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Contents

CDA Document Level Templates

International Patient Summary

Id2.16.840.1.113883.10.22.1.1Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameHL7-IPSDisplay NameInternational Patient Summary
Description

The International Patient Summary is a "Minimal and non-exhaustive Patient Summary, specialty-agnostic, condition-independent, but readily usable by all clinicians for the unscheduled (cross-border) care of a patient."

The IPS templates aim to:

  • Serve for both cross-jurisdictional (through adaptation/extension for multi-language and realm scenarios, including translation) and national (through localization) patient summaries.
  • Support emergency care and unplanned care in any country (home and foreign), regardless of language
  • Define value sets based on international vocabularies that are usable and understandable in any country  
ContextPathname /
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 20 templates
Uses as NameVersion
2.16.840.1.113883.10.22.2.1IncludeKorange.png IPS CDA recordTarget (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.2IncludeKorange.png IPS CDA author (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.3IncludeKorange.png IPS CDA custodian (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.4IncludeKorange.png IPS CDA legalAuthenticator (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.5IncludeKorange.png IPS Patient Contacts (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.6IncludeKorange.png IPS CDA documentationOf (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.7IncludeKorange.png IPS CDA relatedDocument (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.1ContainmentKorange.png IPS Medication Summary Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.2ContainmentKorange.png IPS Allergies and Intolerances Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.3ContainmentKorange.png IPS Problems Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.4ContainmentKorange.png IPS History of Procedures Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.5ContainmentKorange.png IPS Immunizations Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.6ContainmentKorange.png IPS Medical Devices Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.14ContainmentKorange.png IPS Results Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.7ContainmentKorange.png IPS History of Past Illness Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.8ContainmentKorange.png IPS Functional Status Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.9ContainmentKorange.png IPS Plan of Care Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.10ContainmentKorange.png IPS Social History Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.11ContainmentKorange.png IPS History of Pregnancy Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.12ContainmentKorange.png IPS Advance Directives Section (STU1)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 (2013‑12‑20)
Adaptation: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example
Example
<ClinicalDocument>
  <realmCode code="ES"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="2.16.840.1.113883.10.22.1.1"/>  <id root="2.16.724.4.8.10.200.10" extension="PSCTD0160f274530a031"/>  <code displayName="Patient Summary" code="60591-5" codeSystem="2.16.840.1.113883.6.1"/>  <title>Patient Summary</title>  <effectiveTime value="20111113125600+0200"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="es-ES"/>  <setId root="2.16.724.4.8.10.200.10" extension="PSCTD0160f274530a031S"/>  <versionNumber value="2"/>  <!-- include template 2.16.840.1.113883.10.22.2.1 'IPS CDA recordTarget' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.10.22.2.2 'IPS CDA author' (dynamic) 1..* M -->
  <!-- include template 2.16.840.1.113883.10.22.2.3 'IPS CDA custodian' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.10.22.2.4 'IPS CDA legalAuthenticator' (dynamic) 0..1 R -->
  <!-- include template 2.16.840.1.113883.10.22.2.5 'IPS Patient Contacts' (dynamic) 0..* O -->
  <!-- include template 2.16.840.1.113883.10.22.2.6 'IPS CDA documentationOf ' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.10.22.2.7 'IPS CDA relatedDocument' (dynamic) 0..* R -->
  <component>
    <structuredBody classCode="DOCBODY">
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.1 'IPS Medication Summary Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.2 'IPS Allergies and Intolerances Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.3 'IPS Problems Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.4 'IPS History of Procedures Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.5 'IPS Immunizations Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.6 'IPS Medical Devices Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.7 'IPS History of Past Illness Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.14 'IPS Results Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.8 'IPS Functional Status Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.9 'IPS Plan of Treatment Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.10 'IPS Social History Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.11 'IPS History of Pregnancy Section' (dynamic) -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.3.12 'IPS Advance Directives Section' (dynamic) -->
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
RCDA header(HL7-IPS)
Treetree.pnghl7:realmCode
CS1 … 1R(HL7-IPS)
Treetree.pnghl7:typeId
II1 … 1M The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

(HL7-IPS)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
 Example<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
Treetree.pnghl7:templateId
II1 … 1M(HL7-IPS)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.1.1
Treetree.pnghl7:id
II1 … 1MUnique identifier of this instance of the Patient Summary.(HL7-IPS)
Treetree.pnghl7:code
CE.IPS1 … 1MDetermines the document type that is the "Patient Summary" document(HL7-IPS)
Treeblank.pngTreetree.png@displayName
1 … 1R
Treeblank.pngTreetree.png@code
CONF1 … 1F60591-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
 Example<code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/>
Treeblank.pngTreetree.pnghl7:translation
CD.IPS0 … *RThis element can be here used either to provide the originally used document code if this IPS is the result of a transformation.(HL7-IPS)
Treetree.pnghl7:title
ST1 … 1MClinicalDocument/title is used for display purposes.(HL7-IPS)
 Example<title>Patient Summary</title>
 Example<title>Profilo Sanitario Sintetico</title>
Treetree.pnghl7:effectiveTime
TS.IPS.TZ1 … 1MTime of creation of the Patient Summary(HL7-IPS)
 Example<effectiveTime value="20111113125600+0200"/>
Treetree.pnghl7:confidentialityCode
CE.IPS1 … 1R(HL7-IPS)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
 Example<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/>
Treetree.pnghl7:language​Code
CS1 … 1MDocument Language Code(HL7-IPS)
 ConstraintThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)
 Example<languageCode code="en-GB"/>
 Example<languageCode code="fil-PH"/>
 Schematron assertroleKred.png error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO country code; CC is ISO language code) 
Treetree.pnghl7:setId
II0 … 1R

This attribute “represents an identifier that is common across all document revisions”.

In the case the IPS instance is generated as result of one or more transformations (translation/transcoding) the setId is supposed to remain unchanged across all those transformations.

Implementers are recommended to use this attribute.

