hl7:ClinicalDocument
|
|
|
|
|
(Med ent) |
| |
|
| 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 |
(Medent) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.1.3 |
@extension
|
st |
1 … 1 |
F |
POCD_HD000040 |
| Included |
|
|
from 2.16.756.5.30.1.1.10.2.18 Document Template Ids CDA-CH v2.0 - structuredBody (DYNAMIC)
|
hl7:templateId
|
II |
0 … 1 |
|
CDA-CH v2.0 specification. This is an informational reference, only. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.1.1.4 |
hl7:templateId
|
II |
1 … 1 |
M |
CDA-CH v2.0 structuredBody |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.1.9 |
hl7:templateId
|
II |
1 … 1 |
M |
HL7 CDA R2 (2005); contains ClinicalDocument.component as structuredBody. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.12.2 |
hl7:templateId
|
II |
1 … 1 |
M |
HL7 CDA R2 (2005). |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.12.1 |
hl7:templateId
|
II |
1 … 1 |
M |
Exchange format according to the Swiss EPR |
(Medent) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.127.1.4 |
hl7:templateId
|
II |
1 … 1 |
M |
IHE PCC |
(Medent) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.1.1 |
hl7:templateId
|
II |
1 … 1 |
M |
IHE PHARM PML |
(Medent) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.9.1.1.5 |
hl7:templateId
|
II |
1 … 1 |
M |
CDA-CH-EMED Medication List document |
(Medent) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.1.13 |
| Included |
|
|
from 2.16.756.5.30.1.1.10.9.46 Header Template Compilation Medication List 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 2.16.756.5.30.1.1.10.2.50 Document Code Medication List (DYNAMIC)
|
hl7:code
|
CE |
1 … 1 |
M |
IHE PHARM PML document code |
(Medent) |
@code
|
CONF |
1 … 1 |
F |
56445-0 |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
@codeSystemName
|
1 … 1 |
F |
LOINC |
@displayName
|
1 … 1 |
F |
Medication summary |
hl7:translation
|
CD |
1 … 1 |
M |
Translation to the Swiss EPR XDS.b metadata. |
(Medent) |
| |
|
@code
|
CONF |
1 … 1 |
F |
721912009 |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.6.96 (Snomed-CT) |
@codeSystemName
|
1 … 1 |
F |
SNOMED CT |
@displayName
|
1 … 1 |
F |
Medication summary document (record artifact) |
hl7:title
|
ST |
1 … 1 |
M |
The German title shall be "Medikationsliste".
The French title shall be "Liste de médication".
The Italian title shall be "Elenco delle terapie farmacologiche".
The English title shall be "Medication List".
Titles in other languages are allowed and unrestricted.
|
(Medent) |
| |
|
| |
Variable let |
Name |
languageCode |
|
| |
Value |
substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2) |
|
| |
Schematron assert |
role |
 error
|
|
| |
test |
not($languageCode='de') or text()='Medikationsliste' |
|
| |
Message |
The German title SHALL be 'Medikationsliste' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='fr') or text()='Liste de médication' |
|
| |
Message |
The French title SHALL be 'Liste de médication' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='it') or text()='Elenco delle terapie farmacologiche' |
|
| |
Message |
The Italian title SHALL be 'Elenco delle terapie farmacologiche' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='en') or text()='Medication List' |
|
| |
Message |
The English title SHALL be 'Medication List' |
|
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.
