Id1.3.182.11.13Effective Date2020‑01‑15 08:57:58
Statusdraft DraftVersion Label
NameCDADCSHDisplay NameCDA DCSH
ContextPathname /
ClassificationCDA Document Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 13 templates
Used by as NameVersion
1.3.182.7.5.1.4.2Transactiondraft Send DCSH2020‑01‑17 11:47:42
Uses as NameVersion
1.3.182.7.5.1.10.1Includedraft participantDYNAMIC
1.3.182.11.13.1.1Includedraft recordTargetDYNAMIC
1.3.182.11.13.1.2Includedraft authorDYNAMIC
1.3.182.11.13.1.3Includedraft custodianDYNAMIC
1.3.182.11.13.1.5Includedraft componentOfDYNAMIC
1.3.182.11.13.2.1Containmentdraft administrativeInformationDYNAMIC
1.3.182.11.13.2.2Containmentdraft encounterInformationDYNAMIC
1.3.182.11.13.2.3Containmentdraft servicesDYNAMIC
1.3.182.11.13.2.4Containmentdraft intervenantsDYNAMIC
1.3.182.11.13.2.5Containmentdraft proceduresDYNAMIC
1.3.182.11.13.2.6Containmentdraft diagnosticsDYNAMIC
1.3.182.11.13.2.7Containmentdraft newbornDYNAMIC
1.3.182.11.13.2.8Containmentdraft drgDYNAMIC
Example
Example
<hl7:ClinicalDocument classCode="DOCCLIN" moodCode="EVN">
  <hl7:realmCode code="LU"/>  <hl7:typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <hl7:templateId root="1.3.182.11.13"/>  <!-- Unique ID of document -->
  <hl7:id root="A4813B2D-78DC-4BE9-BDE4-E6DDAD00C0CE"/>  <hl7:code code="DT-00004" codeSystem="1.3.182.5.9" displayName="DCSH"/>  <!-- Document creation date -->
  <hl7:effectiveTime value="20180221163000+0100"/>  <hl7:confidentialityCode nullFlavor="NI"/>  <!-- Patient -->
  <hl7:recordTarget>
    <hl7:patientRole>
      <!-- Matricule, always root="1.3.182.4.4 -->
      <hl7:id extension="1980072700120" root="1.3.182.4.4"/>      <!-- Address -->
      <hl7:addr>
        <hl7:postalCode>0121</hl7:postalCode>        <hl7:country>LU</hl7:country>      </hl7:addr>      <hl7:patient>
        <!-- Gender -->
        <hl7:administrativeGenderCode code="M" codeSystem="1.3.182.5.40"/>        <!-- Birth Date -->
        <hl7:birthTime value="18800808"/>      </hl7:patient>    </hl7:patientRole>  </hl7:recordTarget>  <!-- Mandatory in CDA, Author of the document -->
  <!-- Here, an automatic system -->
  <hl7:author>
    <hl7:time value="20180221163000+0100"/>    <hl7:assignedAuthor>
      <hl7:id nullFlavor="NI"/>      <hl7:code code="DEV" codeSystem="1.3.182.5.6"/>      <hl7:assignedAuthoringDevice>
        <hl7:softwareName>Report Generator</hl7:softwareName>      </hl7:assignedAuthoringDevice>    </hl7:assignedAuthor>  </hl7:author>  <!-- Mandatory, the responsible for the document, e.g. an hospital -->
  <!-- Also identifies the hospital emitting -->
  <hl7:custodian>
    <hl7:assignedCustodian>
      <hl7:representedCustodianOrganization>
        <hl7:id extension="70100179" root="1.3.182.4.6"/>      </hl7:representedCustodianOrganization>    </hl7:assignedCustodian>  </hl7:custodian>  <!-- Matricule of the mother -->
  <hl7:participant typeCode="IND">
    <hl7:associatedEntity classCode="PRS">
      <!-- Matricule, always root="1.3.182.4.4 -->
      <hl7:id extension="1820080800000" root="1.3.182.4.4"/>      <hl7:code code="MTH" codeSystem="2.16.840.1.113883.5.111"/>    </hl7:associatedEntity>  </hl7:participant>  <!-- Encounter -->
  <hl7:componentOf>
    <hl7:encompassingEncounter>
      <!-- Encounter id -->
      <hl7:id root="1.3.182.4.14" extension="0120b6789"/>      <!-- Provenance -->
      <hl7:code code="H0" codeSystem="1.3.182.5.22"/>      <!-- Start/End time of admission (high = discharge) -->
      <hl7:effectiveTime>
        <hl7:low value="201901021521"/>        <hl7:high value="201901050810"/>      </hl7:effectiveTime>      <!-- Modalité de sortie -->
      <hl7:dischargeDispositionCode code="2" codeSystem="1.3.182.5.24"/>      <!-- Médecin responsable de l'admission -->
      <hl7:responsibleParty>
        <hl7:assignedEntity>
          <hl7:id extension="20145000" root="1.3.182.4.6"/>        </hl7:assignedEntity>      </hl7:responsibleParty>      <!-- Etabl. Provenance -->
      <hl7:encounterParticipant typeCode="REF">
        <hl7:templateId root="1.3.182.11.13.1.6"/>        <hl7:assignedEntity>
          <hl7:id nullFlavor="NA"/>          <hl7:code code="70101189" codeSystem="1.3.182.5.39"/>        </hl7:assignedEntity>      </hl7:encounterParticipant>      <!-- Etabl. Destination -->
      <hl7:encounterParticipant typeCode="DIS">
        <hl7:templateId root="1.3.182.11.13.1.7"/>        <hl7:assignedEntity>
          <hl7:id nullFlavor="NA"/>          <hl7:code code="70131101" codeSystem="1.3.182.5.39"/>        </hl7:assignedEntity>      </hl7:encounterParticipant>    </hl7:encompassingEncounter>  </hl7:componentOf>  <hl7:component>
    <hl7:structuredBody>
      <hl7:component>
        <!-- Administrative information -->
        <hl7:section>