(HL7-IPS)
Treetree.pnghl7:versionNumber
0 … 1R(HL7-IPS)
Included1 … 1M from 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget (DYNAMIC)
Treetree.pnghl7:recordTarget
1 … 1M(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs0 … 1FRCT
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Example<recordTarget typeCode="RCT" contextControlCode="OP">
  <patientRole classCode="PAT">
    <id root="1.2.3.999" extension="__example only__"/>    <addr>
      <streetAddressLine>HSE M CASSAR STR</streetAddressLine>      <city>ISLA</city>      <country>MT</country>    </addr>
    <telecom use="HP" value="tel:+356124567891"/>    <telecom use="WP" value="mailto:elif@foo.too.mt"/>    <patient>
      <name>
        <family>BORG</family>        <given>TANIA</given>      </name>
      <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/>      <birthTime value="19430130"/>      <!-- Optional guardian information ; see example below-->
      <!-- Optional languageCommunication information see example below -->
    </patient>
  </patientRole>
</recordTarget>
Treeblank.pngTreetree.pnghl7:patientRole
1 … 1M(HL7-IPS)
 
Target.png
hl7ips-data​element-2.1Kyellow.png Patient Attributes Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPAT
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)(HL7-IPS)
 
Target.png
hl7ips-data​element-7Kyellow.png Insurance identifier Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-202Kyellow.png Healthcare related Identifiers Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RThe patient address.(HL7-IPS)
 
Target.png
hl7ips-data​element-162Kyellow.png Address Kyellow.png CEN/TC 251 prEN 17269
 ConstraintWhen used for cross-border exchange the country address part has to be provided.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertroleKred.png error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. (HL7-IPS)
 
Target.png
hl7ips-data​element-100Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
 Example<telecom use="HP" value="tel:+356124567891"/>
 Example<telecom use="WP" value="mailto:elif@foo.too.mt"/>
 Example<telecom nullFlavor="NI"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
1 … 1M(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
 Example
Japanese example (Person Name)
<patient>
  <name use="IDE">
    <family>木村</family>    <given>通男</given>  </name>
  <name use="SYL">
    <family>きむら</family>    <given>みちお</given>  </name>
  <name use="ABC">
    <family>KIMURA</family>    <given>MICHIO</given>  </name>
  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *MPatient Name(HL7-IPS)
 
Target.png
hl7ips-data​element-3Kyellow.png Patient's Name Kyellow.png CEN/TC 251 prEN 17269
 ConstraintThe Alphabetic representation of the name SHALL be always provided
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient's Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient's Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE.IPS1 … 1RPatient's Gender(HL7-IPS)
 
Target.png
hl7ips-data​element-4Kyellow.png Administrative Gender Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FUNK
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
 Example<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
  <translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.(HL7-IPS)
 
Target.png
hl7ips-data​element-5Kyellow.png Date of Birth Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian
0 … *R

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FGUARD
 Example<guardian classCode="GUARD">
  <code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/>  <addr nullFlavor="NI"/>  <telecom use="MC" value="tel:+33-12345678"/>  <guardianPerson>
    <name>
      <family>Curie</family>      <given>Marie</given>    </name>
  </guardianPerson>
</guardian>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. (HL7-IPS)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertroleKred.png error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. (HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian​Person
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Guardian's Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
ENXP1 … *RPatient Guardian's Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
ENXP1 … *RPatient Guardian's Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Communication
0 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Code
CS1 … 1RPatient’s language(HL7-IPS)
 
Target.png
hl7ips-data​element-135Kyellow.png Patient’s preferred language Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)
 Example
British English
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertroleKred.png error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO country code; CC is ISO language code) 
Included1 … *M from 2.16.840.1.113883.10.22.2.2 IPS CDA author (DYNAMIC)
Treetree.pnghl7:author
1 … *M(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs0 … 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Example<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr use="WP">
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
  </assignedAuthor>
  <representedOrganization>
    <!-- template 'IPS CDA Organization' (dynamic) -->
  </representedOrganization>
</author>
Treeblank.pngTreetree.pnghl7:functionCode
CE.IPS0 … 1R(HL7-IPS)
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. (HL7-IPS)
 Example<time value="201212290600+0100"/>
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RAuthor Identifier(s)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.(HL7-IPS)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
 Example<code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
 Example<addr use="WP">
  <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr>
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
st0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device containing template 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(HL7-IPS)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CContains 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)(HL7-IPS)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(HL7-IPS)
Included1 … 1M from 2.16.840.1.113883.10.22.2.3 IPS CDA custodian (DYNAMIC)
Treetree.pnghl7:custodian
1 … 1M(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCST
 Example<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
Treeblank.pngTreetree.pnghl7:assignedCustodian
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
1 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Included0 … 1R from 2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator (DYNAMIC)
Treetree.pnghl7:legalAuthenticator
0 … 1R(HL7-IPS)
 Example<legalAuthenticator>
  <time value="20111013150937-0800"/>  <signatureCode code="S"/>  <assignedEntity>
    <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/>    <assignedPerson>
      <name>
        <given>John</given>        <family>Español Smith</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <name>Healthcare Facility's name</name>      <addr>
        <country>NL</country>        <streetName>Duinweg</streetName>        <houseNumber>23</houseNumber>        <postalCode>7364 RX</postalCode>        <city>Amsterdam</city>      </addr>
    </representedOrganization>
  </assignedEntity>
</legalAuthenticator>
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1MTime of signing the document(HL7-IPS)
Treeblank.pngTreetree.pnghl7:signatureCode
CS0 … 1RSignature code(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FS
Treeblank.pngTreetree.pnghl7:assignedEntity
0 … 1RThe entity that is responsible for the legal authentication of the CDA document(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
1 … *RUnique identification of legal authenticator(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the legal authenticator(HL7-IPS)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RHP Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RHP Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MOrganization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [not(@nullFlavor)]
Included0 … * from 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (DYNAMIC)
Treetree.pnghl7:participant
0 … *RPatient contacts or the Preferred Health Professional to contact in case of emergency.(HL7-IPS)
Treeblank.png where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']
 
