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active Template  CDA-CH v2.1 - structuredBody

Id 2.16.756.5.30.1.1.10.1.9
ref
hl7chcda-
Effective Date 2019‑10‑17 15:22:41
Other versions this id:
Status active Active Version Label 2020
Name CDA-CHv2.0-structuredBody Display Name CDA-CH v2.1 - structuredBody
Description
This document template is used as the primary base for CDA-CH exchange formats. All CDA-CH V2 derivatives, i.e. Swiss exchange formats SHALL use this template by specialisation.
It only specifies the usage of CDA header templates. It requires a structured CDA body, but does not define any CDA body rules. For CDA body rules, see the derived exchange formats.
Context Pathname //
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
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
2.16.756.5.30.1.1.10.9.36 Include active CDA-CH v2.0 Header Template Compilation (2017) DYNAMIC
2.16.840.1.113883.10.12.201 Include active CDA Section DYNAMIC
2.16.756.5.30.1.1.10.3.2 Include active Remarks Section - coded (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.45 Include draft Original Representation Section - coded (2017) DYNAMIC
Relationship Version: template 2.16.756.5.30.1.1.10.1.9 CDA-CH v2.0 - structuredBody (2018‑04‑18)
ref
hl7chcda-

Specialization: template 2.16.840.1.113883.10.12.2 CDA ClinicalDocument (with StructuredBody) (2005‑09‑07)
ref
ad1bbr-
Example
Example
<!-- The following line is required in a CDA-CH document. It is commented here due to ART-DECOR validation issues, only -->
<!-- <?xml version="1.0" encoding="UTF-8"?> -->
<ClinicalDocument>
  <!-- include template cdach_header_DocumentRealm[2.16.756.5.30.1.1.10.2.25] '?' (dynamic) 1..1 M -->
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <!-- CDA-CH v2.0 ART-DECOR model - structuredBody. -->
  <templateId root="2.16.756.5.30.1.1.10.1.9"/>  <!-- include template cdach_header_DocumentTemplateIdsCdaChV2StructuredBody[2.16.756.5.30.1.1.10.2.18] '?' (dynamic) -->
  <!-- include template cdach_other_HeaderTemplates[2.16.756.5.30.1.1.10.9.36] '?' (dynamic) -->
  <component>
    <structuredBody>
      <component/>    </structuredBody>
  </component>
</ClinicalDocument>
Item DT Card Conf Description Label
hl7:ClinicalDocument
1 … 1 M

This document template is used as the primary base for CDA-CH exchange formats. It specifies the usage of CDA header templates and optional two sections comment / orginial represenation. It requires a structured CDA body, but does not define any CDA body rules. For CDA body rules, see the derived exchange formats.

Conformity rules that are not further modelled in ART-DECOR:

  • XML encoding
    UTF-8 encoding is required. All CDA-CH V2 documents MUST start with this line:
    <?xml version="1.0" encoding="UTF-8"?>

  • Phone numbers
    Phone numbers MUST be declared in the international format.
    Dots (.) MUST be used as separators for grouping of number blocks.
    The minus sign (-) MUST be used as a separator between public and internal telephone numbers. Purpose: Some telephone exchanges - especially in the US, allow direct dial-up of an internal telephone number after the actual connection has been established over the public telephone network.
    Examples:
    <telecom value="tel:+41.33.123.45.67"/>
    <telecom value="tel:+1.987.654.3210-999"/>