          <hl7:templateId root="1.3.182.11.13.2.1"/>          <!-- Nationalité -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.19"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="66476-3" codeSystem="2.16.840.1.113883.6.1"/>              <hl7:value xsi:type="ST">LU</hl7:value>            </hl7:observation>          </hl7:entry>          <!-- Age en jours -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.20"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="30525-0" codeSystem="2.16.840.1.113883.6.1"/>              <hl7:value xsi:type="PQ" value="0" unit="d"/>            </hl7:observation>          </hl7:entry>        </hl7:section>      </hl7:component>      <hl7:component>
        <!-- Encounter information -->
        <hl7:section classCode="DOCSECT" moodCode="EVN">
          <hl7:templateId root="1.3.182.11.13.2.2"/>          <!-- Mode d'admission -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.15"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="ModeAdmission" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">P</hl7:value>            </hl7:observation>          </hl7:entry>          <!-- Modalité d'entrée -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.16"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="ModaliteEntree" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="CV" code="AM" codeSystem="1.3.182.5.38"/>            </hl7:observation>          </hl7:entry>          <!-- Mode d'adressage -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.17"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="ModeAdressage" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">MA</hl7:value>            </hl7:observation>          </hl7:entry>          <!-- Passage aux urgences -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.18"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="PassageUrgence" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">0</hl7:value>            </hl7:observation>          </hl7:entry>        </hl7:section>      </hl7:component>      <hl7:component>
        <!-- Services -->
        <hl7:section>
          <hl7:templateId root="1.3.182.11.13.2.3"/>          <hl7:entry>
            <hl7:organizer classCode="BATTERY" moodCode="EVN">
              <hl7:statusCode code="completed"/>              <hl7:component>
                <!-- First service -->
                <hl7:encounter classCode="ENC" moodCode="EVN">
                  <!-- Service type -->
                  <hl7:code code="CORT" codeSystem="1.3.182.5.25"/>                  <!-- Start/End date -->
                  <hl7:effectiveTime>
                    <hl7:low value="201901021521"/>                    <hl7:high value="201901040800"/>                  </hl7:effectiveTime>                  <!-- Site -->
                  <hl7:performer>
                    <hl7:assignedEntity>
                      <hl7:id nullFlavor="NA"/>                      <hl7:code code="A1" codeSystem="1.3.182.5.37"/>                    </hl7:assignedEntity>                  </hl7:performer>                </hl7:encounter>              </hl7:component>              <hl7:component>
                <!-- Second service -->
                <hl7:encounter classCode="ENC" moodCode="EVN">
                  <!-- Service type -->
                  <hl7:code code="PSYA" codeSystem="1.3.182.5.25"/>                  <!-- Start/End date -->
                  <hl7:effectiveTime>
                    <hl7:low value="201901040800"/>                    <hl7:high value="201901050810"/>                  </hl7:effectiveTime>                  <!-- Site -->
                  <hl7:performer>
                    <hl7:assignedEntity>
                      <hl7:id nullFlavor="NA"/>                      <hl7:code code="A1" codeSystem="1.3.182.5.37"/>                    </hl7:assignedEntity>                  </hl7:performer>                </hl7:encounter>              </hl7:component>            </hl7:organizer>          </hl7:entry>        </hl7:section>      </hl7:component>      <hl7:component>
        <!-- Médecins ayant pris en charge le patient -->
        <hl7:section>
          <hl7:templateId root="1.3.182.11.13.2.4"/>          <hl7:entry>
            <hl7:organizer classCode="BATTERY" moodCode="EVN">
              <hl7:statusCode code="completed"/>              <hl7:component>
                <hl7:act classCode="PCPR" moodCode="EVN">
                  <hl7:code nullFlavor="NI"/>                  <hl7:performer>
                    <!-- Start/End date -->
                    <hl7:time>
                      <hl7:low value="201901021521"/>                      <hl7:high value="201901040800"/>                    </hl7:time>                    <!-- Spécialité -->
