1.2.40.0.34.777.14.10.1/static-2024-11-20T092734

Id	1.2.40.0.34.777.14.10.1	Gültigkeit ab	2024‑11‑20 09:27:34
Status	Entwurf	Versions-Label	2024
Name	HL7-IPS	Bezeichnung	International Patient Summary
Beschreibung 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
Kontext	Pfadname /
Klassifikation	CDA Document Level Template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt	Benutzt 21 Templates Benutzt als Name Version 2.16.840.1.113883.10.22.2.1 Inklusion IPS CDA recordTarget (2021) DYNAMIC 2.16.840.1.113883.10.22.2.2 Inklusion IPS CDA author (STU1) DYNAMIC 2.16.840.1.113883.10.22.2.3 Inklusion IPS CDA custodian (2021) DYNAMIC 2.16.840.1.113883.10.22.2.4 Inklusion IPS CDA legalAuthenticator (STU1) DYNAMIC 2.16.840.1.113883.10.22.2.5 Inklusion IPS Patient Contacts (STU1) DYNAMIC 2.16.840.1.113883.10.22.2.6 Inklusion IPS CDA documentationOf (STU1) DYNAMIC 2.16.840.1.113883.10.22.2.7 Inklusion IPS CDA relatedDocument (STU1) DYNAMIC 2.16.840.1.113883.10.22.3.1 Containment IPS Medication Summary Section (STU1) DYNAMIC 2.16.840.1.113883.10.22.3.2 Containment IPS Allergies and Intolerances Section (STU2) DYNAMIC 2.16.840.1.113883.10.22.3.3 Containment IPS Problems Section (STU1) DYNAMIC 2.16.840.1.113883.10.22.3.4 Containment IPS History of Procedures Section (STU1) DYNAMIC 2.16.840.1.113883.10.22.3.5 Containment IPS Immunizations Section (STU1) DYNAMIC 2.16.840.1.113883.10.22.3.6 Containment IPS Medical Devices Section (2021) DYNAMIC 2.16.840.1.113883.10.22.3.14 Containment IPS Results Section (STU1) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Containment IHE Coded Vital Signs Section (2014) DYNAMIC 2.16.840.1.113883.10.22.3.7 Containment IPS History of Past Illness Section (STU1) DYNAMIC 2.16.840.1.113883.10.22.3.8 Containment IPS Functional Status Section (TI-2020) DYNAMIC 2.16.840.1.113883.10.22.3.9 Containment IPS Plan of Care Section (TI-2020) DYNAMIC 2.16.840.1.113883.10.22.3.10 Containment IPS Social History Section (TI-2020) DYNAMIC 2.16.840.1.113883.10.22.3.11 Containment IPS History of Pregnancy Section (TI-2020) DYNAMIC 2.16.840.1.113883.10.22.3.12 Containment IPS Advance Directives Section (TI-2020) DYNAMIC
Beziehung	Spezialisierung: Template 2.16.840.1.113883.10.22.1.2 International Patient Summary (2024‑08‑02 13:02:39) ref hl7ips- Spezialisierung: Template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2020‑07‑14 16:08:21) ref hl7ips- Version: Template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2020‑05‑08 12:30:59) ref hl7ips- Version: Template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2017‑04‑11) ref hl7ips- Adaptation: Template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 epSOS-Patient Summary (2013‑12‑20) ref epsos- Adaptation: Template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07) ref ad1bbr-
Beispiel	Beispiel <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>        <component>           <!-- template 2.16.840.1.113883.10.22.15 'IPS Alerts Section' (dynamic) -->         </component>        <component>           <!-- template 2.16.840.1.113883.10.22.16 'IPS Patient Story Section' (dynamic) -->         </component>      </structuredBody>    </component>  </code></ClinicalDocument>
Item DT Kard Konf Beschreibung Label hl7:ClinicalDocument R CDA header hl7:realmCode CS 0 … 1 R hl7:typeId II 1 … 1 M The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier. @root uid 1 … 1 F 2.16.840.1.113883.1.3 @extension st 1 … 1 F POCD_HD000040   Beispiel <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> hl7:templateId II 1 … 1 M @root uid 1 … 1 F 2.16.840.1.113883.10.22.1.1 hl7:id II 1 … 1 M Unique identifier of this instance of the Patient Summary. hl7:code CE.IPS 1 … 1 M Determines the document type that is the "Patient Summary" document @displayName 1 … 1 R @code CONF 1 … 1 F 60591-5 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)   Beispiel <code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/> hl7:translation CD.IPS 0 … * R This element can be here used either to provide the originally used document code if this IPS is the result of a transformation. hl7:title ST 1 … 1 M ClinicalDocument/title is used for display purposes. hl7:effectiveTime TS.IPS.TZ 1 … 1 M Time of creation of the Patient Summary   Beispiel <effectiveTime value="20111113125600+0200"/> hl7:confidentialityCode CE.IPS 1 … 1 R   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)   