Item | DT | Card | Conf | Description | Label |
---|
hl7:ClinicalDocument
| | 1 … 1 | M | | ePreDAL3 |
hl7:realmCode
| | 1 … 1 | M | | ePreDAL3 |
@code
| cs | 1 … 1 | F | LU |
hl7:typeId
| | 1 … 1 | M | | ePreDAL3 |
@root
| oid | 1 … 1 | F | 2.16.840.1.113883.1.3 |
@extension
| st | 1 … 1 | F | POCD_HD000040 |
hl7:templateId
| | 1 … 1 | M | | ePreDAL3 |
@root
| oid | 1 … 1 | F | 1.3.182.11.5.1 |
| ePrescription CDA Level 3
|
hl7:templateId
| | 1 … 1 | M | | ePreDAL3 |
@root
| oid | 1 … 1 | F | 2.16.840.1.113883.10.20.30 |
hl7:id
| | 1 … 1 | M | The unique identifier of the document. @root shall be a valid UUID
| ePreDAL3 |
@root
| uuid | 1 … 1 | R | |
| Example | <id root="fa625fd5-2ea9-433c-af17-71f0a1484443"/> |
hl7:code
| | 1 … 1 | M | | ePreDAL3 |
@code
| cs | 1 … 1 | R | |
@codeSystem
| oid | 1 … 1 | R | |
| Constraint | Only 2 possibilities here: 57833-6 (codeSystem=2.16.840.1.113883.6.1) for medications prescriptions or DT-65004 (codeSystem=1.3.182.5.9) for laboratory prescriptions. Be sure to use the appropriate section
|
| Example | <code code="57833-6" codeSystem="2.16.840.1.113883.6.1"/> |
| Schematron assert | role | error | |
| test | (@code="57833-6" and @codeSystem="2.16.840.1.113883.6.1" and ../hl7:component/hl7:structuredBody/hl7:component/hl7:section/hl7:templateId/@root="1.3.182.11.5.2.2.1") or (@code="DT-65004" and @codeSystem="1.3.182.5.9" and ../hl7:component/hl7:structuredBody/hl7:component/hl7:section/hl7:templateId/@root="1.3.182.11.5.3.2.1") | |
| Message | The codes shall match the type of dispensation | |
hl7:effectiveTime
| TS.DATETIMETZ.MIN | 1 … 1 | M | The date of creation of the document, shall have the format yyyyMMddHHmmss[+/-]HHmm | ePreDAL3 |
hl7:confidentialityCode
| | 1 … 1 | M | | ePreDAL3 |
@code
| cs | 1 … 1 | F | N |
@codeSystem
| oid | 1 … 1 | F | 2.16.840.1.113883.5.25 |
| Example | <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> |
Included | 1 … 1 | M | from 1.3.182.11.1.16.1 CDA recordTarget A1 (DYNAMIC) |
hl7:recordTarget
| | 1 … 1 | M | | CDAretA1 |
hl7:patientRole
| | 1 … 1 | M | | CDAretA1 |
hl7:id
| II | 1 … * | M | The first id of recordTarget/patientRole represents the local patient ID. It shall not be nullFlavored and shall have root and extension attribute, root being a valid OID string
| CDAretA1 |
@extension
| st | 1 … 1 | R | |
@root
| oid | 1 … 1 | R | |
hl7:id
| II | 1 … * | M | | CDAretA1 |
@extension
| st | 1 … 1 | R | |
@root
| oid | 1 … 1 | F | 1.3.182.4.4 |
hl7:id
| II | 1 … * | R | | CDAretA1 |
@root
| uid | 0 … 1 | F | 1.3.182.2.11.2 |
@extension
| st | 0 … 1 | | |
Included | 1 … * | M | from 1.3.182.11.1.1 ADDR (DYNAMIC) |
hl7:addr
| AD | 1 … * | M | | ADDR |
@use
| cs | 0 … 1 | | Information about the usage or context of the address information. E.g. home, work, … Not mandatory if addr is nullFlavored.
