Sample patient
<recordTarget>
  <templateId root="2.16.756.5.30.1.1.10.2.1"/>  <patientRole>
    <id root="2.999" extension="898989"/>    <addr use="HP">
      <streetName>Leidensweg</streetName>      <houseNumber>10</houseNumber>      <postalCode>9876</postalCode>      <city>Specimendorf</city>      <country>CH</country>    </addr>    <telecom use="HP" value="tel:+41.32.685.12.34"/>    <telecom use="PUB" value="mailto:sesuna.tigrinja@sampledomain.ch"/>    <patient>
      <name>
        <given>Sesuna</given>        <family>Tigrinja</family>      </name>      <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender" displayName="Female"/>      <birthTime value="20000404"/>    </patient>    <providerOrganization>
      <id root="2.51.1.3" extension="7608888888888"/>      <name>Gruppenpraxis CH, Dr. med. Allzeit Bereit</name>    </providerOrganization>  </patientRole></recordTarget>
Example
Pseudonymizing with initials
<recordTarget>
  <templateId root="2.16.756.5.30.1.1.10.2.1"/>  <patientRole>
    <id nullFlavor="MSK"/>    <addr nullFlavor="MSK"/>    <telecom nullFlavor="MSK"/>    <patient>
      <name nullFlavor="MSK">
        <family>(only first letter)</family>        <given>(only first letter)</given>      </name>      <administrativeGenderCode nullFlavor="MSK"/>      <birthTime nullFlavor="MSK"/>    </patient>  </patientRole></recordTarget>
Item DT Card Conf Description Label
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
 
target
cdachemed-dataelement-5 draft Patient/Patientin draft Dataset 1
hl7:templateId
 II 1 … 1 M CDA‑CH V2
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.2.1
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
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)]]
 
target
cdachemed-dataelement-9 draft Names draft Dataset 1
cdachemed-dataelement-10 draft First names draft Dataset 1
hl7:administrativeGenderCode
 CE 1 … 1 R The patient's gender according to the Swiss EPR XDS.b metadata. 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
  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
 
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
treeblank treeblank where [hl7:id [@root = '2.51.1.3']]