Beispiel <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/> hl7:language​Code CS 1 … 1 M Document Language Code   Constraint The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)   Beispiel <languageCode code="en-GB"/>   Beispiel <languageCode code="fil-PH"/>   Schematron assert role  error     test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')     Meldung The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code)   hl7:setId II 0 … 1 R 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:versionNumber 0 … 1 R Eingefügt 1 … 1 M von 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget (DYNAMIC) hl7:recordTarget 1 … 1 M @typeCode cs 0 … 1 F RCT @context​Control​Code cs 0 … 1 F OP   Beispiel <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> hl7:patientRole 1 … 1 M   hl7ips-data​element-2.1  Patient Attributes  CEN/TC 251 prEN 17269 @classCode cs 0 … 1 F PAT hl7:id II 1 … * R Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)   hl7ips-data​element-202  Healthcare related Identifiers  CEN/TC 251 prEN 17269 hl7ips-data​element-7  Insurance identifier  CEN/TC 251 prEN 17269 hl7:addr AD.IPS 1 … * R The patient address.   hl7ips-data​element-162  Address  CEN/TC 251 prEN 17269   Constraint When used for cross-border exchange the country address part has to be provided. Eingefügt von 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01) @nullFlavor cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Meldung If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Meldung If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province hl7:country ADXP 0 … 1 C Subject's Country.   Constraint The 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. hl7:telecom TEL 1 … * R Patient’s telecom information : e.g. telephone number, e-mail address.    hl7ips-data​element-100  Telecoms  CEN/TC 251 prEN 17269 @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) @nullFlavor cs 0 … 1 F NI   Constraint If 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.   Beispiel <telecom use="HP" value="tel:+356124567891"/>   Beispiel <telecom use="WP" value="mailto:elif@foo.too.mt"/>   Beispiel <telecom nullFlavor="NI"/> hl7:patient 1 … 1 M @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE   Beispiel 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> hl7:name PN 1 … * M Patient Name   hl7ips-data​element-3  Patient's name  CEN/TC 251 prEN 17269   Constraint The Alphabetic representation of the name SHALL be always provided hl7:family 1 … * R Patient's Family Name/Surname hl7:given 1 … * R Patient's Given Name hl7:administrative​Gender​Code CE.IPS 1 … 1 R Patient's Gender   hl7ips-data​element-4  Administrative gender  CEN/TC 251 prEN 17269 @nullFlavor cs 0 … 1 F UNK   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)   Beispiel <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> hl7:birthTime TS 1 … 1 R Patient's Date of Birth. The patient date of birth may be a partial date such as only the year.   hl7ips-data​element-5  Date of birth  CEN/TC 251 prEN 17269 hl7: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. @classCode cs 1 … 1 F GUARD   Beispiel <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> hl7:code CD.IPS 0 … 1 R The relationship between the patient and the guardian or other contact may be recorded in the element.    CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC) hl7:addr AD.IPS 1 … * R   Constraint 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. Eingefügt von 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01) @nullFlavor cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Meldung If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Meldung If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province hl7:country ADXP 0 … 1 C Subject's Country.   Constraint The 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. hl7:telecom TEL 1 … * R Guardian’s telecom information: e.g. telephone number; e-mail address.  @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) @nullFlavor cs 0 … 1 F NI   Constraint If 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:guardian​Person 1 … 1 R hl7:name PN 1 … * R Patient Guardian's Name hl7:family ENXP 1 … * R Patient Guardian's Family Name/Surname hl7:given ENXP 1 … * R Patient Guardian's Given Name hl7:language​Communication 0 … * R hl7:language​Code CS 1 … 1 R Patient’s language   hl7ips-data​element-135  Patient’s preferred language  CEN/TC 251 prEN 17269   Constraint The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)   Beispiel British English <languageCode code="en-GB"/>   Beispiel Amurdak (Australia) <languageCode code="amg-AU"/>   Schematron assert role  error     test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')     Meldung The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code)   Eingefügt 1 … * M von 2.16.840.1.113883.10.22.2.2 IPS CDA author (DYNAMIC) hl7:author 1 … * M @typeCode cs 0 … 1 F AUT @context​Control​Code cs 0 … 1 F OP   Beispiel <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> hl7:functionCode CE.IPS 0 … 1 R hl7:time TS.IPS.TZ 1 … 1 R The author/time element represents the start time of the author’s participation in the creation of the clinical document.    Beispiel <time value="201212290600+0100"/> hl7:assignedAuthor 1 … 1 R @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * R Author Identifier(s) @nullFlavor cs 0 … 1   hl7:code CE.IPS (extensible) 0 … 1 R A code, which identifies the profession/competence/specialty of the author when it is a person.   CONF Der Wert von @code SOLLTE gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)   Beispiel <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/> hl7:addr AD.IPS 1 … * R   Beispiel <addr use="WP">   <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr> hl7:telecom TEL.IPS 1 … * R @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) @value url 0 … 1     Beispiel <telecom use="WP" value="tel:+39-051-34343434"/>   Beispiel <telecom nullFlavor="NI"/> Auswahl 1 … 1 Elemente in der Auswahl: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 1 … * R Name of the person (e.g. the Healthcare Professional)  authoring this document   Beispiel <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * R hl7:given 1 … * R hl7:assigned​Authoring​Device 0 … 1 C   Beispiel <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">   <softwareName displayName="Turriano"/></assignedAuthoringDevice> Eingefügt von 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:code CE 0 … 1 hl7:manufacturer​Model​Name SC 0 … 1 hl7:softwareName SC 0 … 1 hl7:represented​Organization 0 … 1 R Eingefügt von 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) @classCode cs 1 … 1 F ORG @determiner​Code cs 1 … 1 F INSTANCE hl7:id II 1 … * R @nullFlavor cs 0 … 1   hl7:name ON 1 … 1 R @nullFlavor cs 0 … 1   hl7:telecom TEL 1 … * R @use set_cs 1 … 1 R   CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) @nullFlavor cs 0 … 1     Constraint If 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.IPS 1 … 1 R Eingefügt von 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01) @nullFlavor cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Meldung If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Meldung If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province hl7:country ADXP 0 … 1 C Subject's Country.   Constraint The 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. Eingefügt 1 … 1 M von 2.16.840.1.113883.10.22.2.3 IPS CDA custodian (DYNAMIC) hl7:custodian 1 … 1 M @typeCode cs 0 … 1 F CST   Beispiel <custodian typeCode="CST">   <assignedCustodian classCode="ASSIGNED">     <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">       <!-- template 'IPS CDA Organization' (dynamic) -->     </representedCustodianOrganization>  </assignedCustodian></custodian> hl7:assignedCustodian 1 … 1 R @classCode cs 0 … 1 F ASSIGNED hl7:represented​Custodian​Organization 1 … 1 R @classCode cs 0 … 1 F ORG @determiner​Code cs 0 … 1 F INSTANCE hl7:id II 1 … * R @nullFlavor cs 0 … 1   hl7:name ON 1 … 1 R @nullFlavor cs 0 … 1   hl7:telecom TEL 1 … 1 R @use set_cs 1 … 1 R   CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) @nullFlavor cs 0 … 1     Constraint If 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.IPS 1 … 1 R Eingefügt von 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01) @nullFlavor cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Meldung If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Meldung If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province hl7:country ADXP 0 … 1 C Subject's Country.   