|
| CONF | The value of @use shall be drawn from value set 1.3.182.10.2.1 eSante_AddressUse (DYNAMIC) |
|
hl7:streetAddressLine
| ADXP | 0 … 1 | | | ADDR |
hl7:streetName
| ADXP | 0 … 1 | | | ADDR |
hl7:houseNumber
| ADXP | 0 … 1 | | | ADDR |
hl7:postalCode
| ADXP | 0 … 1 | R | | ADDR |
hl7:city
| ADXP | 0 … 1 | R | | ADDR |
hl7:state
| ADXP | 0 … 1 | | | ADDR |
hl7:country
| ADXP | 0 … 1 | R | | ADDR |
| Constraint | The country code shall come from the value set eSanté_CountryCodes
|
| Variable let | Name | country | |
| Value | text() | |
| Schematron assert | role | error | |
| test | count(distinct-values(doc('include/voc-1.3.182.10.33.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $country]))=1 | |
| Message | The country code shall come from the value set eSanté_CountryCodes | |
hl7:additionalLocator
| ADXP | 0 … 1 | | | ADDR |
| Schematron assert | role | error | |
| test | @nullFlavor or (((hl7:streetAddressLine and not(hl7:streetName) and not(hl7:houseNumber)) or (hl7:streetName and hl7:houseNumber and not(hl7:streetAddressLine))) and @use) | |
| Message | Address can either have @nullFlavor or need to have @use attribute and streetAddressLine or houseNumber and streetName. | |
| Schematron assert | role | error | |
| test | @nullFlavor or (hl7:postalCode and hl7:city and hl7:country) | |
| Message | If addr is not nullFlavored, PostalCode, City and Country shall be provided. | |
Included | 0 … * | | from 1.3.182.11.22 CDA telecom (DYNAMIC) |
hl7:telecom
| | 0 … * | | | CDAtecom |
@use
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 1.3.182.10.28.1 eSante_TelecomAddressUse (DYNAMIC) |
|
@value
| st | 1 … 1 | R | |
| Variable let | Name | myAttValue | |
| Value | substring-before(@value,':') | |
| Variable let | Name | myAttCheck | |
| Value | distinct-values(doc('include/voc-1.3.182.10.29.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $myAttValue]) | |
| Schematron assert | role | error | |
| test | count($myAttValue)=count($myAttCheck) | |
| Message | Value must start with communication - scheme from value set eSanté_URLScheme | |
hl7:patient
| | 1 … 1 | M | | CDAretA1 |
hl7:id
| II | 0 … 1 | | | CDAretA1 |
hl7:name
| PN | 1 … * | M | | CDAretA1 |
@use
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 1.3.182.10.19.1 eSante_NameUse (DYNAMIC) |
|
hl7:prefix
| ST | 0 … * | | | CDAretA1 |
@qualifier
| cs | 0 … 1 | | |
| CONF | The value of @qualifier shall be drawn from value set 1.3.182.10.18.1 eSante_NamePartQualifier (DYNAMIC) |
|
hl7:family
| ST | 1 … * | M | | CDAretA1 |
@qualifier
| cs | 0 … 1 | | |
| CONF | The value of @qualifier shall be drawn from value set 1.3.182.10.18.1 eSante_NamePartQualifier (DYNAMIC) |
|
hl7:given
| ST | 1 … * | M | | CDAretA1 |
@qualifier
| cs | 0 … 1 | | |
| CONF | The value of @qualifier shall be drawn from value set 1.3.182.10.18.1 eSante_NamePartQualifier (DYNAMIC) |
|
hl7:suffix
| ST | 0 … * | | | CDAretA1 |
@qualifier
| cs | 0 … 1 | | |
| CONF | The value of @qualifier shall be drawn from value set 1.3.182.10.18.1 eSante_NamePartQualifier (DYNAMIC) |
|
hl7:administrativeGenderCode
| CE | 1 … 1 | M | | CDAretA1 |
| CONF | The value of @code shall be drawn from value set 1.3.182.10.3.1 eSante_AdministrativeGender (DYNAMIC) |
|
hl7:birthTime
| TS | 1 … 1 | R | | CDAretA1 |
@nullFlavor
| cs | 0 … 1 | F | UNK |
@value
| ts | 0 … 1 | | |
| Schematron assert | role | error | |
| test | hl7:id[2]/@root='1.3.182.4.4' and matches(hl7:id[2]/@extension,'^(\d{11}|\d{13})$') | |
| Message | The second id of recordTarget/patientRole shall have @root=1.3.182.4.4 and @extension representing the SSN (11-digits or 13-digits) | |
| Schematron assert | role | error | |
| test | (hl7:id[3]/@nullFlavor) or (hl7:id[3]/@root='1.3.182.2.11.2') | |
| Message | The third id of recordTarget/patientRole if not nullFlavored, shall have @root=1.3.182.2.11.2 and @extension | |
| Schematron assert | role | error | |
| test | count(hl7:id)=3 | |
| Message | 3 id shall be present | |
Included | 1 … 1 | M | from 1.3.182.7.6.1.10.1 CDA author A2 (DYNAMIC)
More information on the meaning of some elements:
Prescriber Profession => author/functionCode Timestamp of prescribing => author/time Prescriber ID => author/assignedAuthor/id Prescriber Specialty => author/assignedAuthor/code Prescriber Name => author/assignedAuthor/assignedPerson/name Prescriber Organization Identifier => author/assignedAuthor/representedOrganization/id Prescriber Organization Name => author/assignedAuthor/representedOrganization/name Prescriber Organization Address => author/assignedAuthor/representedOrganization/addr
All the author information shall be copied in the section exactly as it is here.
