1.2.40.0.34.777.14.10.1

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1 Template HL7-IPS

1.1 Aktuelle Version

Id1.2.40.0.34.777.14.10.1Gültigkeit ab2024‑11‑20 09:27:34
Status  EntwurfVersions-Label2024
NameHL7-IPSBezeichnungInternational 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  

KontextPfadname /
KlassifikationCDA Document Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt
Benutzt 21 Templates
Benutzt als NameVersion
2.16.840.1.113883.10.22.2.1Inklusion  IPS CDA recordTarget (2021)DYNAMIC
2.16.840.1.113883.10.22.2.2Inklusion  IPS CDA author (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.3Inklusion  IPS CDA custodian (2021)DYNAMIC
2.16.840.1.113883.10.22.2.4Inklusion  IPS CDA legalAuthenticator (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.5Inklusion  IPS Patient Contacts (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.6Inklusion  IPS CDA documentationOf (STU1)DYNAMIC
2.16.840.1.113883.10.22.2.7Inklusion  IPS CDA relatedDocument (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.1Containment  IPS Medication Summary Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.2Containment  IPS Allergies and Intolerances Section (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.3Containment  IPS Problems Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.4Containment  IPS History of Procedures Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.5Containment  IPS Immunizations Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.6Containment  IPS Medical Devices Section (2021)DYNAMIC
2.16.840.1.113883.10.22.3.14Containment  IPS Results Section (STU1)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2Containment  IHE Coded Vital Signs Section (2014)DYNAMIC
2.16.840.1.113883.10.22.3.7Containment  IPS History of Past Illness Section (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.8Containment  IPS Functional Status Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.9Containment  IPS Plan of Care Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.10Containment  IPS Social History Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.11Containment  IPS History of Pregnancy Section (TI-2020)DYNAMIC
2.16.840.1.113883.10.22.3.12Containment  IPS Advance Directives Section (TI-2020)DYNAMIC
BeziehungSpezialisierung: 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>
ItemDTKardKonfBeschreibungLabel
hl7:ClinicalDocument
R  CDA header
 hl7:realmCode
CS0 … 1R
 hl7:typeId
II1 … 1M  The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier.

  @root
uid1 … 1F2.16.840.1.113883.1.3
  @extension
st1 … 1FPOCD_HD000040
 Beispiel<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
 hl7:templateId
II1 … 1M
  @root
uid1 … 1F2.16.840.1.113883.10.22.1.1
 hl7:id
II1 … 1M  Unique identifier of this instance of the Patient Summary.
 hl7:code
CE.IPS1 … 1M  Determines the document type that is the "Patient Summary" document
  @displayName
1 … 1R
  @code
CONF1 … 1F60591-5
  @codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
 Beispiel<code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/>
  hl7:translation
CD.IPS0 … *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
ST1 … 1M  ClinicalDocument/title is used for display purposes.
 hl7:effectiveTime
TS.IPS.TZ1 … 1M  Time of creation of the Patient Summary
 Beispiel<effectiveTime value="20111113125600+0200"/>
 hl7:confidentialityCode
CE.IPS1 … 1R
 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
CS1 … 1M  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 assertrole error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MeldungThe 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
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:versionNumber
0 … 1R
Eingefügt1 … 1M von 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget (DYNAMIC)
 hl7:recordTarget
1 … 1M
  @typeCode
cs0 … 1FRCT
  @context​Control​Code
cs0 … 1FOP
 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 … 1M
 
 
hl7ips-data​element-2.1  Patient Attributes   CEN/TC 251 prEN 17269
   @classCode
cs0 … 1FPAT
   hl7:id
II1 … *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.IPS1 … *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_cs0 … 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
cs0 … 1FNI
 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 assertrole error 
 test@nullFlavor or hl7:* 
 MeldungIf addr is not nullflavored at least one sub element has to be provided 
    hl7:streetAddressLine
ADXP0 … *C  Subject's or Organization's Street Address Line
 Schematron assertrole error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MeldungIf the address line is included either the city or the zip code has to be provided 
    hl7:city
ADXP0 … 1C  Subject's or Organization's City
    hl7:postalCode
ADXP0 … 1C  Subject's or Organization's Postal Code
    hl7:state
ADXP0 … 1C  Subject's or Organization's State or Province
    hl7:country
ADXP0 … 1C  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
TEL1 … *R  Patient’s telecom information : e.g. telephone number, e-mail address. 
 
