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pending Template  Immunization Recommendation Request

Id 2.16.756.5.30.1.1.10.1.17 Effective Date 2018‑04‑19
Status pending Under pre-publication review Version Label 2018
Name CDA-CH-VACD-REQ-V2 Display Name Immunization Recommendation Request
Description Swiss eVACDOC - Immunization Recommendation Request
Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 27 templates
Used by as Name Version
cdachvacd-transaction-5 Transaction pending CDA-CH-VACD - Immunization Recommendation Request (2018) 2018‑04‑10 18:08:44
Uses as Name Version
2.16.756.5.30.1.1.10.2.25 Include active Document Realm (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.18 Include active Document Template Ids CDA-CH v2.0 - structuredBody (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.71 Include pending Document Template Ids CDA-CH-VACD V2 non Swiss EPR (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.63 Include pending Document Code (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.19 Include active Document Confidentiality Code (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.22 Include active Document Language (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.20 Include active Document Set Id and Version Number (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.69 Include pending Masked Patient - recordTarget (2018) DYNAMIC
2.16.756.5.30.1.1.10.9.23 Include active Author (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.7 Include active Data Enterer (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.3 Include active Custodian (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.4 Include active Recipient - informationRecipient (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.5 Include active Legal Authenticator (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.6 Include active Authenticator (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.16 Include active Order Reference - inFulfillmentOf (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.46 Include active Health Service - documentationOf (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.14 Include active Insurance Card - participant (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.15 Include active Insurance - participant (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.13 Include active Document Replacement - relatedDocument (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.47 Containment pending Immunizations Section - coded (2016) DYNAMIC
2.16.756.5.30.1.1.10.3.25 Containment pending Active Problems Section - coded (2016) DYNAMIC
2.16.756.5.30.1.1.10.3.50 Containment pending History Of Past Illness Section - coded (2016) DYNAMIC
2.16.756.5.30.1.1.10.3.51 Containment pending Allergies and other Adverse Reactions Section - coded (2016) DYNAMIC
2.16.756.5.30.1.1.10.3.46 Containment pending Other Relevant Observations Section - coded (2018) DYNAMIC
2.16.756.5.30.1.1.10.3.3 Containment pending Laboratory Speciality Section - coded (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.53 Containment pending Current Pregnancy Section - coded (2018) DYNAMIC
2.16.756.5.30.1.1.10.3.2 Containment pending Remarks Section - coded (2017) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.1.14 (DYNAMIC)
Specialization: template 2.16.756.5.30.1.1.10.1.9 (DYNAMIC)
Specialization: template 2.16.840.1.113883.10.12.2 (2005‑09‑07)
Example
Example
<!-- See http://svn.code.sf.net/p/hl7ch/code/trunk/projects/eHealthSuisse/eVACDOC/v2.0/ for examples -->
Item DT Card Conf Description Label
hl7:ClinicalDocument
1 … 1 M

Swiss eVACDOC - Immunization Recommendation Request

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"/>

(CDAdots-V2)
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 (CDAdots-V2)
@root
uid 1 … 1 F 2.16.840.1.113883.1.3
@extension
st 1 … 1 F POCD_HD000040
Included from 2.16.756.5.30.1.1.10.2.18 Document Template Ids CDA-CH v2.0 - structuredBody (DYNAMIC)
hl7:templateId
II 0 … 1 CDA-CH v2.0 specification. This is an informational reference, only. CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.1.1.4
hl7:templateId
II 1 … 1 M HL7 CDA R2 (2005); contains ClinicalDocument.component as structuredBody. CDA‑CH V2
@root
uid 1 … 1 F 2.16.840.1.113883.10.12.2
hl7:templateId
II 1 … 1 M HL7 CDA R2 (2005). CDA‑CH V2
@root
uid 1 … 1 F 2.16.840.1.113883.10.12.1
Included from 2.16.756.5.30.1.1.10.2.71 Document Template Ids CDA-CH-VACD V2 non Swiss EPR (DYNAMIC)
hl7:templateId
II 0 … 1 CDA-CH-VACD / eVACDOC V2 specification. This is an informational reference, only. CDA‑dotsVACD
@root
uid 1 … 1 F 2.16.756.5.30.1.1.1.1.3.5.2
hl7:templateId
II 1 … 1 M Immunization Content (IC) Content Module, IHE PCC Technical Framework Revision 11.0 - November 11, 2016. CDA‑dotsVACD
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2
hl7:templateId
II 1 … 1 M Medical Documents Specification, IHE PCC Technical Framework Revision 11.0 - November 11, 2016. CDA‑dotsVACD
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.1
  Schematron assert role red error  
  test not(/hl7:ClinicalDocument/hl7:templateId[@root='2.16.756.5.30.1.127.1.4'])  
  Message This document is not allowed for the Swiss EPR. It therefore MAY NOT contain the templateID for exchange formats according to the Swiss EPR.  
hl7:templateId
II 1 … 1 M CDA-CH-VACD / Immunization Recommendation Request ART-DECOR model. (CDAdots-V2)
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.1.17
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.63 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.