|
hl7:author
| | 1 … 1 | M | | CDAaorA2 |
hl7:time
| TS.DATETIMETZ.MIN | 1 … 1 | M | | CDAaorA2 |
hl7:assignedAuthor
| | 1 … 1 | M | | CDAaorA2 |
hl7:id
| II | 1 … * | R | Identifier of the author of this document, more than one identifier can be provided. For health professionals the hpdID (root OID = 1.3.182.4.1) from the HPD shall be provided. Additionally, if known, the code prestataire from CNS (UCM) with OID 1.3.182.4.6 may be provided. Identifiers shall be provided as specified in chapter: 2.2.2 and following the specification of the II data type in chapter: 2.2 When a patient authors a document e.g. his national identifier (root OID = 1.3.182.4.4) or the DSPPID (root OID = 1.3.182.2.4.2) can be used.
If the author is a device, then the id of the device inside the institution shall be given. | CDAaorA2 |
Included | 0 … * | | from 1.3.182.11.1.1 ADDR (DYNAMIC) |
hl7:addr
| AD | 0 … * | | | ADDR |
@use
| cs | 0 … 1 | | Information about the usage or context of the address information. E.g. home, work, … Not mandatory if addr is nullFlavored.
|
| CONF | The value of @use shall be drawn from value set 1.3.182.10.2.1 eSante_AddressUse (DYNAMIC) |
|
hl7:streetAddressLine
| ADXP | 0 … 1 | | | ADDR |
hl7:streetName
| ADXP | 0 … 1 | | | ADDR |
hl7:houseNumber
| ADXP | 0 … 1 | | | ADDR |
hl7:postalCode
| ADXP | 0 … 1 | R | | ADDR |
hl7:city
| ADXP | 0 … 1 | R | | ADDR |
hl7:state
| ADXP | 0 … 1 | | | ADDR |
hl7:country
| ADXP | 0 … 1 | R | | ADDR |
| Constraint | The country code shall come from the value set eSanté_CountryCodes
|
| Variable let | Name | country | |
| Value | text() | |
| Schematron assert | role | error | |
| test | count(distinct-values(doc('include/voc-1.3.182.10.33.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $country]))=1 | |
| Message | The country code shall come from the value set eSanté_CountryCodes | |
hl7:additionalLocator
| ADXP | 0 … 1 | | | ADDR |
| Schematron assert | role | error | |
| test | @nullFlavor or (((hl7:streetAddressLine and not(hl7:streetName) and not(hl7:houseNumber)) or (hl7:streetName and hl7:houseNumber and not(hl7:streetAddressLine))) and @use) | |
| Message | Address can either have @nullFlavor or need to have @use attribute and streetAddressLine or houseNumber and streetName. | |
| Schematron assert | role | error | |
| test | @nullFlavor or (hl7:postalCode and hl7:city and hl7:country) | |
| Message | If addr is not nullFlavored, PostalCode, City and Country shall be provided. | |
Included | 0 … * | | from 1.3.182.11.22 CDA telecom (DYNAMIC) |
hl7:telecom
| | 0 … * | | | CDAtecom |
@use
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 1.3.182.10.28.1 eSante_TelecomAddressUse (DYNAMIC) |
|
@value
| st | 1 … 1 | R | |
| Variable let | Name | myAttValue | |
| Value | substring-before(@value,':') | |
| Variable let | Name | myAttCheck | |
| Value | distinct-values(doc('include/voc-1.3.182.10.29.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $myAttValue]) | |
| Schematron assert | role | error | |
| test | count($myAttValue)=count($myAttCheck) | |
| Message | Value must start with communication - scheme from value set eSanté_URLScheme | |
Choice | 0 … 1 | | Elements to choose from:- hl7:assignedPerson containing template 1.3.182.11.1.15 CDA Person (DYNAMIC)
|
hl7:assignedPerson
| | 0 … 1 | | Contains 1.3.182.11.1.15 CDA Person (DYNAMIC) | CDAaorA2 |
hl7:representedOrganization
| | 0 … 1 | | Contains 1.3.182.11.1.13 CDA Organization (DYNAMIC) | CDAaorA2 |
Included | 1 … 1 | M | from 1.3.182.11.1.7 CDA custodian (DYNAMIC) |
hl7:custodian
| | 1 … 1 | M | | CDAcdian |
@typeCode
| cs | 0 … 1 | F | CST |
hl7:assignedCustodian
| | 1 … 1 | M | | CDAcdian |
@classCode
| cs | 0 … 1 | F | ASSIGNED |
hl7:representedCustodianOrganization
| | 1 … 1 | M | | CDAcdian |
@classCode
| cs | 0 … 1 | F | ORG |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:id
| II | 1 … * | R | Identifiers of the organization. This should be the identifier given from the healthcare provider directory (HPD).