                    <hl7:assignedEntity>
                      <hl7:id nullFlavor="NI"/>                      <hl7:code code="L0" codeSystem="1.3.182.5.26"/>                    </hl7:assignedEntity>                  </hl7:performer>                  <!-- Degré d'urgence -->
                  <hl7:entryRelationship typeCode="COMP">
                    <hl7:observation classCode="OBS" moodCode="EVN">
                      <hl7:code code="DegreUrgence" codeSystem="1.3.182.5.23"/>                      <hl7:value xsi:type="ST">1</hl7:value>                    </hl7:observation>                  </hl7:entryRelationship>                </hl7:act>              </hl7:component>              <hl7:component>
                <hl7:act classCode="PCPR" moodCode="EVN">
                  <hl7:code nullFlavor="NI"/>                  <hl7:performer>
                    <!-- Start/End date -->
                    <hl7:time>
                      <hl7:low value="201901021523"/>                      <hl7:high value="201901050810"/>                    </hl7:time>                    <!-- Spécialité -->
                    <hl7:assignedEntity>
                      <hl7:id nullFlavor="NI"/>                      <hl7:code code="P0" codeSystem="1.3.182.5.26"/>                    </hl7:assignedEntity>                  </hl7:performer>                  <!-- Degré d'urgence -->
                  <hl7:entryRelationship typeCode="COMP">
                    <hl7:observation classCode="OBS" moodCode="EVN">
                      <hl7:code code="DegreUrgence" codeSystem="1.3.182.5.23" displayName="Degré d'urgence"/>                      <hl7:value xsi:type="ST">0</hl7:value>                    </hl7:observation>                  </hl7:entryRelationship>                </hl7:act>              </hl7:component>            </hl7:organizer>          </hl7:entry>        </hl7:section>      </hl7:component>      <hl7:component>
        <!-- Procédures -->
        <hl7:section>
          <hl7:templateId root="1.3.182.11.13.2.5"/>          <hl7:entry>
            <hl7:organizer classCode="BATTERY" moodCode="EVN">
              <hl7:statusCode code="completed"/>              <!-- First procedure -->
              <hl7:component>
                <hl7:procedure classCode="PROC" moodCode="EVN">
                  <!-- ICD-10 PCS code -->
                  <hl7:code code="0LJX0ZZ" codeSystem="1.3.182.5.30"/>                  <!-- Time of the procedure -->
                  <hl7:effectiveTime value="201901021020"/>                  <!-- Doctor -->
                  <hl7:performer>
                    <hl7:assignedEntity>
                      <!-- Doctor ID -->
                      <hl7:id extension="20001122" root="1.3.182.4.6"/>                      <!-- Doctor specialty -->
                      <hl7:code code="E0" codeSystem="1.3.182.5.26"/>                    </hl7:assignedEntity>                  </hl7:performer>                  <!-- Lieu de la procédure -->
                  <hl7:entryRelationship typeCode="COMP">
                    <hl7:observation classCode="OBS" moodCode="EVN">
                      <hl7:code code="LieuProcedure" codeSystem="1.3.182.5.23"/>                      <hl7:value xsi:type="ST">D</hl7:value>                    </hl7:observation>                  </hl7:entryRelationship>                </hl7:procedure>              </hl7:component>              <!-- Second procedure -->
              <hl7:component>
                <hl7:procedure classCode="PROC" moodCode="EVN">
                  <hl7:code code="0BQJ8ZZ" codeSystem="1.3.182.5.30"/>                  <hl7:effectiveTime value="201901041145"/>                  <hl7:performer>
                    <hl7:assignedEntity>
                      <hl7:id extension="20022447" root="1.3.182.4.6"/>                      <hl7:code code="E1" codeSystem="1.3.182.5.26"/>                    </hl7:assignedEntity>                  </hl7:performer>                  <hl7:entryRelationship typeCode="COMP">
                    <hl7:observation classCode="OBS" moodCode="EVN">
                      <hl7:code code="LieuProcedure" codeSystem="1.3.182.5.23"/>                      <hl7:value xsi:type="ST">A</hl7:value>                    </hl7:observation>                  </hl7:entryRelationship>                </hl7:procedure>              </hl7:component>            </hl7:organizer>          </hl7:entry>        </hl7:section>      </hl7:component>      <hl7:component>
        <!-- Diagnostics -->
        <hl7:section>
          <hl7:templateId root="1.3.182.11.13.2.6"/>          <hl7:entry>
            <!-- Groupe des diagnnostics principaux -->
            <hl7:templateId root="1.3.182.11.13.3.13"/>            <hl7:organizer classCode="BATTERY" moodCode="EVN">