|
(Medent) |
| |
|
| 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 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 |
|
| 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 |
| 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 |
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 |
hl7:administrativeGenderCode
|
CE |
1 … 1 |
R |
The patient's gender |
CDA‑CH V2 |
@code
|
cs |
0 … 1 |
|
|
@codeSystem
|
oid |
0 … 1 |
F |
2.16.840.1.113883.5.1 |
@codeSystemName
|
st |
0 … 1 |
F |
HL7 AdministrativeGender |
@displayName
|
st |
0 … 1 |
|
|
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 |
2.16.840.1.113883.5.2 |
@codeSystemName
|
st |
1 … 1 |
F |
HL7 MaritalStatus |
@displayName
|
st |
1 … 1 |
R |
|
| |
CONF |
|
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 |
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 |
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 |
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 |
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 |
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 |
|
hl7:modeCode
|
CE |
0 … 1 |
|
|
CDA‑CH V2 |
| |
CONF |
|
hl7:proficiencyLevelCode
|
CE |
0 … 1 |
|
|
CDA‑CH V2 |
| |
CONF |
|
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 |
| |
|
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 |
|
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 |
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 |
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 … * |
|
|
(Medent) |
@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)
|
(Medent) |
hl7:relatedEntity
|
|
|
|
Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)
|
(Medent) |
| 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 … 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 |
|
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 |
|
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 |
|
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 |
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 |
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 |
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 |
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 … * |
|
|
(Medent) |
@typeCode
|
|
0 … 1 |
F |
AUTH |
hl7:consent
|
|
1 … 1 |
|
|
(Medent) |
@classCode
|
|
0 … 1 |
F |
CONS |
@moodCode
|
|
0 … 1 |
F |
EVN |
hl7:id
|
II |
0 … * |
|
|
(Medent) |
hl7:code
|
CE |
0 … 1 |
|
|
(Medent) |
| |
CONF |
| shall be drawn from concept domain "ActCode" |
|
hl7:statusCode
|
CS |
1 … 1 |
R |
|
(Medent) |
@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 |
|
|
(Medent) |
@typeCode
|
|
0 … 1 |
F |
COMP |
hl7:encompassingEncounter
|
|
1 … 1 |
|
|
(Medent) |
@classCode
|
|
0 … 1 |
F |
ENC |
@moodCode
|
|
0 … 1 |
F |
EVN |
hl7:id
|
II |
0 … * |
|
|
(Medent) |
hl7:code
|
CE |
0 … 1 |
|
|
(Medent) |
| |
CONF |
|
hl7:effectiveTime
|
IVL_TS |
1 … 1 |
R |
|
(Medent) |
hl7:dischargeDispositionCode
|
CE |
0 … 1 |
|
|
(Medent) |
| |
CONF |
| shall be drawn from concept domain "EncounterDischargeDisposition" |
|
hl7:responsibleParty
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(Medent) |
@typeCode
|
|
0 … 1 |
F |
RESP |
hl7:encounterParticipant
|
|
0 … * |
|
|
(Medent) |
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(Medent) |
hl7:assignedEntity
|
|
1 … 1 |
|
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
|
(Medent) |
hl7:location
|
|
0 … 1 |
|
|
(Medent) |
@typeCode
|
|
0 … 1 |
F |
LOC |
hl7:healthCareFacility
|
|
1 … 1 |
|
|
(Medent) |
@classCode
|
|
0 … 1 |
F |
SDLOC |
hl7:id
|
II |
0 … * |
|
|
(Medent) |
hl7:code
|
CE |
0 … 1 |
|
|
(Medent) |
| |
CONF |
|
hl7:location
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)
|
(Medent) |
hl7:serviceProviderOrganization
|
|
0 … 1 |
|
Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
|
(Medent) |
hl7:component
|
|
1 … 1 |
R |
|
(Medent) |
@contextConductionInd
|
bl |
0 … 1 |
|
It's recommended not to set this attribute.
|
hl7:structuredBody
|
|
1 … 1 |
M |
|
(Medent) |
hl7:component
|
|
1 … 1 |
M |
Contains 2.16.756.5.30.1.1.10.3.44 Medication List Section Content Module (DYNAMIC)
|
(Medent) |
| |
|
hl7:component
|
|
0 … 1 |
|
Contains 2.16.756.5.30.1.1.10.3.45 Original Representation Section - coded (DYNAMIC)
|
(Medent) |
Template Medication List document
Document Realm (2017)
Transaction