Target.png
hl7ips-data​element-154Kyellow.png Patient’s Address Book Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-163Kyellow.png Preferred Healthcare providers Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1FIND
 Example<participant typeCode="IND">
  <templateId root="2.16.840.1.113883.10.22.2.5"/>  <associatedEntity classCode="NOK">
    <addr>
      <streetAddressLine>Promenade des Anglais 111</streetAddressLine>      <city>Lyon</city>      <postalCode>69001</postalCode>      <country>FR</country>    </addr>
    <telecom value="tel:(+33)555-20036" use="WP"/>    <associatedPerson>
      <name>
        <given>Martha</given>        <family>Mum</family>      </name>
    </associatedPerson>
  </associatedEntity>
</participant>
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.2.5
Treeblank.pngTreetree.pnghl7:functionCode
0 … 1CThe  <functionCode> element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.</functionCode>(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FPCP
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.88 (Participation Function)
Treeblank.pngTreetree.pnghl7:associated​Entity
RThe <associatedEntity> element identifies the type of contact. </associatedEntity>(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes (DYNAMIC)
 Example<associatedEntity classCode="ECON">
  <addr>
    <streetAddressLine>Karl Strasse</streetAddressLine>    <city>Freiberg</city>    <postalCode>09599</postalCode>    <country>DE</country>  </addr>
  <telecom value="tel:+49-761-11110000" use="WP"/>  <associatedPerson>
    <name>
      <given>Arzt</given>      <family>Guter</family>    </name>
  </associatedPerson>
</associatedEntity>
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CV.IPS0 … 1RThis element indicates the relationship between the patient and this participant.(HL7-IPS)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.54 IPS Personal Relationship (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
 Example<code code="AUNT" displayName="θεία" codeSystem="2.16.840.1.113883.5.111"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RPatient Contact's / Preferred HP's Address(HL7-IPS)
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(HL7-IPS)
 Schematron assertroleKred.png error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(HL7-IPS)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required.</telecom>(HL7-IPS)
 
Target.png
hl7ips-data​element-174Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-169Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present
 Example<telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
Choice1 … 2Elements to choose from:
  • hl7:associated​Person
  • hl7:scoping​Organization
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(HL7-IPS)
 
Target.png
hl7ips-data​element-165Kyellow.png Healthcare Provider (person) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Contact's Name / Preferred HP's Name(HL7-IPS)
 
Target.png
hl7ips-data​element-121Kyellow.png Name Kyellow.png CEN/TC 251 prEN 17269
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient Contact's Family Name/Surname / Preferred HP's Family Name/Surname(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient Contact's Given Name / Preferred HP's Given Name(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(HL7-IPS)
 
Target.png
hl7ips-data​element-166Kyellow.png Healthcare Provider (organisation) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … *ROrganization's Name(HL7-IPS)
 
Target.png
hl7ips-data​element-172Kyellow.png Organisation’s Name Kyellow.png CEN/TC 251 prEN 17269
Included1 … 1M from 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (DYNAMIC)
Treetree.pnghl7:documentationOf
1 … 1MThe documentationOf relationship in an International Patient Summary contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs0 … 1FDOC
 Example<documentationOf>
  <serviceEvent classCode="PCPR">
    <effectiveTime>
      <low nullFlavor="NI"/>      <high value="20110308"/>    </effectiveTime>
    <performer typeCode="PRF">
      <!-- See example below -->
    </performer>
  </serviceEvent>
</documentationOf>
Treeblank.pngTreetree.pnghl7:serviceEvent
1 … 1RThe main activity being described by a IPS is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).

For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the low value should represent the date when the treatment relationship between the patient and the GP started; and the high value the date of the latest care event.
(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPCPR
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:low
TS1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:high
TS1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:performer
0 … *RIt represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)
 Example<performer typeCode="PRF">
  <assignedEntity>
    <id assigningAuthorityName="MEF" displayable="false" extension="DVLMMG57R07F205G" root="2.16.840.1.113883.2.9.4.3.2"/>    <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors">
      <translation codeSystem="2.16.840.1.113883.2.9.5.1.111" code="MMG" displayName="Medico di Medicina Generale"/>    </code>
    <addr nullFlavor="NI"/>    <telecom nullFlavor="NI"/>    <assignedPerson>
      <name>
        <family>DVALUNO</family>        <given>MMG</given>      </name>
    </assignedPerson>
    <representedOrganization>
      <id assigningAuthorityName="A.S.L. DELLA PROVINCIA DI LECCO" extension="030305" root="2.16.840.1.113883.2.9.4.1.1"/>      <name>A.S.L. DELLA PROVINCIA DI LECCO</name>      <telecom nullFlavor="NI"/>      <addr>
        <state>LECCO</state>        <city>LECCO</city>        <country>IT</country>        <postalCode>23900</postalCode>        <streetAddressLine>CORSO CARLO ALBERTO,120</streetAddressLine>      </addr>
    </representedOrganization>
  </assignedEntity>
</performer>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:functionCode
CE.IPS0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
IVL_TS.IPS.TZ0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1M(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RHealthcare provider ID number(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS (extensible)0 … 1RIt describes the professional role of the healthcare provider involved in the current or pertinent historical care of the patient.(HL7-IPS)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1Contains 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(HL7-IPS)
Included0 … *R from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)
Treetree.pnghl7:relatedDocument
0 … *R(HL7-IPS)
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
Treeblank.pngTreetree.pnghl7:parentDocument
1 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDOCCLIN
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs0 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:setId
II0 … 1R(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.pnghl7:versionNumber
INT0 … 1R(HL7-IPS)
Treetree.pnghl7:component
1 … 1M(HL7-IPS)
Treeblank.pngTreetree.pnghl7:structuredBody
1 … 1MNote: the proposed order of the sections hereafter indicated is not mandatory(HL7-IPS)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDOCBODY
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1MContains 2.16.840.1.113883.10.22.3.1 IPS Medication Summary Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '10160-0' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1MContains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '48765-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1MContains 2.16.840.1.113883.10.22.3.3 IPS Problems Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '11450-4' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '47519-4' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.5 IPS Immunizations Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '11369-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '46264-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RContains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '30954-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '11348-0' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '47420-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '18776-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '29762-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '10162-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC)(HL7-IPS)
Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '42348-3' and @codeSystem = '2.16.840.1.113883.6.1')]]]

CDA Header Level Templates

IPS CDA author

Id2.16.840.1.113883.10.22.2.2Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAauthorDisplay NameIPS CDA author
Description

A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).

For definition “The author element represents the creator of the clinical document. If the role of the actor is the entry of information from his or her own knowledge or application of skills, that actor is the author. If one actor provides information to another actor who filters, reasons, or algorithmically creates new information, then that second actor is also an author, having created information from his or her own knowledge or skills. [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March 2009].

According to this definition, not any device that generates the electronic document has to be considered as an author:

  • a spider collecting and filtering information from different repositories, according to defined rules and policies, for the scope of creating a Patient Summary is definitely a document author (and in some cases the only one );
  • an application that transforms a Patient Summary record into this CDA format may not be an author;
  • For cross-border exchange purposes, a device, which modifies the concepts conveyed (e.g. applying code system mappings), should appear as one of the authors. In this case (document generated through a transformation process) the authors of the parent (original) patient summary should appear as authors as well.