              <hl7:statusCode code="completed"/>              <!-- First diagnostic principal -->
              <hl7:component>
                <hl7:observation classCode="OBS" moodCode="EVN">
                  <hl7:code code="86255-7" codeSystem="2.16.840.1.113883.6.1"/>                  <hl7:value xsi:type="CV" code="S56.012A" codeSystem="1.3.182.5.29"/>                  <!-- Présence à l'admission -->
                  <hl7:entryRelationship typeCode="COMP">
                    <hl7:observation classCode="OBS" moodCode="EVN">
                      <hl7:code code="78026-2" codeSystem="2.16.840.1.113883.6.1"/>                      <hl7:value xsi:type="ST">E</hl7:value>                    </hl7:observation>                  </hl7:entryRelationship>                </hl7:observation>              </hl7:component>            </hl7:organizer>          </hl7:entry>          <hl7:entry>
            <!-- Groupe des diagnnostics secondaires -->
            <hl7:templateId root="1.3.182.11.13.3.14"/>            <hl7:organizer classCode="BATTERY" moodCode="EVN">
              <hl7:statusCode code="completed"/>              <!-- First diagnnostic secondaire -->
              <hl7:component>
                <hl7:observation classCode="OBS" moodCode="EVN">
                  <hl7:code code="81885-6" codeSystem="2.16.840.1.113883.6.1"/>                  <hl7:value xsi:type="CV" code="H61.112" codeSystem="1.3.182.5.29"/>                  <hl7:entryRelationship typeCode="COMP">
                    <hl7:observation classCode="OBS" moodCode="EVN">
                      <hl7:code code="78026-2" codeSystem="2.16.840.1.113883.6.1"/>                      <hl7:value xsi:type="ST">Y</hl7:value>                    </hl7:observation>                  </hl7:entryRelationship>                </hl7:observation>              </hl7:component>              <!-- Second diagnnostic secondaire -->
              <hl7:component>
                <hl7:observation classCode="OBS" moodCode="EVN">
                  <hl7:code code="81885-6" codeSystem="2.16.840.1.113883.6.1"/>                  <hl7:value xsi:type="CV" code="F60.2" codeSystem="1.3.182.5.29"/>                  <hl7:entryRelationship typeCode="COMP">
                    <hl7:observation classCode="OBS" moodCode="EVN">
                      <hl7:code code="78026-2" codeSystem="2.16.840.1.113883.6.1"/>                      <hl7:value xsi:type="ST">N</hl7:value>                    </hl7:observation>                  </hl7:entryRelationship>                </hl7:observation>              </hl7:component>            </hl7:organizer>          </hl7:entry>        </hl7:section>      </hl7:component>      <hl7:component>
        <!-- Newborn information -->
        <hl7:section classCode="DOCSECT" moodCode="EVN">
          <hl7:templateId root="1.3.182.11.13.2.7"/>          <!-- Séquence de naissance -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.10"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="SeqNaissance" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="CV" code="0" codeSystem="1.3.182.5.27"/>            </hl7:observation>          </hl7:entry>          <!-- Poids à la naissance -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.11"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="8339-4" codeSystem="2.16.840.1.113883.6.1"/>              <hl7:value xsi:type="PQ" value="3451" unit="g"/>            </hl7:observation>          </hl7:entry>          <!-- Durée de gestation -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.12"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="76516-4" codeSystem="2.16.840.1.113883.6.1"/>              <hl7:value xsi:type="PQ" value="41" unit="wk"/>            </hl7:observation>          </hl7:entry>          <!-- APGAR 1min -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.21"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="9272-6" codeSystem="2.16.840.1.113883.6.1"/>              <hl7:value xsi:type="INT" value="10"/>            </hl7:observation>          </hl7:entry>          <!-- APGAR 5min -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.22"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="9274-2" codeSystem="2.16.840.1.113883.6.1"/>              <hl7:value xsi:type="INT" value="10"/>            </hl7:observation>          </hl7:entry>        </hl7:section>      </hl7:component>      <hl7:component>
        <!-- DRG information -->
        <hl7:section classCode="DOCSECT" moodCode="EVN">