| CDAcdian |
hl7:name
| ON | 1 … 1 | M | Name of the organization | CDAcdian |
@use
| cs | 0 … 1 | | |
hl7:prefix
| ENXP | 0 … * | | | CDAcdian |
@qualifier
| set_cs | 0 … 1 | | |
| CONF | The value of @qualifier shall be drawn from value set 1.3.182.10.18.1 eSante_NamePartQualifier (DYNAMIC) |
|
hl7:suffix
| ADXP | 0 … * | | | CDAcdian |
@qualifier
| cs | 0 … 1 | | |
| CONF | The value of @qualifier shall be drawn from value set 1.3.182.10.18.1 eSante_NamePartQualifier (DYNAMIC) |
|
Included | 0 … 1 | | from 1.3.182.11.22 CDA telecom (DYNAMIC) |
hl7:telecom
| | 0 … 1 | | | CDAtecom |
@use
| set_cs | 0 … 1 | | |
| CONF | The value of @use shall be drawn from value set 1.3.182.10.28.1 eSante_TelecomAddressUse (DYNAMIC) |
|
@value
| st | 1 … 1 | R | |
| Variable let | Name | myAttValue | |
| Value | substring-before(@value,':') | |
| Variable let | Name | myAttCheck | |
| Value | distinct-values(doc('include/voc-1.3.182.10.29.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $myAttValue]) | |
| Schematron assert | role | error | |
| test | count($myAttValue)=count($myAttCheck) | |
| Message | Value must start with communication - scheme from value set eSanté_URLScheme | |
Included | 0 … 1 | | from 1.3.182.11.1.1 ADDR (DYNAMIC) |
hl7:addr
| AD | 0 … 1 | | | ADDR |
@use
| cs | 0 … 1 | | Information about the usage or context of the address information. E.g. home, work, … Not mandatory if addr is nullFlavored.
|
| CONF | The value of @use shall be drawn from value set 1.3.182.10.2.1 eSante_AddressUse (DYNAMIC) |
|
hl7:streetAddressLine
| ADXP | 0 … 1 | | | ADDR |
hl7:streetName
| ADXP | 0 … 1 | | | ADDR |
hl7:houseNumber
| ADXP | 0 … 1 | | | ADDR |
hl7:postalCode
| ADXP | 0 … 1 | R | | ADDR |
hl7:city
| ADXP | 0 … 1 | R | | ADDR |
hl7:state
| ADXP | 0 … 1 | | | ADDR |
hl7:country
| ADXP | 0 … 1 | R | | ADDR |
| Constraint | The country code shall come from the value set eSanté_CountryCodes
|
| Variable let | Name | country | |
| Value | text() | |
| Schematron assert | role | error | |
| test | count(distinct-values(doc('include/voc-1.3.182.10.33.1-DYNAMIC.xml')/*/valueSet/conceptList/concept[@code = $country]))=1 | |
| Message | The country code shall come from the value set eSanté_CountryCodes | |
hl7:additionalLocator
| ADXP | 0 … 1 | | | ADDR |
| Schematron assert | role | error | |
| test | @nullFlavor or (((hl7:streetAddressLine and not(hl7:streetName) and not(hl7:houseNumber)) or (hl7:streetName and hl7:houseNumber and not(hl7:streetAddressLine))) and @use) | |
| Message | Address can either have @nullFlavor or need to have @use attribute and streetAddressLine or houseNumber and streetName. | |
| Schematron assert | role | error | |
| test | @nullFlavor or (hl7:postalCode and hl7:city and hl7:country) | |
| Message | If addr is not nullFlavored, PostalCode, City and Country shall be provided. | |
hl7:documentationOf
| | 0 … 1 | | The validity of the Community Prescription document MAY be defined though the <documentationOf> element.