Further to this, authorship can give information about the nature of Patient Summary :

  • if there is a person author only, then the Patient Summary is the result of a practitioner clinical act;
  • if there are device authors only, the summary was automatically generated according to well defined rules defined by the responsible organization.
The CDA standard allows to provide detailed information about what was authored by whom in the Patient Summary, allowing the specification of authorship at the whole document level, at the section level and also at the entry level. In any case it is not required to repeat this information for each of the mentioned levels, taking advantage of the context conduction propriety.
In fact “context that is specified on an outer tag holds true for all nested tags, unless overridden on a nested tag. Context specified on a tag within the CDA body always overrides context propagated from an outer tag. For instance, the specification of authorship at a document section level overrides all authorship propagated from outer tags.” (HL7 CDA R2 Standard).
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.9.2ContainmentKorange.png IPS CDA Device (STU1)DYNAMIC
2.16.840.1.113883.10.22.9.1ContainmentKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.102 (2005‑09‑07)
Example
Human Author
<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medico"/>    <addr use="WP">
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedOrganization>
  </assignedAuthor>
</author>
Example
Device Author
<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="1.2.3.999" extension="__example only__"/>    <addr use="WP">
      <state>Castilla-La Mancha</state>      <city>Toledo</city>      <precinct>Toledo</precinct>      <country>ES</country>      <postalCode>45071</postalCode>      <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>    </addr>
    <telecom nullFlavor="NI"/>    <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
      <softwareName displayName="Turriano"/>    </assignedAuthoringDevice>
    <representedOrganization classCode="ORG" determinerCode="INSTANCE">
      <id root="1.2.3.999" extension="__example only__"/>      <name>SESCAM</name>      <telecom use="WP" value="tel:+34925274100"/>      <addr use="WP">
        <state>Castilla-La Mancha</state>        <city>Toledo</city>        <precinct>Toledo</precinct>        <country>ES</country>        <postalCode>45071</postalCode>        <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>      </addr>
    </representedOrganization>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
1 … *R(IPS...hor)
Treetree.png@typeCode
cs0 … 1FAUT
Treetree.png@context​Control​Code
cs0 … 1FOP
 Example<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr use="WP">
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
  </assignedAuthor>
  <representedOrganization>
    <!-- template 'IPS CDA Organization' (dynamic) -->
  </representedOrganization>
</author>
Treetree.pnghl7:functionCode
CE.IPS0 … 1R(IPS...hor)
Treetree.pnghl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. (IPS...hor)
 Example<time value="201212290600+0100"/>
Treetree.pnghl7:assignedAuthor
1 … 1R(IPS...hor)
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreetree.pnghl7:id
II1 … *RAuthor Identifier(s)(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreetree.pnghl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.(IPS...hor)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
 Example<code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...hor)
 Example<addr use="WP">
  <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr>
Treeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@value
st0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device containing template 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...hor)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CContains 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)(IPS...hor)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Treeblank.pngTreetree.pnghl7:represented​Organization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(IPS...hor)

IPS CDA custodian

Id2.16.840.1.113883.10.22.2.3Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAcustodianDisplay NameIPS CDA custodian
Description

The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document.

This information is required by the CDA R2 standard and shall be recorded in the ClinicalDocument/custodian/assignedCustodian/ representedCustodianOrganization element.

There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.

ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.9.1ContainmentKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.104 (2005‑09‑07)
Example
Example
<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
ItemDTCardConfDescriptionLabel
hl7:custodian
1 … 1R(IPS...ian)
Treetree.png@typeCode
cs0 … 1FCST
 Example<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
Treetree.pnghl7:assignedCustodian
1 … 1R(IPS...ian)
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreetree.pnghl7:represented​Custodian​Organization
1 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(IPS...ian)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FORG
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE

IPS CDA documentationOf

Id2.16.840.1.113883.10.22.2.6Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSdocumentationOfPCPRDisplay NameIPS CDA documentationOf
Description
The documentationOf relationship in an International Patient Summary contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.

The main activity being described by a IPS is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).

For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the low value should represent the date when the treatment relationship between the patient and the GP started; and the high value the date of the latest care event.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.9.3ContainmentKorange.png IPS CDA Person (STU1)DYNAMIC
2.16.840.1.113883.10.22.9.1ContainmentKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.110 (2005‑09‑07)
Example
Example
<documentationOf typeCode="DOC">
  <serviceEvent classCode="PCPR" moodCode="EVN">
    <id root="1.2.3.999" extension="__example only__"/>    <effectiveTime>
      <low nullFlavor="UNK"/>      <high value="20170613124706"/>    </effectiveTime>
    <performer typeCode="PRF">
      <assignedEntity>
        <id root="1.2.3.999" extension="__example only__"/>        <code code="22" displayName="Health professionals" codeSystem="2.16.840.1.113883.2.9.6.2.7"/>        <addr nullFlavor="NI"/>        <telecom nullFlavor="NI"/>        <assignedPerson>
          <!-- template 'IPS CDA Person' (dynamic) -->
        </assignedPerson>
        <representedOrganization>
          <!-- template 'IPS CDA Organization' (dynamic) -->
        </representedOrganization>
      </assignedEntity>
    </performer>
  </serviceEvent>
</documentationOf>
ItemDTCardConfDescriptionLabel
hl7:documentationOf
0 … *RThe documentationOf relationship in an International Patient Summary contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.(IPS...CPR)
Treetree.png@typeCode
cs0 … 1FDOC
 Example<documentationOf>
  <serviceEvent classCode="PCPR">
    <effectiveTime>
      <low nullFlavor="NI"/>      <high value="20110308"/>    </effectiveTime>
    <performer typeCode="PRF">
      <!-- See example below -->
    </performer>
  </serviceEvent>
</documentationOf>
Treetree.pnghl7:serviceEvent
1 … 1RThe main activity being described by a IPS is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).