Constraint The 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. Eingefügt 0 … 1 R von 2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator (DYNAMIC) hl7:legalAuthenticator 0 … 1 R   Beispiel <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> hl7:time TS.IPS.TZ 1 … 1 M Time of signing the document hl7:signatureCode CS 0 … 1 R Signature code @code CONF 0 … 1 F S hl7:assignedEntity 0 … 1 R The entity that is responsible for the legal authentication of the CDA document hl7:id 1 … * R Unique identification of legal authenticator hl7:addr AD.IPS 1 … * R hl7:telecom TEL.IPS 1 … * R hl7:assigned​Person 1 … 1 R @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 1 … * R Name of the legal authenticator   Beispiel <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * R HP Family Name/Surname hl7:given 1 … * R HP Given Name hl7:represented​Organization 1 … 1 M Organization the legal authenticator is acting for Beinhaltet 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) Eingefügt 0 … * von 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (DYNAMIC) hl7:participant 0 … * R Patient contacts or the Preferred Health Professional to contact in case of emergency. wo [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']   hl7ips-data​element-154  Patient’s Address Book  CEN/TC 251 prEN 17269 hl7ips-data​element-163  Preferred Healthcare providers  CEN/TC 251 prEN 17269 @typeCode cs 1 … 1 F IND   Beispiel <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> hl7:templateId II 1 … 1 M @root uid 1 … 1 F 2.16.840.1.113883.10.22.2.5 hl7:functionCode 0 … 1 C The  <functionCode> element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.</functionCode> @code CONF 0 … 1 F PCP @codeSystem 0 … 1 F 2.16.840.1.113883.5.88 (Participation Function) hl7:associated​Entity R The <associatedEntity> element identifies the type of contact. </associatedEntity> @classCode cs 1 … 1 R   CONF Der Wert von @classCode MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes (DYNAMIC)   Beispiel <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> hl7:code CV.IPS 0 … 1 R This element indicates the relationship between the patient and this participant.   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.54 IPS Personal Relationship (DYNAMIC) oder Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)   Beispiel <code code="AUNT" displayName="θεία" codeSystem="2.16.840.1.113883.5.111"/> hl7:addr AD.IPS 1 … * R Patient Contact's / Preferred HP's Address   Schematron assert role  error     test @nullFlavor or hl7:*     Meldung If addr is not nullflavored at least one sub element has to be provided   Eingefügt von 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC) @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01) @nullFlavor cs 0 … 1 F NI   Constraint SHALL 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 assert role  error     test @nullFlavor or hl7:*     Meldung If addr is not nullflavored at least one sub element has to be provided   hl7:streetAddressLine ADXP 0 … * C Subject's or Organization's Street Address Line   Schematron assert role  error     test hl7:streetAddressLine and (hl7:city or hl7:postalCode)     Meldung If the address line is included either the city or the zip code has to be provided   hl7:city ADXP 0 … 1 C Subject's or Organization's City hl7:postalCode ADXP 0 … 1 C Subject's or Organization's Postal Code hl7:state ADXP 0 … 1 C Subject's or Organization's State or Province hl7:country ADXP 0 … 1 C Subject's Country.   Constraint The 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. hl7:telecom TEL 1 … * R Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail <telecom> element is required.</telecom>   hl7ips-data​element-169  Telecoms  CEN/TC 251 prEN 17269 hl7ips-data​element-174  Telecoms  CEN/TC 251 prEN 17269 @use set_cs 0 … 1     CONF Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC) @nullFlavor cs 0 … 1 F NI   Constraint If 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   Beispiel <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/> Auswahl 1 … 2 Elemente in der Auswahl: hl7:associated​Person hl7:scoping​Organization hl7:associated​Person 0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided   hl7ips-data​element-165  Healthcare Provider (person)  CEN/TC 251 prEN 17269 hl7:name PN 1 … * R Patient Contact's Name / Preferred HP's Name   hl7ips-data​element-121  Name  CEN/TC 251 prEN 17269   Beispiel <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * R Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname hl7:given 1 … * R Patient Contact's Given