| ePreDAL3 |
@typeCode
| cs | 1 … 1 | F | DOC |
hl7:serviceEvent
| | 1 … 1 | M | | ePreDAL3 |
@classCode
| cs | 1 … 1 | F | ACT |
@moodCode
| cs | 1 … 1 | F | EVN |
hl7:id
| | 0 … * | | Several IDs with @root=1.3.182.4.9 can be present to document the different IDs used in the ReferenceIDList metadata at the time of writing the CDA | ePreDAL3 |
@root
| uid | 1 … 1 | F | 1.3.182.4.9 |
@extension
| st | 1 … 1 | R | |
| Example | <id root="1.3.182.4.9" extension="87d42ed0-4b3b-428e-ab61-67ae6a264335^^^^MED"/> |
| Schematron assert | role | error | |
| test | matches(@extension, "^[0-9a-fA-F]{8}-[0-9a-fA-F]{4}-[0-9a-fA-F]{4}-[0-9a-fA-F]{4}-[0-9a-fA-F]{12}\^{4}(MED|LAB|IMA|CIT|ACT|INF|KIN|PAR)$") | |
| Message | @extension shall be a valid correlationID | |
hl7:id
| | 0 … 1 | | One IDs with @root=1.3.182.4.10 can be present to document the short ID of the document, i.e.the 6 last digits of the ClinicalDocument/id | ePreDAL3 |
@root
| uid | 1 … 1 | F | 1.3.182.4.10 |
@extension
| st | 1 … 1 | R | |
| Example | <id root="1.3.182.4.10" extension="484443"/> |
| Variable let | Name | lastChars | |
| Value | substring(/hl7:ClinicalDocument/hl7:id/@extension,31) | |
| Schematron assert | role | error | |
| test | @extension=$lastChars | |
| Message | If present, this short ID shall correspond to the last 6 characters of the CDA ID | |
hl7:id
| | 0 … 1 | | One IDs with @root=1.3.182.4.11 can be present to document the CNS ID of the document. So far, this does not exist but may come later. | ePreDAL3 |
@root
| uid | 1 … 1 | F | 1.3.182.4.11 |
@extension
| st | 1 … 1 | R | |
| Example | <id root="1.3.182.4.11" extension="ABC"/> |
hl7:effectiveTime
| IVL_TS | 1 … 1 | M | This element SHALL be present and specify the start and end date of the validity period of the prescription, i.e., between which dates interval the prescription may be dispensed. In case the beginning or the ending date is unknown, the <low> or <high> sub-elements of this element SHALL be set to nullFlavor "UNK".
| ePreDAL3 |
@value
| ts | 0 | NP | NP/not present |
hl7:low
| IVXB_TS | 1 … 1 | R | | ePreDAL3 |
@nullFlavor
| cs | 0 … 1 | F | UNK |
hl7:high
| IVXB_TS | 1 … 1 | R | | ePreDAL3 |
@nullFlavor
| cs | 0 … 1 | F | UNK |
hl7:component
| | 1 … 1 | M | | ePreDAL3 |
hl7:structuredBody
| | 1 … 1 | M | | ePreDAL3 |
Choice | 1 … 1 | | Elements to choose from: |
hl7:component
| | 0 … 1 | | Contains 1.3.182.11.5.2.2.1 Prescription Meds Section (DYNAMIC) | ePreDAL3 |
hl7:component
| | 0 … 1 | | Contains 1.3.182.11.5.3.2.1 Prescription Bio Section (DYNAMIC) | ePreDAL3 |
| Schematron assert | role | error | |
| test | hl7:id/@root=hl7:component/hl7:structuredBody/hl7:component/hl7:section/hl7:id/@root | |
| Message | The id of the document shall be the same as the section id | |