 
hl7ips-data​element-100  Telecoms   CEN/TC 251 prEN 17269
    @use
set_cs0 … 1 
 CONF
Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
    @nullFlavor
cs0 … 1FNI
 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 … 1M
    @classCode
cs0 … 1FPSN
    @determiner​Code
cs0 … 1FINSTANCE
 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
PN1 … *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.IPS1 … 1R  Patient's Gender
 
 
hl7ips-data​element-4  Administrative gender   CEN/TC 251 prEN 17269
     @nullFlavor
cs0 … 1FUNK
 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
TS1 … 1R  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
cs1 … 1FGUARD
 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.IPS0 … 1R  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.IPS1 … *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_cs0 … 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
cs0 … 1FNI
 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 assertrole error 
 test@nullFlavor or hl7:* 
 MeldungIf addr is not nullflavored at least one sub element has to be provided 
      hl7:streetAddressLine
ADXP0 … *C  Subject's or Organization's Street Address Line
 Schematron assertrole error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MeldungIf the address line is included either the city or the zip code has to be provided 
      hl7:city
ADXP0 … 1C  Subject's or Organization's City
      hl7:postalCode
ADXP0 … 1C  Subject's or Organization's Postal Code
      hl7:state
ADXP0 … 1C  Subject's or Organization's State or Province
      hl7:country
ADXP0 … 1C  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
TEL1 … *R  Guardian’s telecom information: e.g. telephone number; e-mail address. 
      @use
set_cs0 … 1 
 CONF
Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
      @nullFlavor
cs0 … 1FNI
 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 … 1R
      hl7:name
PN1 … *R  Patient Guardian's Name
       hl7:family
ENXP1 … *R  Patient Guardian's Family Name/Surname
       hl7:given
ENXP1 … *R  Patient Guardian's Given Name
    hl7:language​Communication
0 … *R
     hl7:language​Code
CS1 … 1R  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 assertrole error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MeldungThe 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) 
Eingefügt1 … *M von 2.16.840.1.113883.10.22.2.2 IPS CDA author (DYNAMIC)
 hl7:author
1 … *M
  @typeCode
cs0 … 1FAUT
  @context​Control​Code
cs0 … 1FOP
 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.IPS0 … 1R
  hl7:time
TS.IPS.TZ1 … 1R  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 … 1R
   @classCode
cs0 … 1FASSIGNED
   hl7:id
II1 … *R  Author Identifier(s)
    @nullFlavor
cs0 … 1 
   hl7:code
CE.IPS (extensible)0 … 1R  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.IPS1 … *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.IPS1 … *R
    @use
set_cs0 … 1 
 CONF
Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
    @value
url0 … 1 
 Beispiel<telecom use="WP" value="tel:+39-051-34343434"/>
 Beispiel<telecom nullFlavor="NI"/>
Auswahl1 … 1Elemente in der Auswahl:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
    hl7:assigned​Person
0 … 1C
     @classCode
cs0 … 1FPSN
     @determiner​Code
cs0 … 1FINSTANCE
     hl7:name
PN1 … *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 … 1C
 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
cs0 … 1FDEV
     @determiner​Code
cs0 … 1FINSTANCE
     hl7:code
CE0 … 1
     hl7:manufacturer​Model​Name
SC0 … 1
     hl7:softwareName
SC0 … 1
   hl7:represented​Organization
0 … 1R
Eingefügt von 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
    @classCode
cs1 … 1FORG
    @determiner​Code
cs1 … 1FINSTANCE
    hl7:id
II1 … *R
     @nullFlavor
cs0 … 1 
    hl7:name
ON1 … 1R
     @nullFlavor
cs0 … 1 
    hl7:telecom
TEL1 … *R
     @use
set_cs1 … 1R
 CONF
Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
     @nullFlavor
cs0 … 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.IPS1 … 1R
Eingefügt von 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
     @use
set_cs0 … 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
cs0 … 1FNI
 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 assertrole error 
 test@nullFlavor or hl7:* 
 MeldungIf addr is not nullflavored at least one sub element has to be provided 
     hl7:streetAddressLine
ADXP0 … *C  Subject's or Organization's Street Address Line
 Schematron assertrole error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MeldungIf the address line is included either the city or the zip code has to be provided 
     hl7:city
ADXP0 … 1C  Subject's or Organization's City
