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draft Template  XeH RD Patient Summary

Id 2.16.840.1.113883.2.51.10.13 Effective Date 2021‑09‑10 14:50:49
Status draft Draft Version Label 0.1
Name XeHRDPatientSummary Display Name XeH RD 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  
Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 25 templates
Uses as Name Version
2.16.840.1.113883.2.51.10.9 Include draft XeH CDA recordTarget DYNAMIC
2.16.840.1.113883.2.51.10.5 Include draft XeH CDA author DYNAMIC
2.16.840.1.113883.2.51.10.6 Include draft XeH CDA custodian DYNAMIC
2.16.840.1.113883.2.51.10.8 Include draft XeH CDA legalAuthenticator DYNAMIC
2.16.840.1.113883.10.22.2.5 Include pending IPS Patient Contacts (STU1) DYNAMIC
2.16.840.1.113883.10.22.2.6 Include pending IPS CDA documentationOf (STU1) DYNAMIC
2.16.840.1.113883.10.22.2.7 Include pending IPS CDA relatedDocument (STU1) DYNAMIC
2.16.840.1.113883.2.51.10.15 Containment draft XeH Patient History Section (0.1) DYNAMIC
2.16.840.1.113883.2.51.10.16 Containment draft XeH Family History Section (0.1) DYNAMIC
2.16.840.1.113883.2.51.10.17 Containment draft XeH Alerts Section (0.1) DYNAMIC
2.16.840.1.113883.2.51.10.41 Containment draft XeH Medication Summary Section DYNAMIC
2.16.840.1.113883.10.22.3.2 Containment pending IPS Allergies and Intolerances Section (STU1) DYNAMIC
2.16.840.1.113883.2.51.10.23 Containment draft XeH Problems Section (0.1) DYNAMIC
2.16.840.1.113883.10.22.3.4 Containment pending IPS History of Procedures Section (STU1) DYNAMIC
2.16.840.1.113883.2.51.10.65 Containment draft XeH Immunizations Section DYNAMIC
2.16.840.1.113883.10.22.3.6 Containment draft IPS Medical Devices Section (2021) DYNAMIC
2.16.840.1.113883.10.22.3.14 Containment pending IPS Results Section (STU1) DYNAMIC
2.16.840.1.113883.10.22.3.16 Containment pending IPS Vital Signs Section (TI-2020) DYNAMIC
2.16.840.1.113883.2.51.10.57 Containment draft XeH History of Past Illness Section DYNAMIC
2.16.840.1.113883.10.22.3.8 Containment pending IPS Functional Status Section (TI-2020) DYNAMIC
2.16.840.1.113883.10.22.3.9 Containment pending IPS Plan of Care Section (TI-2020) DYNAMIC
2.16.840.1.113883.10.22.3.10 Containment pending IPS Social History Section (TI-2020) DYNAMIC
2.16.840.1.113883.10.22.3.11 Containment pending IPS History of Pregnancy Section (TI-2020) DYNAMIC
2.16.840.1.113883.10.22.3.12 Containment pending IPS Advance Directives Section (TI-2020) DYNAMIC
2.16.840.1.113883.2.51.10.39 Containment draft XeH Care Team Section DYNAMIC
Relationship 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-
Example
Example
<cda:ClinicalDocument>
  <cda:realmCode/>  <cda:typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <cda:templateId root="2.16.840.1.113883.10.22.1.1"/>  <cda:id root="1.2.3.999" extension="--example only--"/>  <cda:code displayName="--TODO--" code="60591-5" codeSystem="2.16.840.1.113883.6.1">
    <cda:translation/>  </cda:code>  <cda:title>title</cda:title>  <cda:effectiveTime value="20220218092735+01:00"/>  <cda:confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/>  <cda:languageCode code="en-US"/>  <cda:setId root="1.2.3.999" extension="--example only--"/>  <cda:versionNumber/>  <!-- include template 2.16.840.1.113883.2.51.10.9 'XeH CDA recordTarget' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.2.51.10.5 'XeH CDA author' (dynamic) 1..* M -->
  <!-- include template 2.16.840.1.113883.2.51.10.6 'XeH CDA custodian' (dynamic) 1..1 M -->
  <!-- include template 2.16.840.1.113883.2.51.10.8 'XeH 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..2 R -->
  <cda:component>
    <cda:structuredBody classCode="DOCBODY">
      <cda:component>
        <!-- template 2.16.840.1.113883.2.51.10.15 'XeH Patient History Section' (2021-09-10T15:17:23) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.2.51.10.16 'XeH Family History Section' (2021-09-10T15:22:07) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.2.51.10.17 'XeH Alerts Section' (2021-09-10T15:24:33) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.2.51.10.41 'XeH Medication Summary Section' (2021-10-19T11:12:56) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.2 'IPS Allergies and Intolerances Section' (2016-11-11T00:00:00) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.2.51.10.23 'XeH Problems Section' (2021-09-22T17:29:31) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.4 'IPS History of Procedures