          <hl7:templateId root="1.3.182.11.13.2.8"/>          <!-- DRG groupe -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.1"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="DRGGroup" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">317</hl7:value>            </hl7:observation>          </hl7:entry>          <!-- Major disease category -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.2"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="MDC" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">08</hl7:value>            </hl7:observation>          </hl7:entry>          <!-- Severity of Illness -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.3"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="Severite" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="CV" code="1" codeSystem="1.3.182.5.28"/>            </hl7:observation>          </hl7:entry>          <!-- Risk of Mortality -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.4"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="Mortalite" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="CV" code="1" codeSystem="1.3.182.5.28"/>            </hl7:observation>          </hl7:entry>          <!-- DRG à l'admission -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.5"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="AdmDRGGroup" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">199</hl7:value>            </hl7:observation>          </hl7:entry>          <!-- Major Disease Category à l’admission -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.6"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="AdmMDC" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">05</hl7:value>            </hl7:observation>          </hl7:entry>          <!-- Severity of Illness à l’admission -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.7"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="AdmSeverite" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="CV" code="1" codeSystem="1.3.182.5.28"/>            </hl7:observation>          </hl7:entry>          <!-- Risk of Mortality à l’admission -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.8"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="AdmMortalite" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="CV" code="1" codeSystem="1.3.182.5.28"/>            </hl7:observation>          </hl7:entry>          <!-- Medical/Surgical -->
          <hl7:entry>
            <hl7:templateId root="1.3.182.11.13.3.9"/>            <hl7:observation classCode="OBS" moodCode="EVN">
              <hl7:code code="MedSurg" codeSystem="1.3.182.5.23"/>              <hl7:value xsi:type="ST">1</hl7:value>            </hl7:observation>          </hl7:entry>        </hl7:section>      </hl7:component>    </hl7:structuredBody>  </hl7:component></hl7:ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
RCDADCSH
@classCode
cs1 … 1FDOCCLIN
@moodCode
cs1 … 1FEVN
hl7:realmCode
1 … 1MCDADCSH
@code
cs1 … 1FLU
hl7:typeId
1 … 1MCDADCSH
@root
uid1 … 1F2.16.840.1.113883.1.3
@extension
st1 … 1FPOCD_HD000040
hl7:templateId
1 … 1MCDADCSH
@root
uid1 … 1F1.3.182.11.13
hl7:id
1 … 1ML'identifiant unique du document.
@root doit être un UUID
@extension ne doit pas être present
CDADCSH
@root
uuid1 … 1R
@extension
st0NPNP/not present
 Example<id root="fa625fd5-2ea9-433c-af17-71f0a1484443"/>
hl7:code
1 … 1MCDADCSH
@code
cs1 … 1FDT-00004
@codeSystem
oid1 … 1F1.3.182.5.9
hl7:effectiveTime
TS.DATETIMETZ.MIN1 … 1MDate de création du document. Ici, correspond à la date ou le systeme a produit le document, c'est la même date que celle de l'auteur. Attention à la timezone pour l'heure d'été/hiver.CDADCSH
 Example<effectiveTime value="20180221163000+0100"/>
hl7:confidentialityCode
1 … 1RCDADCSH
@nullFlavor
cs1 … 1FNI
Included1 … 1M from 1.3.182.11.13.1.1 recordTarget (DYNAMIC)
Informations sur le patient
hl7:recordTarget
1 … 1MInformations sur le patientrecodotsrget
hl7:patientRole
1 … 1Mrecodotsrget
hl7:id
1 … 1Mrecodotsrget
@root
uid1 … 1F1.3.182.4.4
@extension
st1 … 1RLe matricule
 Schematron assertrolered error 
 test@extension="7000010105084" or matches(@extension,'^(1|2)\d{12}$') 
 MessageLe matricule doit être correct, ou valoir 7000010105084 
hl7:addr
1 … 1Mrecodotsrget
hl7:postalCode
1 … 1MCode postal, sans le préfixe du paysrecodotsrget
hl7:country
1 … 1MCode pays sur 2 chiffresrecodotsrget
 Variable letNamecountry 
 Valuehl7:country 
 Variable letNamepCode 
 Valuehl7:postalCode 
 Schematron assertrolered error 
 testcount(distinct-values(doc('include/voc-1.3.182.10.61.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $country]))=1 
 MessageLes codes pays doivent etre ISO 3166-1 alpha 2 
 Schematron assertrolered error 
 testnot($country='LU') or count(distinct-values(doc('include/voc-1.3.182.10.62.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $pCode]))=1 
 MessageSi le pays est LU, le code postal doit etre valide ou 0000 pour les patients RCAM, 0001 pour les personnes non visées et 0002 pour les sans-abris. 