     hl7:postalCode
ADXP0 … 1C  Subject's or Organization's Postal Code
     hl7:state
ADXP0 … 1C  Subject's or Organization's State or Province
     hl7:country
ADXP0 … 1C  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.
Eingefügt1 … 1M von 2.16.840.1.113883.10.22.2.3 IPS CDA custodian (DYNAMIC)
 hl7:custodian
1 … 1M
  @typeCode
cs0 … 1FCST
 Beispiel<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>  </assignedCustodian></custodian>
  hl7:assignedCustodian
1 … 1R
   @classCode
cs0 … 1FASSIGNED
   hl7:represented​Custodian​Organization
1 … 1R
    @classCode
cs0 … 1FORG
    @determiner​Code
cs0 … 1FINSTANCE
    hl7:id
II1 … *R
     @nullFlavor
cs0 … 1 
    hl7:name
ON1 … 1R
     @nullFlavor
cs0 … 1 
    hl7:telecom
TEL1 … 1R
     @use
set_cs1 … 1R
 CONF
Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
     @nullFlavor
cs0 … 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.IPS1 … 1R
Eingefügt von 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
     @use
set_cs0 … 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
cs0 … 1FNI
 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 assertrole error 
 test@nullFlavor or hl7:* 
 MeldungIf addr is not nullflavored at least one sub element has to be provided 
     hl7:streetAddressLine
ADXP0 … *C  Subject's or Organization's Street Address Line
 Schematron assertrole error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MeldungIf the address line is included either the city or the zip code has to be provided 
     hl7:city
ADXP0 … 1C  Subject's or Organization's City
     hl7:postalCode
ADXP0 … 1C  Subject's or Organization's Postal Code
     hl7:state
ADXP0 … 1C  Subject's or Organization's State or Province
     hl7:country
ADXP0 … 1C  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.
Eingefügt0 … 1R von 2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator (DYNAMIC)
 hl7:legalAuthenticator
0 … 1R
 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.TZ1 … 1M  Time of signing the document
  hl7:signatureCode
CS0 … 1R  Signature code
   @code
CONF0 … 1FS
  hl7:assignedEntity
0 … 1R  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.IPS1 … *R
   hl7:telecom
TEL.IPS1 … *R
   hl7:assigned​Person
1 … 1R
    @classCode
cs0 … 1FPSN
    @determiner​Code
cs0 … 1FINSTANCE
    hl7:name
PN1 … *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 … 1M  Organization the legal authenticator is acting for
Beinhaltet 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
Eingefügt0 … * 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
cs1 … 1FIND
 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
II1 … 1M
   @root
uid1 … 1F2.16.840.1.113883.10.22.2.5
  hl7:functionCode
0 … 1C  The  <functionCode> element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency.</functionCode>
   @code
CONF0 … 1FPCP
   @codeSystem
0 … 1F2.16.840.1.113883.5.88 (Participation Function)
  hl7:associated​Entity
R  The <associatedEntity> element identifies the type of contact. </associatedEntity>
   @classCode
cs1 … 1R
 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.IPS0 … 1R  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.IPS1 … *R  Patient Contact's / Preferred HP's Address
 Schematron assertrole error 
 test@nullFlavor or hl7:* 
 MeldungIf 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_cs0 … 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
cs0 … 1FNI
 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 assertrole error 
 test@nullFlavor or hl7:* 
 MeldungIf addr is not nullflavored at least one sub element has to be provided 
    hl7:streetAddressLine
ADXP0 … *C  Subject's or Organization's Street Address Line
 Schematron assertrole error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MeldungIf the address line is included either the city or the zip code has to be provided 
    hl7:city
ADXP0 … 1C  Subject's or Organization's City
    hl7:postalCode
ADXP0 … 1C  Subject's or Organization's Postal Code
    hl7:state
ADXP0 … 1C  Subject's or Organization's State or Province
    hl7:country
ADXP0 … 1C  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
TEL1 … *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_cs0 … 1 
 CONF
Der Wert von @use MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
    @nullFlavor
cs0 … 1FNI
 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"/>
Auswahl1 … 2Elemente in der Auswahl:
  • hl7:associated​Person
  • hl7:scoping​Organization
    hl7:associated​Person
0 … 1C  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
PN1 … *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 … 1C  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
ON1 … *R  Organization's Name
 