For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the low value should represent the date when the treatment relationship between the patient and the GP started; and the high value the date of the latest care event.
(IPS...CPR)
Treeblank.pngTreetree.png@classCode
cs1 … 1FPCPR
Treeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreetree.pnghl7:id
II0 … *R(IPS...CPR)
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS1 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
TS1 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
TS1 … 1R(IPS...CPR)
Treeblank.pngTreetree.pnghl7:performer
0 … *RIt represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)
 Example<performer typeCode="PRF">
  <assignedEntity>
    <id assigningAuthorityName="MEF" displayable="false" extension="DVLMMG57R07F205G" root="2.16.840.1.113883.2.9.4.3.2"/>    <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors">
      <translation codeSystem="2.16.840.1.113883.2.9.5.1.111" code="MMG" displayName="Medico di Medicina Generale"/>    </code>
    <addr nullFlavor="NI"/>    <telecom nullFlavor="NI"/>    <assignedPerson>
      <name>
        <family>DVALUNO</family>        <given>MMG</given>      </name>
    </assignedPerson>
    <representedOrganization>
      <id assigningAuthorityName="A.S.L. DELLA PROVINCIA DI LECCO" extension="030305" root="2.16.840.1.113883.2.9.4.1.1"/>      <name>A.S.L. DELLA PROVINCIA DI LECCO</name>      <telecom nullFlavor="NI"/>      <addr>
        <state>LECCO</state>        <city>LECCO</city>        <country>IT</country>        <postalCode>23900</postalCode>        <streetAddressLine>CORSO CARLO ALBERTO,120</streetAddressLine>      </addr>
    </representedOrganization>
  </assignedEntity>
</performer>
Treeblank.pngTreeblank.pngTreetree.pnghl7:functionCode
CE.IPS0 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
IVL_TS.IPS.TZ0 … 1R(IPS...CPR)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1M(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RHealthcare provider ID number(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE.IPS (extensible)0 … 1RIt describes the professional role of the healthcare provider involved in the current or pertinent historical care of the patient.(IPS...CPR)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1Contains 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)(IPS...CPR)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)(IPS...CPR)

IPS CDA legalAuthenticator

Id2.16.840.1.113883.10.22.2.4Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAlegalAuthenticatorDisplay NameIPS CDA legalAuthenticator
Description
The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated.
The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication.
All clinical documents have the potential for legal authentication, given the appropriate credentials.

Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system.
Note that the legal authenticator, if present, must be a person.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.9.1ContainmentKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.106 (2005‑09‑07)
Example
Example
<legalAuthenticator>
  <time value="20111013150937-0800"/>  <signatureCode code="S"/>  <assignedEntity>
    <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/>    <assignedPerson>
      <name>
        <given>John</given>        <family>Español Smith</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <name>Healthcare Facility's name</name>      <addr>
        <country>NL</country>        <streetName>Duinweg</streetName>        <houseNumber>23</houseNumber>        <postalCode>7364 RX</postalCode>        <city>Amsterdam</city>      </addr>
    </representedOrganization>
  </assignedEntity>
</legalAuthenticator>
ItemDTCardConfDescriptionLabel
hl7:legalAuthenticator
R(IPS...tor)
 Example<legalAuthenticator>
  <time value="20111013150937-0800"/>  <signatureCode code="S"/>  <assignedEntity>
    <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/>    <assignedPerson>
      <name>
        <given>John</given>        <family>Español Smith</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <name>Healthcare Facility's name</name>      <addr>
        <country>NL</country>        <streetName>Duinweg</streetName>        <houseNumber>23</houseNumber>        <postalCode>7364 RX</postalCode>        <city>Amsterdam</city>      </addr>
    </representedOrganization>
  </assignedEntity>
</legalAuthenticator>
Treetree.pnghl7:time
TS.IPS.TZ1 … 1MTime of signing the document(IPS...tor)
Treetree.pnghl7:signatureCode
CS0 … 1RSignature code(IPS...tor)
Treeblank.pngTreetree.png@code
CONF0 … 1FS
Treetree.pnghl7:assignedEntity
0 … 1RThe entity that is responsible for the legal authentication of the CDA document(IPS...tor)
Treeblank.pngTreetree.pnghl7:id
1 … *RUnique identification of legal authenticator(IPS...tor)
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...tor)
Treeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(IPS...tor)
Treeblank.pngTreetree.pnghl7:assigned​Person
1 … 1R(IPS...tor)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the legal authenticator(IPS...tor)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RHP Family Name/Surname(IPS...tor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RHP Given Name(IPS...tor)
Treeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MOrganization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
(IPS...tor)
Treeblank.pngTreeblank.png where [not(@nullFlavor)]

IPS CDA Organization

Id2.16.840.1.113883.10.22.9.1Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAOrganizationDisplay NameIPS CDA Organization
DescriptionThis is a reusable template providing essential information for describing / identifying an organization.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.11IncludeKorange.png IPS Address (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.3.1937.777.11.10.111 (2013‑12‑20)
Example
Example
<id root="1.2.3.999" extension="__example only__"/><name>name</name><name>SESCAM</name><telecom use="WP" value="tel:+34925274100"/><telecom use="WP" value="mailto:best.organization@foo.too.es"/><addr use="WP">
  <state>Castilla-La Mancha</state>  <city>Toledo</city>  <precinct>Toledo</precinct>  <country>ES</country>  <postalCode>45071</postalCode>  <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine></addr>
ItemDTCardConfDescriptionLabel
@classCode
cs1 … 1FORG
@determiner​Code
cs1 … 1FINSTANCE
hl7:id
II1 … *R(IPS...ion)
Treetree.png@nullFlavor
cs0 … 1 
hl7:name
ON1 … 1R(IPS...ion)
Treetree.png@nullFlavor
cs0 … 1 
hl7:telecom
TEL1 … *R(IPS...ion)
Treetree.png@use
set_cs1 … 1R
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treetree.png@nullFlavor
cs0 … 1 
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
hl7:addr
AD.IPS1 … 1R(IPS...ion)
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...ion)
 Schematron assertroleKred.png error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...ion)
Treetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...ion)
Treetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...ion)
Treetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...ion)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.

