XDS-SD OID

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Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Scanned Document Specification oid tbd

This section outlines the content of the HL7 CDA R2 wrapper for the document. We note here that requirements specified below are to ensure the presence of a minimum amount of wrapper data in order to enhance description and facilitate sharing of the document. Implementers of this profile can and should make use of additional annotation within the CDA header to provide richer context. The examples in the following sections contain the minimal amount of wrapper data, as specified, and in many cases do make use of additional CDA header elements for enriched context.

Assumptions and Definitions We assume that the scanning facility and equipment within it are assigned an OID and that the scanning facility assembles the wrapped scanned content. More information regarding the construction of OIDS can be found in the ITI Technical Framework, Volume 2, Appendix B. We define the following nomenclature for entity roles concerned in forming the wrapper content.

  • Original content – Legacy paper or electronic document intended for wrapping.
  • Scanned content – Scanned or appropriately converted/encoded electronic version of the original content.
  • Original author – Author of the original content.
  • (Scanner) Operator – Person assembling the scanned content.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:iti:xds-sd:2008

Parent Template

This document is an instance of the Medical Summary <--! parent is CDA, not medical summary --> template.

Standards
CDAR2 HL7 CDA Release 2.0
Data Element Index
Data Elements HL7 Care Record Summary CDA Release 2.0
Original Author ? author
Scanner ? author
Scanner Operator ? dataEnterer
Specification
Data Element Name Opt Template ID
Original Author C tbd
Scanner C tbd
Scanner Operator C tbd


Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary <--! parent is CDA, not medical summary --> content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Scanned Document Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='oid tbd'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Scanned Document</title>
  <effectiveTime value='20240418012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_oid tbd'>
 <rule context='*[cda:templateId/@root="oid tbd"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Scanned Document can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Scanned Document is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Scanned Document must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "tbd"]'>
     See http://wiki.ihe.net/index.php?title=oid tbd
   </assert> 
   <assert test='.//cda:templateId[@root = "tbd"]'>
     See http://wiki.ihe.net/index.php?title=oid tbd
   </assert> 
   <assert test='.//cda:templateId[@root = "tbd"]'>
     See http://wiki.ihe.net/index.php?title=oid tbd
   </assert> 
 </rule>
</pattern>

ClinicalDocument Header rendering

todo

ClinicalDocument Header constraints

<template id="XDS-SD OID"/>

ClinicalDocument/templateId shall be present and shall have root value of "tbd" to signify that this ClinicalDocument conforms to the XDS-Lab content profile specification.

<recordTarget/>
<custodian/>
<legalAuthenticator/>
<documentationOf/>

ClinicalDocument Header Content Modules

The table above lists the additional requirements (conformance statements) for this laboratory report which are in the form of header content modules.

ClinicalDocument Header Example

ClinicalDocument Body
The scanned document shall have a nonXMLBody.

ClinicalDocument Body Example




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