Name / Preferred HP's Given Name hl7:scoping​Organization 0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided   hl7ips-data​element-166  Healthcare Provider (organisation)  CEN/TC 251 prEN 17269 hl7:name ON 1 … * R Organization's Name   hl7ips-data​element-172  Organisation’s Name  CEN/TC 251 prEN 17269 Eingefügt 1 … 1 M von 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (DYNAMIC) hl7:documentationOf 1 … 1 M 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. @typeCode cs 0 … 1 F DOC   Beispiel <documentationOf>   <serviceEvent classCode="PCPR">     <effectiveTime>       <low nullFlavor="NI"/>      <high value="20110308"/>    </effectiveTime>    <performer typeCode="PRF">       <!-- See example below -->     </performer>  </serviceEvent></documentationOf> hl7:serviceEvent 1 … 1 R 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. @classCode cs 1 … 1 F PCPR @moodCode cs 1 … 1 F EVN hl7:id II 0 … * R hl7:effectiveTime IVL_TS 1 … 1 R hl7:low TS 1 … 1 R hl7:high TS 1 … 1 R hl7:performer 0 … * R It 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 @typeCode cs 1 … 1 R   CONF Der Wert von @typeCode MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)   Beispiel <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> hl7:functionCode CE.IPS 0 … 1 R hl7:time IVL_TS.IPS.TZ 0 … 1 R hl7:assignedEntity 1 … 1 M hl7:id II 1 … * R Healthcare provider ID number hl7:code CE.IPS (extensible) 0 … 1 R It describes the professional role of the healthcare provider involved in the current or pertinent historical care of the patient.   CONF Der Wert von @code SOLLTE gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC) hl7:addr AD.IPS 1 … * R hl7:telecom TEL.IPS 1 … * R hl7:assigned​Person 0 … 1 Eingefügt von 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC) @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 1 … * R hl7:represented​Organization 0 … 1 Beinhaltet 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) Eingefügt 0 … 2 R von 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)   Constraint A conformant CDA document can have: a single relatedDocument with typeCode "APND"; OR a single relatedDocument with typeCode "RPLC"; OR a single relatedDocument with typeCode "XFRM";  OR a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; OR a combination of two relatedDocuments with typeCodes "XFRM" and "APND".  No other combinations are allowed.  hl7:relatedDocument 0 … 2 R @typeCode cs 1 … 1 R   CONF Der Wert von @typeCode MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC) hl7:parentDocument 1 … 1 R @classCode cs 0 … 1 F DOCCLIN @moodCode cs 0 … 1 F EVN hl7:id II 1 … * R hl7:code CD.IPS 0 … 1 R @codeSystem CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC) hl7:text ED 0 … 1 R hl7:setId II 0 … 1 R hl7:versionNumber INT 0 … 1 R hl7:component 1 … 1 M hl7:structuredBody 1 … 1 M Note: the proposed order of the sections hereafter indicated is not mandatory @classCode cs 0 … 1 F DOCBODY hl7:component 1 … 1 M Beinhaltet 2.16.840.1.113883.10.22.3.1 IPS Medication Summary Section (DYNAMIC) hl7:component 1 … 1 M Beinhaltet 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC) hl7:component 1 … 1 M Beinhaltet 2.16.840.1.113883.10.22.3.3 IPS Problems Section (DYNAMIC) hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC) hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.10.22.3.5 IPS Immunizations Section (DYNAMIC) hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC) hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC) hl7:component 0 … 1 R Beinhaltet 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 IHE Coded Vital Signs Section (DYNAMIC) hl7:component 0 … 1 Beinhaltet 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section (DYNAMIC) hl7:component 0 … 1 Beinhaltet 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC) hl7:component 0 … 1 Beinhaltet 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC) hl7:component 0 … 1 Beinhaltet 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC) hl7:component 0 … 1 Beinhaltet 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC) hl7:component 0 … 1 Beinhaltet 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC) hl7:component 0 … 1 Beinhaltet Fehler: Kann das Template "2.16.840.1.113883.10.22.15" (DYNAMIC) nicht finden hl7:component 0 … 1 Beinhaltet Fehler: Kann das Template "2.16.840.1.113883.10.22.16" (DYNAMIC) nicht finden