hl7:patient
1 … 1Mrecodotsrget
hl7:administrativeGenderCode
CE1 … 1MSexe du patientrecodotsrget
 CONF
@code shall be "F"
@codeSystem shall be "1.3.182.5.40"
or
@code shall be "M"
@codeSystem shall be "1.3.182.5.40"
or
@code shall be "U"
@codeSystem shall be "1.3.182.5.40"
hl7:birthTime
TS.DATE.FULL1 … 1MDate de naissance du patientrecodotsrget
Included1 … 1M from 1.3.182.11.13.1.2 author (DYNAMIC)
Informations sur l'auteur du document
hl7:author
1 … 1Mauthor
hl7:time
TS.DATETIMETZ.MIN1 … 1MDate de création du document par l'auteurauthor
hl7:assignedAuthor
1 … 1Rauthor
hl7:id
1 … 1Rauthor
@nullFlavor
cs1 … 1FNI
hl7:code
1 … 1Mauthor
@codeSystem
oid1 … 1F1.3.182.5.6
@code
cs1 … 1FDEV
hl7:assignedAuthoringDevice
1 … 1Mauthor
hl7:softwareName
ST1 … 1MLe nom du logiciel ou système qui crée le documentauthor
Included1 … 1M from 1.3.182.11.13.1.3 custodian (DYNAMIC)
Information sur la source du document
hl7:custodian
1 … 1MIdentification de l’établissement hospitalier
custodian
hl7:assignedCustodian
1 … 1Mcustodian
hl7:representedCustodianOrganization
1 … 1Mcustodian
hl7:id
1 … 1Mcustodian
@extension
st1 … 1RLe code CNS (fournisseur) de l'établissement
@root
uid1 … 1F1.3.182.4.6
 Schematron assertrolered error 
 test@extension=("70100179", "70101189", "70131101", "70126148", "70135040", "70125037", "70140801", "70105031", "70128067", "70129077", "70142518") 
 MessageLe code CNS doit être parmi les valeurs prévues 
Included0 … 1C from 1.3.182.7.5.1.10.1 participant (DYNAMIC)
Si besoin, informations sur la mère du patient
hl7:participant
0 … 1MMatricule de la mère, à préciser si c'est un séjour nouveau-né et que la provenance est N0 ou N1

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

partdotspant
@typeCode
cs1 … 1FIND
hl7:associatedEntity
1 … 1Mpartdotspant
@classCode
cs1 … 1FPRS
hl7:id
1 … 1Mpartdotspant
@root
uid1 … 1F1.3.182.4.4
@extension
st1 … 1RLe matricule
 Schematron assertrolered error 
 test@extension="7000010105084" or matches(@extension,'^(1|2)\d{12}$') 
 MessageLe matricule doit être correct, ou valoir 7000010105084 
hl7:code
1 … 1Mpartdotspant
@codeSystem
oid1 … 1F2.16.840.1.113883.5.111
@code
cs1 … 1FMTH
Included1 … 1M from 1.3.182.11.13.1.5 componentOf (DYNAMIC)
Informations sur l'admission
hl7:componentOf
1 … 1McompdotsntOf
hl7:encompassingEncounter
1 … 1McompdotsntOf
hl7:id
1 … 1McompdotsntOf
@root
uid1 … 1F1.3.182.4.14
@extension
st1 … 1RLe numéro du séjour
 Schematron assertrolered error 
 testmatches(@extension, '^\w{9}$') 
 MessageNuméro d'admission : numéro décerné au séjour du patient par l’établissement, code alphanumérique à 9 caractères (le numéro doit être préfixé d'un ou de plusieurs 0 si le numéro utilisé en interne dispose de moins de 9 caractères) 
hl7:code
CE1 … 1MProvenance du patient, suivant la liste de codescompdotsntOf
 CONF
The value of @code shall be drawn from value set 1.3.182.10.42.1 provenance (DYNAMIC)
hl7:effectiveTime
1 … 1MDates de début (low) et de fin (high) du séjourcompdotsntOf
hl7:low
TS1 … 1McompdotsntOf
@value
ts1 … 1R
 Schematron assertrolered error 
 testmatches(@value,'^20\d{10}$') 
 MessageLes dates doivent etre au format YYYYMMDDHHMM 
hl7:high
TS1 … 1McompdotsntOf
@value
ts0 … 1 
 Schematron assertrolered error 
 testmatches(@value,'^20\d{10}$') 
 MessageLes dates doivent etre au format YYYYMMDDHHMM 
 Schematron assertrolered error 
 testhl7:high/@value>=hl7:low/@value 
 MessageLa date/heure de sortie doit être égale ou supérieure à la date/heure d'entrée 
hl7:dischargeDispositionCode
CE1 … 1MModalité de sortie, suivant la liste de codescompdotsntOf
 CONF
The value of @code shall be drawn from value set 1.3.182.10.44.1 modaliteSortie (DYNAMIC)
hl7:responsibleParty
1 … 1MMédecin responsable de l'admissioncompdotsntOf
hl7:assignedEntity
1 … 1McompdotsntOf
hl7:id
1 … 1McompdotsntOf
@root
uid1 … 1F1.3.182.4.6
@extension
st1 … 1RNuméro prestataire (CNS) du médecin
hl7:encounterParticipant