 
hl7ips-data​element-172  Organisation’s Name   CEN/TC 251 prEN 17269
Eingefügt1 … 1M von 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (DYNAMIC)
 hl7:documentationOf
1 … 1M  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
cs0 … 1FDOC
 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 … 1R  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
cs1 … 1FPCPR
   @moodCode
cs1 … 1FEVN
   hl7:id
II0 … *R
   hl7:effectiveTime
IVL_TS1 … 1R
    hl7:low
TS1 … 1R
    hl7:high
TS1 … 1R
   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
cs1 … 1R
 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.IPS0 … 1R
    hl7:time
IVL_TS.IPS.TZ0 … 1R
    hl7:assignedEntity
1 … 1M
     hl7:id
II1 … *R  Healthcare provider ID number
     hl7:code
CE.IPS (extensible)0 … 1R  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.IPS1 … *R
     hl7:telecom
TEL.IPS1 … *R
     hl7:assigned​Person
0 … 1
Eingefügt von 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)
      @classCode
cs0 … 1FPSN
      @determiner​Code
cs0 … 1FINSTANCE
      hl7:name
PN1 … *R
     hl7:represented​Organization
0 … 1Beinhaltet 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
Eingefügt0 … 2R 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 … 2R
  @typeCode
cs1 … 1R
 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 … 1R
   @classCode
cs0 … 1FDOCCLIN
   @moodCode
cs0 … 1FEVN
   hl7:id
II1 … *R
   hl7:code
CD.IPS0 … 1R
    @codeSystem
CONF0 … 1F2.16.840.1.113883.6.1 (LOINC)
   hl7:text
ED0 … 1R
   hl7:setId
II0 … 1R
   hl7:versionNumber
INT0 … 1R
 hl7:component
1 … 1M
  hl7:structuredBody
1 … 1M  Note: the proposed order of the sections hereafter indicated is not mandatory
   @classCode
cs0 … 1FDOCBODY
   hl7:component
1 … 1MBeinhaltet 2.16.840.1.113883.10.22.3.1 IPS Medication Summary Section (DYNAMIC)
   hl7:component
1 … 1MBeinhaltet 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC)
   hl7:component
1 … 1MBeinhaltet 2.16.840.1.113883.10.22.3.3 IPS Problems Section (DYNAMIC)
   hl7:component
0 … 1RBeinhaltet 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC)
   hl7:component
0 … 1RBeinhaltet 2.16.840.1.113883.10.22.3.5 IPS Immunizations Section (DYNAMIC)
   hl7:component
0 … 1RBeinhaltet 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC)
   hl7:component
0 … 1RBeinhaltet 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC)
   hl7:component
0 … 1RBeinhaltet 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 IHE Coded Vital Signs Section (DYNAMIC)
   hl7:component
0 … 1Beinhaltet 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section (DYNAMIC)
   hl7:component
0 … 1Beinhaltet 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC)
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0 … 1Beinhaltet 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC)
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0 … 1Beinhaltet 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC)
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0 … 1Beinhaltet 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC)
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0 … 1Beinhaltet 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC)
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0 … 1Beinhaltet
 Fehler: Kann das Template "2.16.840.1.113883.10.22.15" (DYNAMIC) nicht finden
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0 … 1Beinhaltet
 Fehler: Kann das Template "2.16.840.1.113883.10.22.16" (DYNAMIC) nicht finden


1.2 Zusammenstellung aller Versionen dieses Templates

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