Section' (2017-03-27T00:00:00) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.5 'IPS Immunizations Section' (2017-04-05T00:00:00) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.6 'IPS Medical Devices Section' (2021-10-20T17:11:42) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.14 'IPS Results Section' (2017-04-30T00:00:00) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.16 'IPS Vital Signs Section' (2020-05-08T19:22:15) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.2.51.10.57 'XeH History of Past Illness Section' (2022-02-18T09:12:34) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.8 'IPS Functional Status Section' (2020-05-08T19:17:37) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.9 'IPS Plan of Care Section' (2020-05-08T18:28:38) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.10 'IPS Social History Section' (2020-05-10T18:52:32) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.11 'IPS History of Pregnancy Section' (2020-05-07T18:46:08) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.10.22.3.12 'IPS Advance Directives Section' (2020-05-08T16:38:49) -->
      </cda:component>      <cda:component>
        <!-- template 2.16.840.1.113883.2.51.10.39 'XeH Care Team Section' (2021-10-19T09:35:03) -->
      </cda:component>    </cda:structuredBody>  </cda:component></cda:ClinicalDocument>
Item DT Card Conf Description Label
hl7:ClinicalDocument
 		R CDA header (XeHdotsary)
hl7:realmCode
 		CS 0 … 1 R (XeHdotsary)
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.

(XeHdotsary)
@root
 		uid 1 … 1 F 2.16.840.1.113883.1.3
@extension
 		st 1 … 1 F POCD_HD000040
  Example <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
hl7:templateId
 		II 1 … 1 M (XeHdotsary)
@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. (XeHdotsary)
hl7:code
 		CE.IPS 1 … 1 M Determines the document type that is the "Patient Summary" document (XeHdotsary)
@displayName
 		1 … 1 R
@code
 		CONF 1 … 1 F 60591-5
@codeSystem
 		1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/>
hl7:translation
 		CD.IPS 0 … * This element can be here used either to provide the originally used document code if this IPS is the result of a transformation. (XeHdotsary)
hl7:title
 		ST 1 … 1 M ClinicalDocument/title is used for display purposes. (XeHdotsary)
  Example <title>Patient Summary</title>
  Example <title>Profilo Sanitario Sintetico</title>
hl7:effectiveTime
 		TS.IPS.TZ 1 … 1 M Time of creation of the Patient Summary (XeHdotsary)
  Example <effectiveTime value="20111113125600+0200"/>
hl7:confidentialityCode
 		CE.IPS 1 … 1 R

ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.

(XeHdotsary)
  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"/>
hl7:languageCode
 		CS 1 … 1 M Document Language Code (XeHdotsary)
  Constraint The 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 assert role red error  
  test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')  
  Message 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 1 … 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.

 (XeHdotsary)
hl7:versionNumber
 		1 … 1 R (XeHdotsary)
Included 1 … 1 M from 2.16.840.1.113883.2.51.10.9 XeH CDA recordTarget (DYNAMIC)
hl7:recordTarget
 		1 … 1 M (XeHdotsary)
@typeCode
 		cs 0 … 1 F RCT
@contextControlCode
 		cs 0 … 1 F OP
  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>
hl7:patientRole
 		1 … 1 M (XeHdotsary)
@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) (XeHdotsary)
hl7:addr
 		AD.IPS 1 … * R The patient address. (XeHdotsary)
  Constraint When 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)
@use
 		set_cs 0 … 1  
  CONF
The value of @use shall be drawn from 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 red error  
  test @nullFlavor or hl7:*  
  Message 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 (XeHdotsary)
  Schematron assert role red error  
  test hl7:streetAddressLine and (hl7:city or hl7:postalCode)  
  Message 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 (XeHdotsary)
hl7:postalCode
 		ADXP 0 … 1 C Subject's or Organization's Postal Code (XeHdotsary)
hl7:state
 		ADXP 0 … 1 C Subject's or Organization's State or Province (XeHdotsary)
hl7:country
 		ADXP 0 … 1 C Subject's Country. (XeHdotsary)
  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.  (XeHdotsary)
@use
 		set_cs 0 … 1  
  CONF
The value of @use shall be drawn from 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.