(CDAdotsody)
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 (CDAdotsody)
@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
Included from 2.16.756.5.30.1.1.10.9.36 CDA-CH v2.0 Header Template Compilation (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 2.16.756.5.30.1.1.10.2.44 Document Code (DYNAMIC)
hl7:code
CE 1 … 1 M A LOINC based document type of a CDA document instance including a translation to the Swiss EPR XDS.b metadata. CDA‑CH V2
@code
cs 1 … 1 R The exact value of @code MUST be specified by the CDA-CH V2 derivative.
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
st 1 … 1 F LOINC
@displayName
st 1 … 1 R The exact value of @displayName MUST be specified by the CDA-CH V2 derivative.
hl7:translation
CD 1 … 1 R A translation to the Swiss EPR XDS.b metadata from DocumentEntry.typeCode. The exact value of @code and @displayName MUST be specified by the CDA-CH V2 derivative. CDA‑CH V2
@code
cs 1 … 1 R The exact value of @code MUST be specified by the CDA-CH V2 derivative.
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R The exact value of @displayName MUST be specified by the CDA-CH V2 derivative.
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.27 DocumentEntry.typeCode (DYNAMIC)
hl7:title
ST 1 … 1 M The expected titles (at least in English, German, French and Italian) MUST be specified by the CDA-CH V2 derivative. CDA‑CH V2
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. CDA‑CH V2
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 … * CDA‑CH V2
@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) CDA‑CH V2
hl7:relatedEntity
Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC) CDA‑CH V2
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 2.16.756.5.30.1.1.10.2.40 Employer - participant (DYNAMIC)
hl7:participant
0 … * Information on the patient's employer, school or other affiliated (e.g., volunteer) organization. CDA‑CH V2
@typeCode
cs 1 … 1 F IND
hl7:templateId
II 1 … 1 M CDA-CH v2.0 ART-DECOR model of Employer. CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.40
hl7:templateId
1 … * M CH-PCC ART-DECOR model of IHE PCC Employer and School Contacts. CDA‑CH V2
@root
cs 1 … 1 F 2.16.756.5.30.1.1.10.2.41
hl7:templateId
II 1 … 1 M IHE PCC Employer and School Contacts. CDA‑CH V2
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.2.2
hl7:time
IVL_TS.CH.TZ 0 … 1 Validity period of contract. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the contract. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the contract. CDA‑CH V2
hl7:associatedEntity
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F CON
hl7:id
II 0 … 1 R The id of the contract ([ge]: Mitarbeiternummer; [fr]: Numéro d'employé). 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 CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.3
@codeSystemName
st 1 … 1 F IHERoleCode
@displayName
st 0 NP NP/not present
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.77 IHERoleCode Employer and School Contacts  (DYNAMIC)
hl7:associatedPerson
0 … 1 Contact person at the employer, school or other affiliated (e.g., volunteer) organization.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:scopingOrganization
1 … 1 The employer, school or other affiliated (e.g., volunteer) organization.
Contains 2.16.756.5.30.1.1.10.9.27 Organization Compilation with name, addr, telecom (DYNAMIC)
CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.2.15 Insurance - participant (DYNAMIC)
hl7:participant
0 … * Information on a patient's insurance. CDA‑CH V2
@typeCode
cs 1 … 1 F COV
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.15
hl7:time
IVL_TS.CH.TZ 0 … 1 Validity period of the contract. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the contract. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the contract. CDA‑CH V2
hl7:associatedEntity
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F PAYOR
hl7:id
II 1 … 1 R The id of the contract ([ge]: Versichertennummer; [fr]: Numéro d'assuré). 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 The underlying law for the contract. CDA‑CH V2
@nullFlavor
cs 0 … 1 F NAV
@code
cs 0 … 1   832.10, 832.20, 221.229.1, 833.1, 831.20
@codeSystem
oid 0 … 1 F 2.16.756.5.30.2.1.1.11
@codeSystemName
st 0 … 1 F ins-laws
@displayName
st 0 … 1   Federal Act on Health Insurance (HIA), Federal Act on Accident Insurance (AIA), Federal Act on Insurance Policies (Insurance Policies Act, IPA), Federal Act on Military Insurance (MilIA), Federal Act on Invalidity Insurance (InvIA)
  Schematron assert role red error  
  test (@nullFlavor='NAV' and not(@codeSystem or @codeSystemName or @code or @displayName)) or (@codeSystem='2.16.756.5.30.2.1.1.11' and @codeSystemName='ins-laws' and @code and @displayName)  
  Message Either a valid insurance law or nullFlavor="NAV" is REQUIRED.  
hl7:associatedPerson
0 … 1 Contact person at the insurance company.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:scopingOrganization
1 … 1 The insurance company.
Contains 2.16.756.5.30.1.1.10.9.26 Organization Compilation with GLN, name, addr and telecom (DYNAMIC)
CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.2.14 Insurance Card - participant (DYNAMIC)
hl7:participant
0 … * Information on a patient's insurance card. CDA‑CH V2
@typeCode
cs 1 … 1 F HLD