IPS CDA Person

Id2.16.840.1.113883.10.22.9.3Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAPersonDisplay NameIPS CDA Person
DescriptionPerson name
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.12.152 (2005‑09‑07)
ItemDTCardConfDescriptionLabel
@classCode
cs0 … 1FPSN
@determiner​Code
cs0 … 1FINSTANCE
hl7:name
PN1 … *R(IPS...son)

IPS CDA recordTarget

Id2.16.840.1.113883.10.22.2.1Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDArecordTargetDisplay NameIPS CDA recordTarget
Description
The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 9 concepts
IdNameData Set
hl7ips-data​element-2.1Kyellow.png Patient Attributes Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-3Kyellow.png Patient's Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-7Kyellow.png Insurance identifier Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-5Kyellow.png Date of Birth Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-202Kyellow.png Healthcare related Identifiers Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-4Kyellow.png Administrative Gender Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-162Kyellow.png Address Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-100Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-135Kyellow.png Patient’s preferred language Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.11IncludeKorange.png IPS Address (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.3.1937.777.11.10.100 (2013‑12‑20)
Adaptation: template 2.16.840.1.113883.10.12.101 (2005‑09‑07)
Example
Example
<recordTarget typeCode="RCT" contextControlCode="OP">
  <patientRole classCode="PAT">
    <id root="1.2.3.999" extension="__example only__"/>    <addr>
      <streetAddressLine>HSE M CASSAR STR</streetAddressLine>      <city>ISLA</city>      <country>MT</country>    </addr>
    <telecom use="HP" value="tel:+356124567891"/>    <telecom use="WP" value="mailto:elif@foo.too.mt"/>    <patient>
      <name>
        <family>BORG</family>        <given>TANIA</given>      </name>
      <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/>      <birthTime value="19430130"/>      <!-- Optional guardian information ; see example below-->
      <!-- Optional languageCommunication information see example below -->
    </patient>
  </patientRole>
</recordTarget>
ItemDTCardConfDescriptionLabel
hl7:recordTarget
1 … *R(IPS...get)
Treetree.png@typeCode
cs0 … 1FRCT
Treetree.png@context​Control​Code
cs0 … 1FOP
 Example<recordTarget typeCode="RCT" contextControlCode="OP">
  <patientRole classCode="PAT">
    <id root="1.2.3.999" extension="__example only__"/>    <addr>
      <streetAddressLine>HSE M CASSAR STR</streetAddressLine>      <city>ISLA</city>      <country>MT</country>    </addr>
    <telecom use="HP" value="tel:+356124567891"/>    <telecom use="WP" value="mailto:elif@foo.too.mt"/>    <patient>
      <name>
        <family>BORG</family>        <given>TANIA</given>      </name>
      <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/>      <birthTime value="19430130"/>      <!-- Optional guardian information ; see example below-->
      <!-- Optional languageCommunication information see example below -->
    </patient>
  </patientRole>
</recordTarget>
Treetree.pnghl7:patientRole
1 … 1M(IPS...get)
 
Target.png
hl7ips-data​element-2.1Kyellow.png Patient Attributes Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@classCode
cs0 … 1FPAT
Treeblank.pngTreetree.pnghl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)(IPS...get)
 
Target.png
hl7ips-data​element-7Kyellow.png Insurance identifier Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-202Kyellow.png Healthcare related Identifiers Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RThe patient address.(IPS...get)
 
Target.png
hl7ips-data​element-162Kyellow.png Address Kyellow.png CEN/TC 251 prEN 17269
 ConstraintWhen used for cross-border exchange the country address part has to be provided.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...get)
 Schematron assertroleKred.png error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...get)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Treeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. (IPS...get)
 
Target.png
hl7ips-data​element-100Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
 Example<telecom use="HP" value="tel:+356124567891"/>
 Example<telecom use="WP" value="mailto:elif@foo.too.mt"/>
 Example<telecom nullFlavor="NI"/>
Treeblank.pngTreetree.pnghl7:patient
1 … 1M(IPS...get)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
 Example
Japanese example (Person Name)
<patient>
  <name use="IDE">
    <family>木村</family>    <given>通男</given>  </name>
  <name use="SYL">
    <family>きむら</family>    <given>みちお</given>  </name>
  <name use="ABC">
    <family>KIMURA</family>    <given>MICHIO</given>  </name>
  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *MPatient Name(IPS...get)
 
Target.png
hl7ips-data​element-3Kyellow.png Patient's Name Kyellow.png CEN/TC 251 prEN 17269
 ConstraintThe Alphabetic representation of the name SHALL be always provided
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient's Family Name/Surname(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient's Given Name(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE.IPS1 … 1RPatient's Gender(IPS...get)
 
Target.png
hl7ips-data​element-4Kyellow.png Administrative Gender Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FUNK
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
 Example<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
  <translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>
Treeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.(IPS...get)
 
Target.png
hl7ips-data​element-5Kyellow.png Date of Birth Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.pnghl7:guardian
0 … *R

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FGUARD
 Example<guardian classCode="GUARD">
  <code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/>  <addr nullFlavor="NI"/>  <telecom use="MC" value="tel:+33-12345678"/>  <guardianPerson>
    <name>
      <family>Curie</family>      <given>Marie</given>    </name>
  </guardianPerson>
</guardian>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. (IPS...get)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...get)
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...get)
 Schematron assertroleKred.png error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...get)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. (IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian​Person
1 … 1R(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Guardian's Name(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
ENXP1 … *RPatient Guardian's Family Name/Surname(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
ENXP1 … *RPatient Guardian's Given Name(IPS...get)
Treeblank.pngTreeblank.pngTreetree.pnghl7:language​Communication
0 … *R(IPS...get)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Code
CS1 … 1RPatient’s language(IPS...get)
 
Target.png
hl7ips-data​element-135Kyellow.png Patient’s preferred language Kyellow.png CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)
 Example
British English
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertroleKred.png error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO country code; CC is ISO language code) 

IPS CDA relatedDocument

Id2.16.840.1.113883.10.22.2.7Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDArelatedDocumentDisplay NameIPS CDA relatedDocument
Description

An IPS may have three types of parent document:

  • A superseded version that the present instance of the document wholly replaces (typeCode = RPLC). 
  • A source document from which the present document is transformed (typeCode = XFRM). An IPS may be created by transformation from an already existing local Patient Summary or an IPS document. An example of this case is the creation of a derived instance in which translations are appended in order to facilitate the cross-border usage of this document; or the case in which a local patient summary is transformed to originate a new IPS instance.
  • An original version that the present document integrates (typeCode = APND). Some cross-border legal agreements (e.g.  the European Digital Service Infrastructure for eHealth) require the patient summary to be accompanied by  a printable representation of the original national data / document this IPS comes from. The relationship between the IPS and this content may be tracked using this relationship. 
Note 1: even for countries not dealing with real documents in their National Infrastructures (e.g. data collected from local databases), this mechanism could be useful to identify the collection of data used for generating the epSOS CDAs, facilitating the information backtracking. In that case the ID might be that of the epSOS friendly document or of any other kind of intermediate document used for generating the NCP document input.
Note 2: even if none of the allowable relationships defined by the CDA standard (XFRM, RPLC, APND) fits perfectly with the described case; the APND relationship seems to be the one that fits the better. In fact “An addendum is a separate document that references the parent document, and may extend or alter the observations in the prior document. The parent document remains a current component of the patient record, and the addendum and its parent are both read by report recipients.”
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipAdaptation: template 2.16.840.1.113883.10.12.111 (2005‑09‑07)
Example
Example of national document identified by its ID
<relatedDocument typeCode="XFRM">
  <!-- the IPS is obtained as trasformation of the "aa-bb-cc" document -->
  <parentDocument>
    <id root="aa-bb-cc"/>  </parentDocument>
</relatedDocument>
Example
Reference to the local PS and to supporting documentation
<!-- the example starts here -->
<relatedDocument typeCode="XFRM">
  <!-- the IPS is obtained as trasformation of the "aa-bb-cc" Local Patient Summary -->
  <parentDocument>
    <id root="aa-bb-cc"/>  </parentDocument>
</relatedDocument>
<relatedDocument typeCode="APND">
  <!-- the IPS is integrated by the information provided by the "aa1-bb1-cc1" document -->
  <parentDocument>
    <id root="aa1-bb1-cc1"/>  </parentDocument>
</relatedDocument>
<!-- the example ends here -->
ItemDTCardConfDescriptionLabel
hl7:relatedDocument
0 … *R(IPS...ent)
Treetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
Treetree.pnghl7:parentDocument
1 … 1R(IPS...ent)
Treeblank.pngTreetree.png@classCode
cs0 … 1FDOCCLIN
Treeblank.pngTreetree.png@moodCode
cs0 … 1FEVN
Treeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ent)
Treeblank.pngTreetree.pnghl7:code
CD.IPS0 … 1R(IPS...ent)
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.pnghl7:text
ED0 … 1R(IPS...ent)
Treeblank.pngTreetree.pnghl7:setId
II0 … 1R(IPS...ent)
Treeblank.pngTreetree.pnghl7:versionNumber
INT0 … 1R(IPS...ent)

IPS Patient Contacts

Id2.16.840.1.113883.10.22.2.5Effective Date2017‑04‑12
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAContactsDisplay NameIPS Patient Contacts
Description
The IPS may record several kinds of patient contacts, including parents, relatives, caregivers, and others related in some way to the patient.
A patient contact may be an individual or an organization with a relationship to the patient, including health provider (person or organization) to be contacted in case of emergency. 
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 8 concepts
IdNameData Set
hl7ips-data​element-154Kyellow.png Patient’s Address Book Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-174Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-163Kyellow.png Preferred Healthcare providers Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-165Kyellow.png Healthcare Provider (person) Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-166Kyellow.png Healthcare Provider (organisation) Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-169Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-121Kyellow.png Name Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-172Kyellow.png Organisation’s Name Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.22.11IncludeKorange.png IPS Address (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.108 (DYNAMIC)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.2.4 (DYNAMIC)
Example
Contact person
<participant typeCode="IND">
  <templateId root="2.16.840.1.113883.10.22.2.5"/>  <associatedEntity classCode="NOK">
    <addr>
      <streetAddressLine>Promenade des Anglais 111</streetAddressLine>      <city>Lyon</city>      <postalCode>69001</postalCode>      <country>FR</country>    </addr>
    <telecom value="tel:(+33)555-20036" use="WP"/>    <associatedPerson>
      <name>
        <given>Martha</given>        <family>Mum</family>      </name>
    </associatedPerson>
  </associatedEntity>
</participant>
Example
Preferred Health Professional for emergency contact
<participant typeCode="IND">
  <templateId root="2.16.840.1.113883.10.22.2.5"/>  <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>  <time value="20070213"/>  <associatedEntity classCode="ECON">
    <addr>
      <streetAddressLine>Karl Strasse</streetAddressLine>      <city>Freiberg</city>      <postalCode>09599</postalCode>      <country>DE</country>    </addr>
    <telecom value="tel:(+49)761-11110000" use="WP"/>    <associatedPerson>
      <name>
        <given>Arzt</given>        <family>Guter</family>      </name>
    </associatedPerson>
  </associatedEntity>
</participant>
ItemDTCardConfDescriptionLabel
hl7:participant
RPatient contacts or the Preferred Health Professional to contact in case of emergency.(IPS...cts)
where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']
 
Target.png
hl7ips-data​element-154Kyellow.png Patient’s Address Book Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-163Kyellow.png Preferred Healthcare providers Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@typeCode
cs1 … 1FIND
 Example<participant typeCode="IND">
  <templateId root="2.16.840.1.113883.10.22.2.5"/>  <associatedEntity classCode="NOK">
    <addr>
      <streetAddressLine>Promenade des Anglais 111</streetAddressLine>      <city>Lyon</city>      <postalCode>69001</postalCode>      <country>FR</country>    </addr>
    <telecom value="tel:(+33)555-20036" use="WP"/>    <associatedPerson>
      <name>
        <given>Martha</given>        <family>Mum</family>      </name>
    </associatedPerson>
  </associatedEntity>
</participant>
Treetree.pnghl7:templateId
II1 … 1M(IPS...cts)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.2.5
Treetree.pnghl7:functionCode
0 … 1CThe  <functionCode> element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.</functionCode>(IPS...cts)
Treeblank.pngTreetree.png@code
CONF0 … 1FPCP
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.88 (Participation Function)
Treetree.pnghl7:associated​Entity
RThe <associatedEntity> element identifies the type of contact. </associatedEntity>(IPS...cts)
Treeblank.pngTreetree.png@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes (DYNAMIC)
 Example<associatedEntity classCode="ECON">
  <addr>
    <streetAddressLine>Karl Strasse</streetAddressLine>    <city>Freiberg</city>    <postalCode>09599</postalCode>    <country>DE</country>  </addr>
  <telecom value="tel:+49-761-11110000" use="WP"/>  <associatedPerson>
    <name>
      <given>Arzt</given>      <family>Guter</family>    </name>
  </associatedPerson>
</associatedEntity>
Treeblank.pngTreetree.pnghl7:code
CV.IPS0 … 1RThis element indicates the relationship between the patient and this participant.(IPS...cts)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.54 IPS Personal Relationship (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
 Example<code code="AUNT" displayName="θεία" codeSystem="2.16.840.1.113883.5.111"/>
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *RPatient Contact's / Preferred HP's Address(IPS...cts)
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertroleKred.png error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...cts)
 Schematron assertroleKred.png error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...cts)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Treeblank.pngTreetree.pnghl7:telecom
TEL1 … *RPatient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required.</telecom>(IPS...cts)
 