The LOINC code of the document MUST read according to IHE PCC TF2, Rev.11: 11369-6 (HISTORY OF IMMUNIZATIONS)

IHE PCC TF2 Rev.11, 6.3.1.10.1
@code
cs 1 … 1 F 11369-6
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
st 1 … 1 F LOINC
@displayName
st 1 … 1 F HISTORY OF IMMUNIZATIONS
hl7:translation
CD 1 … 1 M The translation to the Swiss EPR XDS.b metadata. IHE PCC TF2 Rev.11, 6.3.1.10.1
@code
cs 1 … 1 F 41000179103
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 F Immunization record
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.27 EprDocumentTypeCode (DYNAMIC)
hl7:title
ST 1 … 1 M

The document title MUST read:

  • [en]: 'Immunization Recommendation Request'
  • [de]: 'Anfrage Impfempfehlung'
  • [fr]: 'TOTRANSLATE-FR'
  • [it]: 'TOTRANSLATE-IT'
(CDAdots-V2)
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='en') or starts-with(text(),'Immunization Recommendation Request')  
  Message The English title MUST read 'Immunization Recommendation Request'  
  Schematron assert role red error  
  test not($languageCode='de') or starts-with(text(),'Anfrage Impfempfehlung')  
  Message The German title MUST read 'Anfrage Impfempfehlung'  
  Schematron assert role red error  
  test not($languageCode='fr') or starts-with(text(),'TOTRANSLATE-FR')  
  Message The French title MUST read 'TOTRANSLATE-FR'  
  Schematron assert role red error  
  test not($languageCode='it') or starts-with(text(),'TOTRANSLATE-IT')  
  Message The Italian title MUST read 'TOTRANSLATE-IT'  
hl7:effectiveTime
TS.CH.TZ 1 … 1 M ClinicalDocument/effectiveTime MUST exist. It contains the creation date and time of the laboratory report. If this document replaces a previous version (linked via parentDocument), this is the date and time of the new version. (CDAdots-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
@code
cs 1 … 1 R The value of @code MUST be drawn from value set EprDocumentConfidentialityCode (2.16.756.5.30.1.127.3.10.1.5)
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 R The value of @displayName MUST be drawn from value set EprDocumentConfidentialityCode (2.16.756.5.30.1.127.3.10.1.5)
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.5 EprDocumentConfidentialityCode (DYNAMIC)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.22 Document Language (DYNAMIC)
hl7:languageCode
CS 1 … 1 M The RFC 1766 (ISO-639-1 and ISO 3166) based language in which the narrative texts in this CDA document instance are written. CDA‑CH V2
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.20 Document Set Id and Version Number (DYNAMIC)
hl7:setId
II 1 … 1 M The setId element MUST match the document id of the very first version of that document. It MUST remain the same for all document versions. CDA‑CH V2
@root
uid 1 … 1 R The root attribute MUST contain the setId as Globally Unique Identifier (GUID).
@extension
st 0 NP NP/not present
  Schematron assert role red error  
  test (parent::*/hl7:versionNumber[@value='1'] and @root=parent::*/hl7:id/@root and (@extension=parent::*/hl7:id/@extension or (not(@extension) and not(parent::*/hl7:id/@extension)))) or (parent::*/hl7:versionNumber[not(@value ='1')] and ((@root=parent::*/hl7:id/@root and @extension and not(@extension=parent::*/hl7:id/@extension)) or(not(@root=parent::*/hl7:id/@root))))  
  Message The setId MUST be equal with the document id for version 1 and it MUST differ for all other versions.  
hl7:versionNumber
INT.NONNEG 1 … 1 M 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 M from 2.16.756.5.30.1.1.10.2.69 Masked Patient - recordTarget (DYNAMIC)
hl7:recordTarget
1 … 1 M A human patient for whom this CDA document instance was created. Its demographic data is masked as much as possible. Only the demographic information (such as gender, birthdate and city) that is needed for a immunization recommendation is allowed. CDA‑dotsVACD
hl7:templateId
II 1 … 1 M CDA‑dotsVACD
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.69
hl7:templateId
II 1 … 1 M CDA‑dotsVACD
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.1
hl7:patientRole
1 … 1 R CDA‑dotsVACD
hl7:id
II 1 … * M The patient's id. This information is mandatory to assign immunization recommendation responses to the correct patient in the requester's information system, because demographic data is masked. CDA‑dotsVACD
@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 1 … 1 R The patient's address MUST be masked. CDA‑dotsVACD
hl7:city
ADXP 1 … 1 R Addressed city (in foreign addresses if necessary including province, etc.).
When using the information according to the Swiss Post, the 27-digit city name must be used.
CDA‑dotsVACD
hl7:postalCode
ADXP 1 … 1 R Postal code given by Swiss Post or postal code issued by a post office abroad, that can consist of numbers, letters or a combination of both, possibly even special characters. CDA‑dotsVACD
hl7:country
ADXP 1 … 1 R Two-digit, alphanumeric ISO country code according to [ISO 3166-1] of the country in which the address is located. The country defines the conventions for addressing.
The country code MUST also be declared for Swiss postal addresses.
Caution: Political changes or renaming of countries will result in adjustments to the ISO country list.
The length of the feature is 2 characters.
CDA‑dotsVACD
  Schematron assert role red error  
  see eCH-0010 V7.0, section 5.24.2  
  test string-length(text()) < 3  
  Message eCH-0010 restricts the content length to max. 2 characters  
  Schematron assert role red error  
  test count(child::*)=3 and hl7:postalCode and hl7:city and hl7:country  
  Message Detailed address elements are NOT ALLOWED for masked patients. Only postalCode, city and country MUST be filled.  
hl7:telecom
TEL 0 … 1 R The patient's means of communication (phone, eMail, ...) MUST be masked, if present. CDA‑dotsVACD
@nullFlavor
1 … 1 F MSK
  Schematron assert role red error  
  test not(@value)  
  Message Telecom values are NOT ALLOWED for masked patients.  
hl7:patient
1 … 1 R CDA‑dotsVACD
hl7:name
PN 0 … 1 R The person's name MUST be masked, if present. CDA‑dotsVACD
@nullFlavor
1 … 1 F MSK
  Schematron assert role red error  
  test count(child::*)=0  
  Message Name elements are NOT ALLOWED for masked patients.  
hl7:administrativeGenderCode
CE 1 … 1 M The patient's gender according to the Swiss EPR XDS.b metadata. CDA‑dotsVACD
@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‑dotsVACD
hl7:maritalStatusCode
CE NP The patient's marital status is NOT ALLOWED. CDA‑dotsVACD
hl7:religiousAffiliationCode
CE NP The patient's religion is NOT ALLOWED. CDA‑dotsVACD
hl7:guardian
NP The patient's guardian is NOT ALLOWED. CDA‑dotsVACD
hl7:birthplace
NP The patient's birthplace is NOT ALLOWED. CDA‑dotsVACD
hl7:languageCommunication
NP The patient's language skills are NOT ALLOWED. CDA‑dotsVACD
hl7:providerOrganization
NP The organization who took care of the patient in the same context with the current CDA document is NOT ALLOWED. CDA‑dotsVACD
Included 1 … * M from 2.16.756.5.30.1.1.10.9.23 Author (DYNAMIC)
hl7:author
1 … * M Information about the author of a CDA document, section or entry. An author MAY be a person or a device. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.9.23
hl7:functionCode
CE 1 … 1 R