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.14
hl7:time
IVL_TS.CH.TZ 1 … 1 R Validity period of the insurance card. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 CDA‑CH V2
@nullFlavor
cs 1 … 1 F NASK
hl7:high
TS.CH.TZ 1 … 1 R Expiration date of the insurance card. CDA‑CH V2
hl7:associatedEntity
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F POLHOLD
hl7:id
II 1 … 1 R The insurance card's id. CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.123.100.1.1.1
@extension
st 1 … 1 R Number of the insurance card.
hl7:associatedPerson
0 … 1 Family and given name on the insurance card.
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 The insurance company which issued the insurance card.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (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 … * CDA‑CH V2
@typeCode
0 … 1 F AUTH
hl7:consent
1 … 1 CDA‑CH V2
@classCode
0 … 1 F CONS
@moodCode
0 … 1 F EVN
hl7:id
II 0 … * CDA‑CH V2
hl7:code
CE 0 … 1 CDA‑CH V2
  CONF
shall be drawn from concept domain "ActCode"
hl7:statusCode
CS 1 … 1 R CDA‑CH V2
@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 CDA‑CH V2
@typeCode
0 … 1 F COMP
hl7:encompassingEncounter
1 … 1 CDA‑CH V2
@classCode
0 … 1 F ENC
@moodCode
0 … 1 F EVN
hl7:id
II 0 … * CDA‑CH V2
hl7:code
CE 0 … 1 CDA‑CH V2
  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 CDA‑CH V2
hl7:dischargeDispositionCode
CE 0 … 1 CDA‑CH V2
  CONF
shall be drawn from concept domain "EncounterDischargeDisposition"
hl7:responsibleParty
0 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) CDA‑CH V2
@typeCode
0 … 1 F RESP
hl7:encounterParticipant
0 … * CDA‑CH V2
@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 CDA‑CH V2
hl7:assignedEntity
1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) CDA‑CH V2
hl7:location
0 … 1 CDA‑CH V2
@typeCode
0 … 1 F LOC
hl7:healthCareFacility
1 … 1 CDA‑CH V2
@classCode
0 … 1 F SDLOC
hl7:id
II 0 … * CDA‑CH V2
hl7:code
CE 0 … 1 CDA‑CH V2
  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) CDA‑CH V2
hl7:serviceProviderOrganization
0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) CDA‑CH V2
hl7:component
1 … 1 R (CDAdotsody)
hl7:structuredBody
1 … 1 R (CDAdotsody)
hl7:component
1 … * R (CDAdotsody)
Choice Elements to choose from:
Included 0 … * from 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC)
hl7:section
0 … * (CDAdotsody)
@classCode
0 … 1 F DOCSECT
@moodCode
0 … 1 F EVN
hl7:templateId
II 1 … 1 (CDAdotsody)
@root
1 … 1 F 2.16.840.1.113883.10.12.201
hl7:id
II 0 … 1 (CDAdotsody)
hl7:code
CE 0 … 1 (CDAdotsody)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10871 DocumentSectionType (DYNAMIC)
hl7:title
ST 0 … 1 (CDAdotsody)
hl7:text
SD.TEXT 0 … 1 R (CDAdotsody)
hl7:confidentialityCode
CE 0 … 1 (CDAdotsody)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 x_BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS 0 … 1 (CDAdotsody)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:subject
0 … 1 Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC) (CDAdotsody)
hl7:author
0 … * Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) (CDAdotsody)
hl7:informant
0 … * Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC) (CDAdotsody)
hl7:entry
0 … * Contains 2.16.840.1.113883.10.12.300 CDA Clinical Statement (DYNAMIC) (CDAdotsody)
@typeCode
cs 0 … 1   Default value is COMP
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
@contextConductionInd
bl 0 … 1 F true
hl7:component
0 … * Contains 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC) (CDAdotsody)
@typeCode
0 … 1 F COMP
@contextConductionInd
bl 0 … 1 F true
Included 0 … 1 from 2.16.756.5.30.1.1.10.3.2 Remarks Section - coded (DYNAMIC)
hl7:section
0 … 1 This section can be used to provide comments, remarks or other information that cannot be declared in any of the other existing sections in the document. CDA‑CH V2
hl7:templateId
II 1 … 1 R CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.3.2
hl7:id
II 0 … 1 An ID for this section MAY be filled for traceability. CDA‑CH V2
@root
uid 1 … 1 R MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) 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:code
CE 1 … 1 R CDA‑CH V2
@code
cs 1 … 1 F 48767-8
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
st 1 … 1 F LOINC
@displayName
st 1 … 1 F Annotation comment
hl7:title
ST 1 … 1 M Fixed human readable title of this section.
  • [ge]: 'Kommentar'
  • [fr]: 'Commentaire'
  • [it]: 'Osservazione'
  • [en]: 'Comment'
CDA‑CH V2
  Variable let Name languageCode  
  Value substring(ancestor::cda:ClinicalDocument/cda:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='ge') or (text()='Kommentar')  
  Message The German title must read 'Kommentar'  
  Schematron assert role red error  
  test not($languageCode='fr') or (text()='Commentaire')  
  Message The French title must read 'Commentaire'  
  Schematron assert role red error  
  test not($languageCode='it') or (text()='Osservazione')  
  Message The Italian title must read 'Osservazione'  
  Schematron assert role red error  
  test not($languageCode='en') or (text()='Comment')  
  Message The English title must read 'Comment'  
hl7:text
SD.TEXT 1 … 1 M Human readable text of this section. CDA‑CH V2
hl7:entry
0 … * Contains 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC) CDA‑CH V2
 