Target.png
hl7ips-data​element-174Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-169Kyellow.png Telecoms Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present
 Example<telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
Choice1 … 2Elements to choose from:
  • hl7:associated​Person
  • hl7:scoping​Organization
Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(IPS...cts)
 
Target.png
hl7ips-data​element-165Kyellow.png Healthcare Provider (person) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RPatient Contact's Name / Preferred HP's Name(IPS...cts)
 
Target.png
hl7ips-data​element-121Kyellow.png Name Kyellow.png CEN/TC 251 prEN 17269
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *RPatient Contact's Family Name/Surname / Preferred HP's Family Name/Surname(IPS...cts)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *RPatient Contact's Given Name / Preferred HP's Given Name(IPS...cts)
Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1COr the associatedPerson, or the scopingOrganization, or both elements shall be provided(IPS...cts)
 
Target.png
hl7ips-data​element-166Kyellow.png Healthcare Provider (organisation) Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … *ROrganization's Name(IPS...cts)
 
Target.png
hl7ips-data​element-172Kyellow.png Organisation’s Name Kyellow.png CEN/TC 251 prEN 17269

CDA Section Level Templates

IPS Advance Directives Section

Id2.16.840.1.113883.10.22.3.12Effective Date2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSAdvanceDirectivesSectionDisplay NameIPS Advance Directives Section
Description
The advance directive section shall contain a narrative description of patient's advance directive.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
Entries for references to consent and advance directive documents when known will be specified by future versions of this template.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.12
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-26Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-8Kyellow.png Advance Directives Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 3 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14ContainmentKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKorange.png IPS Translation Section (STU1)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.35 (DYNAMIC)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.34 (DYNAMIC)
Adaptation: template 2.16.840.1.113883.10.20.22.2.17 (DYNAMIC)
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.12"/>  <id root="1.2.3.999" extension="__example_only__"/>  <code code="42348-3" codeSystem="2.16.840.1.113883.6.1" displayName="Advance directives"/>  <title>Advance directives</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-8Kyellow.png Advance Directives Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.12
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F42348-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MAdvance directives(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-26Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:author
0 … *Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)(IPS...ion)
Treeblank.png where [hl7:assignedAuthor]
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)
Treeblank.png where [hl7:section]

IPS Allergies and Intolerances Section

Id2.16.840.1.113883.10.22.3.2Effective Date2016‑11‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSSectionAllergiesOrIntolerancesDisplay NameIPS Allergies and Intolerances Section
Description
This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. 
At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.

The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.2
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-28Kyellow.png Allergy or Intolerance list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-9Kyellow.png Allergies and Intolerances Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-183Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14ContainmentKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.5ContainmentKorange.png IPS Allergy and Intolerance Concern (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKorange.png IPS Translation Section (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Adaptation: template 2.16.840.1.113883.10.20.1.2 (DYNAMIC)
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.2"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies and adverse reactions"/>  <title>Allergies and Intolerances</title>  <text>
    <!-- Textual description of the Allergies and Intolerances -->
  </text>
  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.5 'IPS Allergy and Intolerance Concern' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
Example
No information available
<cda:section>
  <cda:templateId root="2.16.840.1.113883.10.22.3.2"/>  <cda:id root="1.2.3.999" extension="--example only--"/>  <cda:code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies and adverse reactions"/>  <cda:title>Allergies and Intolerances</cda:title>  <cda:text>
    <!-- Textual description of the Allergies and Intolerances -->
  </cda:text>
  <cda:entry>
    <cda:act classCode="ACT" moodCode="EVN">
      <cda:templateId root="2.16.840.1.113883.10.22.4.5"/>      <cda:id root="1.2.3.999" extension="__example only__"/>      <cda:code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <cda:statusCode code="active"/>      <cda:effectiveTime>
        <cda:low nullFlavor="NA"/>      </cda:effectiveTime>
      <cda:entryRelationship typeCode="SUBJ" inversionInd="false">
        <cda:observation classCode="OBS" moodCode="EVN">
          <cda:templateId root="2.16.840.1.113883.10.22.4.1"/>          <cda:code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4"/>          <cda:statusCode code="completed"/>          <cda:effectiveTime>
            <cda:low nullFlavor="NA"/>          </cda:effectiveTime>
          <cda:value code="no-allergy-info" displayName="No information about allergies" codeSystem="2.16.840.1.113883.5.1150.1"/>        </cda:observation>
      </cda:entryRelationship>
    </cda:act>
  </cda:entry>
</cda:section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1R(IPS...ces)
 
Target.png
hl7ips-data​element-9Kyellow.png Allergies and Intolerances Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ces)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.2
Treetree.pnghl7:id
II0 … *R(IPS...ces)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ces)
Treeblank.pngTreetree.png@code
CONF1 … 1F48765-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1M(IPS...ces)
Treetree.pnghl7:text
SD.TEXT1 … 1MSection text(IPS...ces)
 
Target.png
hl7ips-data​element-183Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Treetree.pnghl7:author
0 … *Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)(IPS...ces)
Treeblank.png where [hl7:assignedAuthor]
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ces)
Treetree.pnghl7:entry
1 … *MContains 2.16.840.1.113883.10.22.4.5 IPS Allergy and Intolerance Concern (DYNAMIC)(IPS...ces)
Treeblank.png where [hl7:act [hl7:code [(@code = 'CONC' and @codeSystem = '2.16.840.1.113883.5.6')]]]
 
Target.png
hl7ips-data​element-28Kyellow.png Allergy or Intolerance list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ces)
Treeblank.png where [hl7:section]

IPS Functional Status Section

Id2.16.840.1.113883.10.22.3.8Effective Date2017‑04‑13
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSFunctionalStatusSectionDisplay NameIPS Functional Status Section
Description
The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.
Coded clinical statements will be specified by future versions of this template.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.8
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-137Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-10Kyellow.png Functional Status Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-197Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 3 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14ContainmentKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKorange.png IPS Translation Section (STU1)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.17 (DYNAMIC)
Adaptation: template 2.16.840.1.113883.10.20.1.5 (DYNAMIC)
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.8"/>  <id root="1.2.3.999" extension="__example_only__"/>  <code code="47420-5" codeSystem="2.16.840.1.113883.6.1" displayName="Functional status assessment note"/>  <title>Functional Status Assessment</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-10Kyellow.png Functional Status Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.8
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F47420-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MFunctional Status Assessment(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-137Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-197Kyellow.png Description Kyellow.png CEN/TC 251 prEN 17269