0 … 1CEtablissement de provenance du patient, à préciser si « Provenance du patient » = H0 ou H1 ou H2 ou H3 ou H4compdotsntOf
@typeCode
cs1 … 1FREF
hl7:templateId
1 … 1McompdotsntOf
@root
uid1 … 1F1.3.182.11.13.1.6
@extension
st0NPNP/not present
hl7:assignedEntity
1 … 1McompdotsntOf
hl7:id
1 … 1RcompdotsntOf
@nullFlavor
cs1 … 1FNA
hl7:code
CE1 … 1MCode de l'établissement de provenance, suivant la liste de codescompdotsntOf
 CONF
The value of @code shall be drawn from value set 1.3.182.10.60.1 cnsCodeEtab (DYNAMIC)
hl7:encounterParticipant
0 … 1CEtablissement de destinationdu patient, à préciser si "Modalité de sortie" est 2 ; 51; 62; 63 ou 65
compdotsntOf
@typeCode
cs1 … 1FDIS
hl7:templateId
1 … 1McompdotsntOf
@root
uid1 … 1F1.3.182.11.13.1.7
@extension
st0NPNP/not present
hl7:assignedEntity
1 … 1McompdotsntOf
hl7:id
1 … 1RcompdotsntOf
@nullFlavor
cs1 … 1FNA
hl7:code
CE1 … 1MCode de l'établissement de destination, suivant la liste de codes
compdotsntOf
 CONF
The value of @code shall be drawn from value set 1.3.182.10.60.1 cnsCodeEtab (DYNAMIC)
 Variable letNamemodSortie 
 Valuehl7:dischargeDispositionCode/@code 
 Variable letNameprovCode 
 Valuehl7:code/@code 
 Schematron assertrolered error 
 test($provCode=("H0","H1","H2","H3","H4") and hl7:encounterParticipant[@typeCode="REF"]) or (not($provCode=("H0","H1","H2","H3","H4")) and not(hl7:encounterParticipant[@typeCode="REF"])) 
 MessageCode de l'établissement de provenance : code alphanumérique repris au tableau iii) du chapitre IV (à indiquer si la variable « Provenance du patient » = H0 ou H1 ou H2 ou H3 ou H4) 
 Schematron assertrolered error 
 test($modSortie=("2","51","62","63","65") and hl7:encounterParticipant[@typeCode="DIS"]) or (not($modSortie=("2","51","62","63","65")) and not(hl7:encounterParticipant[@typeCode="DIS"]))  
 MessageCode de l'établissement de destination de sortie : définir le site hospitalier de destination du patient par indication du code alphanumérique repris au tableau iii) du chapitre IV, le code est à indiquer uniquement si la valeur de "Modalité de sortie" est 2 ; 51; 62; 63 ou 65 
hl7:component
1 … 1MCDADCSH
hl7:structuredBody
1 … 1MCDADCSH
hl7:component
1 … 1MContains 1.3.182.11.13.2.1 administrativeInformation (DYNAMIC)CDADCSH
hl7:component
1 … 1MContains 1.3.182.11.13.2.2 encounterInformation (DYNAMIC)CDADCSH
hl7:component
1 … 1MContains 1.3.182.11.13.2.3 services (DYNAMIC)CDADCSH
hl7:component
1 … 1MContains 1.3.182.11.13.2.4 intervenants (DYNAMIC)CDADCSH
hl7:component
1 … 1MContains 1.3.182.11.13.2.5 procedures (DYNAMIC)CDADCSH
hl7:component
1 … 1MContains 1.3.182.11.13.2.6 diagnostics (DYNAMIC)CDADCSH
hl7:component
0 … 1CContains 1.3.182.11.13.2.7 newborn (DYNAMIC)CDADCSH
hl7:component
1 … 1MContains 1.3.182.11.13.2.8 drg (DYNAMIC)CDADCSH
 Variable letNamedateNaissance 
 Valuehl7:recordTarget/hl7:patientRole/hl7:patient/hl7:birthTime/@value 
 Variable letNamedateAdmission 
 Valuesubstring(hl7:componentOf/hl7:encompassingEncounter/hl7:effectiveTime/hl7:low/@value,0,9) 
 Variable letNamedateHeureAdmission 
 Valuehl7:componentOf/hl7:encompassingEncounter/hl7:effectiveTime/hl7:low/@value 
 Variable letNamedateHeureSortie 
 Valuehl7:componentOf/hl7:encompassingEncounter/hl7:effectiveTime/hl7:high/@value 
 Variable letNamedateHeurePremierService 
 Value//hl7:section[hl7:templateId/@root="1.3.182.11.13.2.3"]/hl7:entry/hl7:organizer/hl7:component[1]/hl7:encounter/hl7:effectiveTime/hl7:low/@value 
 Variable letNamedateHeureDernierService 
 Value//hl7:section[hl7:templateId/@root="1.3.182.11.13.2.3"]/hl7:entry/hl7:organizer/hl7:component[last()]/hl7:encounter/hl7:effectiveTime/hl7:high/@value 
 Variable letNamedureeSejourHeures 
 Value(xs:dateTime(concat(substring($dateHeureSortie, 0, 5), '-', substring($dateHeureSortie, 5, 2), '-', substring($dateHeureSortie, 7, 2),'T',substring($dateHeureSortie, 9, 2),':',substring($dateHeureSortie, 11, 2),':00'))-xs:dateTime(concat(substring($dateHeureAdmission, 0, 5), '-', substring($dateHeureAdmission, 5, 2), '-', substring($dateHeureAdmission, 7, 2),'T',substring($dateHeureAdmission, 9, 2),':',substring($dateHeureAdmission, 11, 2),':00'))) div xs:dayTimeDuration('PT1H') 