  Example <telecom use="HP" value="tel:+356124567891"/>
  Example <telecom use="WP" value="mailto:elif@foo.too.mt"/>
  Example <telecom nullFlavor="NI"/>
hl7:patient
 		1 … 1 M (XeHdotsary)
@classCode
 		cs 0 … 1 F PSN
@determinerCode
 		cs 0 … 1 F INSTANCE
  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>
hl7:name
 		PN 1 … * M Patient Name (XeHdotsary)
  Constraint The Alphabetic representation of the name SHALL be always provided
hl7:family
 		1 … * R Patient's Family Name/Surname (XeHdotsary)
hl7:given
 		1 … * R Patient's Given Name (XeHdotsary)
hl7:administrativeGenderCode
 		CE.IPS 1 … 1 R Patient's Gender (XeHdotsary)
@nullFlavor
 		cs 0 … 1 F UNK
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (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>
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. (XeHdotsary)
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.

(XeHdotsary)
@classCode
 		cs 1 … 1 F GUARD
  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>
hl7:code
 		CD.IPS 0 … 1 R The relationship between the patient and the guardian or other contact may be recorded in the element.  (XeHdotsary)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr
 		AD.IPS 1 … * R (XeHdotsary)
  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.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use
 		set_cs 0 … 1  
  CONF
The value of @use shall be drawn from 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 red error  
  test @nullFlavor or hl7:*  
  Message 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 (XeHdotsary)
  Schematron assert role red error  
  test hl7:streetAddressLine and (hl7:city or hl7:postalCode)  
  Message 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 (XeHdotsary)
hl7:postalCode
 		ADXP 0 … 1 C Subject's or Organization's Postal Code (XeHdotsary)
hl7:state
 		ADXP 0 … 1 C Subject's or Organization's State or Province (XeHdotsary)
hl7:country
 		ADXP 0 … 1 C Subject's Country. (XeHdotsary)
  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.  (XeHdotsary)
@use
 		set_cs 0 … 1  
  CONF
The value of @use shall be drawn from 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:guardianPerson
 		1 … 1 R (XeHdotsary)
hl7:name
 		PN 1 … * R Patient Guardian's Name (XeHdotsary)
hl7:family
 		ENXP 1 … * R Patient Guardian's Family Name/Surname (XeHdotsary)
hl7:given
 		ENXP 1 … * R Patient Guardian's Given Name (XeHdotsary)
hl7:languageCommunication
 		0 … * R (XeHdotsary)
hl7:languageCode
 		CS 1 … 1 R Patient’s language (XeHdotsary)
  Constraint The 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
British English
<languageCode code="en-GB"/>
  Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
  Schematron assert role red error  
  test matches(@code,'[a-z]{2,3}-[A-Z]{2,3}')  
  Message 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)  
Included 1 … * M from 2.16.840.1.113883.2.51.10.5 XeH CDA author (DYNAMIC)
hl7:author
 		1 … * M (XeHdotsary)
@typeCode
 		cs 0 … 1 F AUT
@contextControlCode
 		cs 0 … 1 F OP
  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>
hl7:functionCode
 		CE.IPS 0 … 1 R (XeHdotsary)
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.  (XeHdotsary)
  Example <time value="201212290600+0100"/>
hl7:assignedAuthor
 		1 … 1 R (XeHdotsary)
@classCode
 		cs 0 … 1 F ASSIGNED
hl7:id
 		II 1 … * R Author Identifier(s) (XeHdotsary)
@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. (XeHdotsary)
  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"/>
hl7:addr
 		AD.IPS 1 … * R (XeHdotsary)
  Example <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 (XeHdotsary)
@use
 		set_cs 0 … 1  
  CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@value
 		st 0 … 1  
  Example <telecom use="WP" value="tel:+39-051-34343434"/>
  Example <telecom nullFlavor="NI"/>
Choice 1 … 1 Elements to choose from:
hl7:assignedPerson
 		0 … 1 C (XeHdotsary)
@classCode
 		cs 0 … 1 F PSN
@determinerCode