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

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

Translations to other vocabularies are allowed.

CDA‑CH V2
@nullFlavor
st 0 … 1 F NAV
@code
cs 0 … 1  
@codeSystem
oid 0 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 0 … 1 F SNOMED CT
@displayName
st 0 … 1  
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 EprAuthorRole (DYNAMIC)
  Example
Patient
<functionCode code="116154003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Patient"/>
  Example
Nurse
<functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
  Example
Home helper
<functionCode nullFlavor="NAV">
  <originalText>Home helper</originalText></functionCode>
  Example
Laboratory technician
<functionCode nullFlavor="NAV">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
  Schematron assert role red error  
  test (@code and @codeSystem) or (@nullFlavor='NAV')  
  Message Either a code with its code system or nullFlavor='NAV' is required.  
  Schematron assert role red error  
  test not(@nullFlavor) or (hl7:originalText)  
  Message Other Caregivers description MUST be declared in the originalText element in case of nullFlavor.  
hl7:translation
0 … * A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7) CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:time
TS.CH.TZ 1 … 1 R Timestamp of the authorship. CDA‑CH V2
hl7:assignedAuthor
1 … 1 R CDA‑CH V2
  Schematron assert role red error  
  test not(assignedAuthoringDevice/softwareName) or (representedOrganization)  
  Message For device authors the element representedOrganization is REQUIRED.  
hl7:id
II 1 … 1 R The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared.
CDA‑CH V2
@nullFlavor
cs 0 … 1 F NAV
  Temporarily unknown, will be filled later.
@root
cs 0 … 1 F 2.51.1.3
  OID for GS1 GLN.
@extension
st 0 … 1   The GS1 GLN.
  Schematron assert role red error  
  test (@root='2.51.1.3' and @extension) or (@nullFlavor='NAV')  
  Message Either the GS1 GLN or nullFlavor='NAV' is REQUIRED  
hl7:id
II 0 … * Other ids are allowed. CDA‑CH V2
@root
cs 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:addr
AD 0 … * The author's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
hl7:telecom
TEL 0 … * The author's means of communication (phone, eMail, ...). CDA‑CH V2
Choice 1 … 1 Elements to choose from:
hl7:assignedPerson
0 … 1 The author as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:assignedAuthoringDevice
0 … 1 The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
CDA‑CH V2
hl7:representedOrganization
0 … 1 The author's organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.7 Data Enterer (DYNAMIC)
hl7:dataEnterer
0 … 1 Information about the person that entered information in this CDA document. It SHALL be declared, when data recorded in this document has been entered by a person other than the author but only when this is relevant for some reason. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.7
hl7:time
TS.CH.TZ 0 … 1 Timestamp of the data input. CDA‑CH V2
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) CDA‑CH V2
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.3 Custodian (DYNAMIC)
hl7:custodian
1 … 1 M The organization in whose name this CDA document has been created (corresponds to the sender of a letter). CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.3
hl7:assignedCustodian
1 … 1 R CDA‑CH V2
hl7:representedCustodianOrganization
1 … 1 R CDA‑CH V2
hl7:id
II 1 … * M The custodian's id. CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:name
ON 1 … 1 R The custodian's name. CDA‑CH V2
hl7:telecom
TEL 0 … * The custodian's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:addr
AD 0 … * The custodian's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
Included 1 … * M from 2.16.756.5.30.1.1.10.2.4 Recipient - informationRecipient (DYNAMIC)
hl7:informationRecipient
1 … * M A recipient of this CDA document (corresponds to the addressee of a letter - person or organization).

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

  • Other recipients (copy to; Cc) are indicated with typeCode, TRC '(secondary recipient).
CDA‑CH V2
@typeCode
cs 0 … 1   The main recipient of the document is indicated by typeCode 'PRCP' (primary recipient). This is the default value used when the attribute is not present.
Other recipients (copy to; Cc) are indicated with typeCode, TRC '(secondary recipient).
Note: Since it makes no sense to create a CDA document without doing it for someone, in Switzerland at least one recipient MUST be declared. If the document is created for the user's own needs, the user itself or its organization will be the primary recipient.
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.4
hl7:intendedRecipient
1 … 1 R CDA‑CH V2
hl7:id
II 0 … * R The recipient's identification(s). CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:addr
AD 0 … * The recipient's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
hl7:telecom