 Schematron assertrolered error 
 testevery $dateDebItv in //hl7:section[hl7:templateId/@root="1.3.182.11.13.2.4"]//hl7:low/@value satisfies $dateDebItv>=$dateHeureAdmission 
 MessageChaque date/heure de début de prise en charge par un médecin est supérieure ou égale à la date/heure d'admission 
 Schematron assertrolered error 
 testevery $dateFItv in //hl7:section[hl7:templateId/@root="1.3.182.11.13.2.4"]//hl7:high/@value satisfies $dateFItv<=$dateHeureSortie 
 MessageChaque date/heure de fin de prise en charge par un médecin est inférieure ou égale à la date/heure de sortie 
 Schematron assertrolered error 
 test$dateAdmission>=$dateNaissance 
 MessageLa date d'admission doit etre superieure ou egale a la date de naissance du patient 
 Schematron assertrolered error 
 test$dateHeurePremierService=$dateHeureAdmission 
 MessageLa date/heure d'entrée dans le premier service doit etre égale à la date/heure d'admission 
 Schematron assertrolered error 
 test$dateHeureDernierService=$dateHeureSortie 
 MessageLa date/heure de sortie dans le dernier service doit etre égale à la date/heure de sortie 
 Variable letNamecodePremierService 
 Value//hl7:section[hl7:templateId/@root="1.3.182.11.13.2.3"]/hl7:entry/hl7:organizer/hl7:component[1]/hl7:encounter/hl7:code/@code 
 Variable letNamepassageUrgences 
 Value//hl7:entry[hl7:templateId/@root="1.3.182.11.13.3.18"]/hl7:observation/hl7:value 
 Schematron assertrolered error 
 test($passageUrgences="1" and $codePremierService=("URGE", "URGP")) or ($passageUrgences="0" and not($codePremierService="URGE") and not($codePremierService="URGP")) 
 MessageS'il y a un passage aux urgences, le code du premier service doit être URGE ou URGP, sinon ces codes ne doivent pas être utilisés comme premier service 
 Variable letNamemodaliteEntree 
 Value//hl7:entry[hl7:templateId/@root="1.3.182.11.13.3.16"]/hl7:observation/hl7:value/@code 
 Variable letNameageInDays 
 Value//hl7:entry[hl7:templateId/@root="1.3.182.11.13.3.20"]/hl7:observation/hl7:value/@value 
 Variable letNameprovenance 
 Valuehl7:componentOf/hl7:encompassingEncounter/hl7:code/@code 
 Schematron assertrolered error 
 testnot($modaliteEntree="NN") or ($modaliteEntree="NN" and $ageInDays<=1 and $provenance="N0") 
 MessageSi la modalité d'entrée est NN, l'age du nourrisson est inférieur ou égal à 1 et la provenance est N0 
 Schematron assertrolered error 
 testnot($provenance="N1") or not($provenance="NN") 
 MessageSi la provenance est N1, alors la modalité d'entrée ne doit pas être NN 
 Schematron assertrolered error 
 testif ($dureeSejourHeures>=24 and //hl7:section[hl7:templateId/@root="1.3.182.11.13.2.3"]/hl7:entry/hl7:organizer/hl7:component[1]/hl7:encounter/hl7:code/@code=('URGE','URGP')) then (//hl7:entry[hl7:templateId/@root="1.3.182.11.13.3.18"]/hl7:observation/hl7:value='1') else true() 
 MessagePour un séjour stationnaire, si le premier service est de type URGE ou URGP, il doit y avoir passage aux urgences 
 Schematron assertrolered error 
 testif (//hl7:section[hl7:templateId/@root="1.3.182.11.13.2.3"]/hl7:entry/hl7:organizer/hl7:component[1]/hl7:encounter/hl7:code/@code=('CHDJ' ,'MHDJ')) then ($dureeSejourHeures<=24) else true() 
 MessageSi le type de service est CHDJ ou MHDJ, le séjour doit durer maximum 24h 
 Schematron assertrolered error 
 testif (//hl7:section[hl7:templateId/@root="1.3.182.11.13.2.3"]/hl7:entry/hl7:organizer/hl7:component[1]/hl7:encounter/hl7:code/@code='OBST' and //hl7:administrativeGenderCode/@code='M') then ($provenance=('N0', 'N1')) else true() 
 MessageSi le patient est un homme en service obstétrique, le code provenance doit etre N0 ou N1 
 Schematron assertrolered error 
 testnot(//hl7:patientRole/hl7:id/@extension=//hl7:participant/hl7:associatedEntity/hl7:id/@extension) 
 MessageLe matricule de la mère, si présent, ne peut valoir le matricule du patient