 		cs 0 … 1 F INSTANCE
hl7:name
 		PN 1 … * R Name of the person (e.g. the Healthcare Professional)  authoring this document (XeHdotsary)
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
 		1 … * R (XeHdotsary)
hl7:given
 		1 … * R (XeHdotsary)
hl7:assignedAuthoringDevice
 		0 … 1 C Contains 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) (XeHdotsary)
  Example <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
hl7:representedOrganization
 		0 … 1 R Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) (XeHdotsary)
Included 1 … 1 M from 2.16.840.1.113883.2.51.10.6 XeH CDA custodian (DYNAMIC)
hl7:custodian
 		1 … 1 M (XeHdotsary)
@typeCode
 		cs 0 … 1 F CST
  Example <custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>  </assignedCustodian></custodian>
hl7:assignedCustodian
 		1 … 1 R (XeHdotsary)
@classCode
 		cs 0 … 1 F ASSIGNED
hl7:representedCustodianOrganization
 		1 … 1 R Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) (XeHdotsary)
@classCode
 		cs 0 … 1 F ORG
@determinerCode
 		cs 0 … 1 F INSTANCE
Included 0 … 1 R from 2.16.840.1.113883.2.51.10.8 XeH CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
 		0 … 1 R (XeHdotsary)
  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>
hl7:time
 		TS.IPS.TZ 1 … 1 M Time of signing the document (XeHdotsary)
hl7:signatureCode
 		CS 1 … 1 R Signature code (XeHdotsary)
@code
 		CONF 0 … 1 F S
hl7:assignedEntity
 		0 … 1 R The entity that is responsible for the legal authentication of the CDA document (XeHdotsary)
hl7:id
 		1 … * R Unique identification of legal authenticator (XeHdotsary)
hl7:addr
 		AD.IPS 1 … * R (XeHdotsary)
hl7:telecom
 		TEL.IPS 1 … * R (XeHdotsary)
hl7:assignedPerson
 		1 … 1 R (XeHdotsary)
@classCode
 		cs 0 … 1 F PSN
@determinerCode
 		cs 0 … 1 F INSTANCE
hl7:name
 		PN 1 … * R Name of the legal authenticator (XeHdotsary)
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
 		1 … * R HP Family Name/Surname (XeHdotsary)
hl7:given
 		1 … * R HP Given Name (XeHdotsary)
hl7:representedOrganization
 		1 … 1 M Organization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) 		(XeHdotsary)
Included 0 … * from 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. (XeHdotsary)
where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5']
@typeCode
 		cs 1 … 1 F IND
  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>
hl7:templateId
 		II 1 … 1 M (XeHdotsary)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.22.2.5
hl7:functionCode
 		0 … 1 C The   element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency. (XeHdotsary)
@code
 		CONF 0 … 1 F PCP
@codeSystem
 		0 … 1 F 2.16.840.1.113883.5.88 (Participation Function)
hl7:associatedEntity
 		R The element identifies the type of contact.  (XeHdotsary)
@classCode
 		cs 1 … 1 R
  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>
hl7:code
 		CV.IPS 0 … 1 R This element indicates the relationship between the patient and this participant. (XeHdotsary)
  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"/>
hl7:addr
 		AD.IPS 1 … * R Patient Contact's / Preferred HP's Address (XeHdotsary)
  Schematron assert role red error  
  test @nullFlavor or hl7:*  
  Message If 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)
@use
 		set_cs 0 … 1  
  CONF
The value of @use shall be drawn from 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 red error  
  test @nullFlavor or hl7:*  
  Message 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 (XeHdotsary)
  Schematron assert role red error  
  test hl7:streetAddressLine and (hl7:city or hl7:postalCode)  
  Message 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 (XeHdotsary)
hl7:postalCode
 		ADXP 0 … 1 C Subject's or Organization's Postal Code (XeHdotsary)
hl7:state
 		ADXP 0 … 1 C Subject's or Organization's State or Province (XeHdotsary)
hl7:country
 		ADXP 0 … 1 C Subject's Country. (XeHdotsary)
  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 element is required. (XeHdotsary)