TEL 0 … * The recipient's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:informationRecipient
0 … 1 The addressee person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:receivedOrganization
0 … 1 The addressee organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.5 Legal Authenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1 Information about the legal authenticator of a CDA document. A legal authenticator MUST be a person. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.5
hl7:time
TS.CH.TZ 1 … 1 R Timestamp of the signature. CDA‑CH V2
hl7:signatureCode
CS 1 … 1 R CDA‑CH V2
@code
cs 1 … 1 F S
@codeSystem
oid 0 NP NP/not present
@codeSystemName
st 0 NP NP/not present
@displayName
st 0 NP NP/not present
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) CDA‑CH V2
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.6 Authenticator (DYNAMIC)
hl7:authenticator
0 … 1 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 … 1 from 2.16.756.5.30.1.1.10.2.16 Order Reference - inFulfillmentOf (DYNAMIC)
hl7:inFulfillmentOf
0 … 1 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 … 1 from 2.16.756.5.30.1.1.10.2.46 Health Service - documentationOf (DYNAMIC)
hl7:documentationOf
0 … 1 Information about a health service describing the context of this CDA document. CDA‑CH V2
@typeCode
cs 1 … 1 F DOC
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.46
hl7:serviceEvent
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F ACT
@moodCode
cs 1 … 1 F EVN
hl7:id
II 0 … * Health service identifiers such as case number ([ge]: Fallnummer; [fr]: Numéro de cas), consultation id, episode id, etc. CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   The id itself. It MUST be unique within the issuing system.
hl7:code
CE 1 … 1 R As long as the eventCodeList for the Swiss EPR metadata is not defined yet by the FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), the nullFlavor='NAV' MUST be used in this template. Other codes MAY be declared as translation. CDA‑CH V2
@nullFlavor
st 1 … 1 F NAV
@code
cs 0 NP NP/not present
@codeSystem
oid 0 NP NP/not present
@codeSystemName
st 0 NP NP/not present
@displayName
st 0 NP NP/not present
hl7:translation
0 … * A translation of the code to another coding system. CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:effectiveTime
IVL_TS.CH.TZ 1 … 1 R Duration of the health service. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the health service. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the health service. CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.9.31 Performer (DYNAMIC)
hl7:performer
0 … * Information about a healthcare provider who was the primary performer of the act. CDA‑CH V2
@typeCode
cs 1 … 1 F PRF
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.9.31
hl7:templateId
1 … 1 R CDA‑CH V2
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.24.3.5
hl7:functionCode
CE 1 … 1 R The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.
If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, the code 133932002 (Other Caregiver) MUST be used. In this case, the originalText element MUST contain the description of the role.
Translations to other vocabularies are allowed.
CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 R
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 EprAuthorRole (DYNAMIC)
  Example <functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
  Example <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
  <originalText>Home helper</originalText></functionCode>
  Example <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
  Schematron assert role red error  
  test not(@code='133932002') or (hl7:originalText/text())  
  Message Other Caregivers description MUST be declared in the originalText element.  
Included 0 … 1 C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:originalText
ED 0 … 1 C CDA‑CH V2
hl7:reference
TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
  Schematron assert role red error  
  test parent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text()  
  Message The originalText content MUST be identical to the narrative text for this reference.  
hl7:translation
0 … * A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7) CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:time
IVL_TS.CH.TZ 0 … 1 Duration of the performance. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the performance. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the performance. CDA‑CH V2
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.32 Assigned Entity Compilation with id, name, addr, telecom, person and organization (DYNAMIC) CDA‑CH V2
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 2.16.756.5.30.1.1.10.2.15 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
treeblank treeblank treeblank where [hl7:id [@root='2.51.1.3']]
Included 0 … * from 2.16.756.5.30.1.1.10.2.13 Document Replacement - relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … *

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

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

  • Values that were only contained in the previous document have to be treated as deleted.
  • Values that are present in both documents are overwritten with the contents of the new document.
  • Values that are only contained in the new document are to be added.
CDA‑CH V2
@typeCode
cs 1 … 1 F RPLC
  Indicates that it is a relationship to another document that needs to be replaced.
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.13
hl7:parentDocument
1 … 1 R Relationship to the document that needs to be replaced. CDA‑CH V2
hl7:id
II 1 … 1 M The id of the document to be replaced MUST be declared. CDA‑CH V2
@root
uid 1 … 1 R The id (GUID) of the document to be replaced.
@extension
st 0 NP NP/not present
hl7:setId
II 1 … 1 M The setId of the document to be replaced MUST be declared. CDA‑CH V2
@extension
st 0 NP NP/not present
@root
uid 1 … 1 R The setId (GUID) of the document to be replaced and MUST be identical with the content of the setId of the current document.
  Schematron assert role red error  
  test (@root=/hl7:ClinicalDocument/hl7:id/@root) and not(@extension) and not(/hl7:ClinicalDocument/hl7:id/@extension)  
  Message ClinicalDocument/setId: MUST be identical to the one of the replaced document  
hl7:versionNumber
INT 1 … 1 M The version number of the document to be replaced. CDA‑CH V2
  Schematron assert role red error  
  test @value > /hl7:ClinicalDocument/hl7:versionNumber/@value  
  Message ClinicalDocument/versionNumber: MUST be higher than the one of the replaced document  
hl7:component
1 … 1 R (CDAdots-V2)
hl7:structuredBody
1 … 1 R (CDAdots-V2)
hl7:component
1 … 1 R Contains 2.16.756.5.30.1.1.10.3.47 Immunizations Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.47'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.6'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.23']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.25 Active Problems Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.25'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.6'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.11']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.50 History Of Past Illness Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.50'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.8']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.51 Allergies and other Adverse Reactions Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.51'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.13'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.2']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.46 Other Relevant Observations Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.46'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.27'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.28']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.3 Laboratory Speciality Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.3'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.2.1']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.53 Current Pregnancy Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.53'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'] and hl7:templateId [@root='2.16.756.5.30.1.127.77.1.10.1']]]
hl7:component
0 … 1 Contains 2.16.756.5.30.1.1.10.3.2 Remarks Section - coded (DYNAMIC) (CDAdots-V2)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.2']]]
  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.