target
cdachemed-dataelement-142 draft Allgemeine Bemerkungen * draft Dataset 1
cdachemed-dataelement-86 draft Allgemeine Bemerkungen * draft Dataset 1
cdachemed-dataelement-146 draft Allgemeine Bemerkungen * draft Dataset 1
cdachemed-dataelement-73 draft Allgemeine Bemerkungen * draft Dataset 1
cdachemed-dataelement-147 cancelled Allgemeine Bemerkungen * draft Dataset 1
cdachemed-dataelement-39 draft Allgemeine Bemerkungen * draft Dataset 1
Included 0 … 1 from 2.16.756.5.30.1.1.10.3.45 Original Representation Section - coded (DYNAMIC)
hl7:section
0 … 1 Contains the original representation of the current CDA document as it has been seen by the legal authenticator while signing. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.3.45
hl7:id
II 0 … 1 An ID for this section MAY be filled for traceability. CDA‑CH V2
@root
uid 1 … 1 R MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) 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:code
CE 1 … 1 M CDA‑CH V2
@code
CONF 1 … 1 F 55108-5
@codeSystem
1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@codeSystemName
1 … 1 F LOINC
@displayName
1 … 1 F Clinical presentation
hl7:title
ST 1 … 1 M Fixed human readable title of this section.
  • [de]: 'Original Darstellung'
  • [fr]: 'Représentation originale'
  • [it]: 'Rappresentazione originale'
  • [en]: 'Original representation'
CDA‑CH V2
  Variable let Name languageCode  
  Value substring(ancestor::hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='de') or (text()='Original Darstellung')  
  Message The German title must read 'Original Darstellung'  
  Schematron assert role red error  
  test not($languageCode='fr') or (text()='Représentation originale')  
  Message The French title must read 'Représentation originale'  
  Schematron assert role red error  
  test not($languageCode='it') or (text()='Rappresentazione originale')  
  Message The Italian title must read 'Rappresentazione originale'  
  Schematron assert role red error  
  test not($languageCode='en') or (text()='Original representation')  
  Message The English title must read 'Original representation'  
hl7:text
SD.TEXT 1 … 1 M MUST contain the reference (renderMultiMedia/@referencedObject) to the corrsponding observationMedia (embedded PDF) that shows the original representation signed by the legal authenticator. CDA‑CH V2
hl7:renderMultiMedia
1 … 1 M CDA‑CH V2
@referencedObject
1 … 1 R The reference to the corrsponding observationMedia element.
hl7:entry
1 … 1 M Contains 2.16.756.5.30.1.1.10.4.83 Observation Media (DYNAMIC) CDA‑CH V2
@typeCode
st 1 … 1 F DRIV
  Schematron assert role red error  
  test hl7:text/hl7:renderMultiMedia/@referencedObject=hl7:entry/hl7:observationMedia[hl7:templateId/@root='2.16.756.5.30.1.1.10.4.83']/@ID  
  Message The referenced multimedia object MUST be declared in an entry of the same section.  
  Schematron assert role red error  
  test hl7:entry/hl7:observationMedia[hl7:templateId/@root='2.16.756.5.30.1.1.10.4.83']/hl7:value/@mediaType='application/pdf'  
  Message The referenced multimedia object MUST have the mime type set to 'application/pdf'.  
  Schematron assert role orange warning  
  test not(//hl7:id[@root='2.16.756.5.30.1.127.3.10.3'])  
  Message This CDA-CH V2 document contains a Swiss EPR-SPID. Please make sure, that this fits the legal base.  
  Schematron report role orange warning  
  test //hl7:id[@root=('2.16.756.5.31', '2.16.756.5.32')]/parent::hl7:patientRole  
  Message This CDA-CH V2 document contains a Swiss Social Security number as patient identifier. Please make sure, that this fits the legal base.  
  Schematron assert role red error  
  test not(//hl7:id[@root=('2.16.756.5.30.1.127.3.10.3', '2.16.756.5.31', '2.16.756.5.32')]/../..[not(hl7:patientRole)])  
  Message Swiss EPR-SPID and Social Security numbers are not allowed in CDA-CH V2 documents for other objects than the patient.