@use
 		set_cs 0 … 1  
  CONF
The value of @use shall be drawn from 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
  Example <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
Choice 1 … 2 Elements to choose from:
  • hl7:associatedPerson
  • hl7:scopingOrganization
hl7:associatedPerson
 		0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided (XeHdotsary)
hl7:name
 		PN 1 … * R Patient Contact's Name / Preferred HP's Name (XeHdotsary)
  Example <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 (XeHdotsary)
hl7:given
 		1 … * R Patient Contact's Given Name / Preferred HP's Given Name (XeHdotsary)
hl7:scopingOrganization
 		0 … 1 C Or the associatedPerson, or the scopingOrganization, or both elements shall be provided (XeHdotsary)
hl7:name
 		ON 1 … * R Organization's Name (XeHdotsary)
Included 1 … 1 M from 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. (XeHdotsary)
@typeCode
 		cs 0 … 1 F DOC
  Example <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. 		(XeHdotsary)
@classCode
 		cs 1 … 1 F PCPR
@moodCode
 		cs 1 … 1 F EVN
hl7:id
 		II 0 … * R (XeHdotsary)
hl7:effectiveTime
 		IVL_TS 1 … 1 R (XeHdotsary)
hl7:low
 		TS 1 … 1 R (XeHdotsary)
hl7:high
 		TS 1 … 1 R (XeHdotsary)
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 (XeHdotsary)
@typeCode
 		cs 1 … 1 R
  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>
hl7:functionCode
 		CE.IPS 0 … 1 R (XeHdotsary)
hl7:time
 		IVL_TS.IPS.TZ 0 … 1 R (XeHdotsary)
hl7:assignedEntity
 		1 … 1 M (XeHdotsary)
hl7:id
 		II 1 … * R Healthcare provider ID number (XeHdotsary)
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. (XeHdotsary)
  CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
hl7:addr
 		AD.IPS 1 … * R (XeHdotsary)
hl7:telecom
 		TEL.IPS 1 … * R (XeHdotsary)
hl7:assignedPerson
 		0 … 1 Contains 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC) (XeHdotsary)
hl7:representedOrganization
 		0 … 1 Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) (XeHdotsary)
Included 0 … 2 R from 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 (XeHdotsary)
@typeCode
 		cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument
 		1 … 1 R (XeHdotsary)
@classCode
 		cs 0 … 1 F DOCCLIN
@moodCode
 		cs 0 … 1 F EVN
hl7:id
 		II 1 … * R (XeHdotsary)
hl7:code
 		CD.IPS 0 … 1 R (XeHdotsary)
@codeSystem
 		CONF 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:text
 		ED 0 … 1 R (XeHdotsary)
hl7:setId
 		II 0 … 1 R (XeHdotsary)
hl7:versionNumber
 		INT 0 … 1 R (XeHdotsary)
hl7:component
 		1 … 1 M (XeHdotsary)
hl7:structuredBody
 		1 … 1 M Note: the proposed order of the sections hereafter indicated is not mandatory (XeHdotsary)
@classCode
 		cs 0 … 1 F DOCBODY
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.2.51.10.15 XeH Patient History Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.2.51.10.16 XeH Family History Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.2.51.10.17 XeH Alerts Section (DYNAMIC) (XeHdotsary)
hl7:component
 		1 … 1 M Contains 2.16.840.1.113883.2.51.10.41 XeH Medication Summary Section (DYNAMIC) (XeHdotsary)
hl7:component
 		1 … 1 M Contains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC) (XeHdotsary)
hl7:component
 		1 … 1 M Contains 2.16.840.1.113883.2.51.10.23 XeH Problems Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 R Contains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 R Contains 2.16.840.1.113883.2.51.10.65 XeH Immunizations Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 R Contains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 R Contains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 R Contains 2.16.840.1.113883.10.22.3.16 IPS Vital Signs Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.2.51.10.57 XeH History of Past Illness Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC) (XeHdotsary)
hl7:component
 		0 … 1 Contains 2.16.840.1.113883.2.51.10.39 XeH Care Team Section (DYNAMIC) (XeHdotsary)