CDA Header Content Modules

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CDA Header Content Modules

The following content modules define the structure of elements in the header of CDA Release 2.0 document.

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 Language Communication 1.3.6.1.4.1.19376.1.5.3.1.2.1

Languages spoken shall be recorded using the languageCommunication infrastructure class associated with the patient. The <languageCommunication> element describes the primary and secondary languages of communication for a person. When used, these shall be described using the languageCommunication element as follows.


Uses

See Templates using Language Communication

Specification
Language Communication Example
<languageCommunication>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>
  <languageCode code='en-US'/>
  <modeCode code='' codeSystem='2.16.840.1.113883.5.60'
    codeSystemName='LanguageAbilityMode'/>
  <preferenceInd value='true|false'/>
</languageCommunication>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>

The <templateId> element identifies this <languageCommunication> element for validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.1'.

<languageCode code=' '/>

This element describes the language code. It uses the same vocabulary described for the ClinicalDocument/languageCode element described in more detail in HL7 CRS: 2.1.1. This element is required.

<modeCode code=' ' codeSystem='2.16.840.1.113883.5.60' codeSystemName='LanguageAbilityMode'/>

This element describes the mode of use, and is only necessary when there are differences between expressive and receptive abilities. This element is optional. When not present, the assumption is that any further detail provided within the languageCommunication element refers to all common modes of communication. The coding system used shall be the HL7 LanguageAbilityMode vocabulary when this element is communicated.

<proficiencyLevelCode code=' ' codeSystem='2.16.840.1.113883.5.61' codeSystemName='LanguageProficiencyCode' />

This element describes the proficiency of the patient (with respect to the mode if specified). This element is optional. The coding system used shall be the HL7 LanguageProficiencyCode vocabulary when this element is communicated.

<preferenceInd value=' '/>

This element shall be present on all languageCommunication elements when more than one is provided. It shall be valued "true" if this language is the patient’s preferred language for communication, or "false" if this is not the patient’s preferred language. More than one language may be preferred, and at least one must be preferred.

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 Employer and School Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.2

Employer and school informational contacts shall be recorded as participants in the CDA Header as demonstrated in the figure below. These contacts shall conform to the General Constraints found in HL7 CRS: 2.1.1 with respect to the requirements for name, address, telephone numbers and other contact information.

The figure below shows how the information for this element is coded, and further constraints are provided in the following sections.


Uses

See Templates using Employer and School Contacts

Specification
Employer and School Contacts Example
<participant typeCode='IND'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>
  <time>
    <low value=''/>
    <high value=''/>
  </time>
  <associatedEntity classCode='CON'>
    <id root='' extension=''/>
    <code code='EMPLOYER|SCHOOL|AFFILIATED' codeSystem='1.3.5.1.4.1.19376.1.5.3.3' codeSystemName='IHERoleCode'/>
    <associatedPerson><name>…</name></associatedPerson>
    <scopingOrganization>
      <name>…</name>
      <telecom value='' use=''/>
      <addr>…</addr>
    </scopingOrganization>
  </associatedEntity>
</participant>  


<participant typeCode='IND'>

The typeCode of the participant shall be IND.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>

The <templateId> element identifies this <participant> as a school or employer contact for validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.2'.

<time><low value=' '/><high value=' '/></time>

The time element indicates the start and stop time range for this contact. These dates shall correspond to the start and stop dates for employment, enrollment, or other affiliation with the organization described.

<associatedEntity classCode='CON'>

The <associatedEntity> element provides the contact information (classCode='CON') for the school, employer or affiliated organization.

<code code='EMPLOYER|SCHOOL|AFFILIATED' codeSystem='1.3.5.1.4.1.19376.1.5.3.3' codeSystemName='IHERoleCode'/>

The code value shall indicate whether the participant is the employer, school or other affiliated (e.g., volunteer) organization. See also the IHE Role Code Vocabulary(1.3.5.1.4.1.19376.1.5.3.3)

<associatedPerson><name>…</name></associatedPerson>

This element should be present. When present is shall provide the name of a contact person within the organization.

<scopingOrganization><name>…</name><telecom value= use=/><addr>…</addr></scopingOrganization>

This element shall be present, and shall provide the name, address and telephone number of the organization.

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 Healthcare Providers and Pharmacies 1.3.6.1.4.1.19376.1.5.3.1.2.3

Healthcare providers (including pharmacies) shall be recorded as described in CCD: 3.17. The identifier that the patient is known by to these providers may be included using the Patient Identifier extension described in Extensions to HL7 CDA Release 2.0. See the example shown in for use of this extension element.


Uses

See Templates using Healthcare Providers and Pharmacies

Specification
Healthcare Providers and Pharmacies Example
<documentationOf>
  <serviceEvent classCode="PCPR">
    <effectiveTime><low value=""/><high value=""/></effectiveTime>
    <performer typeCode="PRF">
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.3'/>
      <functionCode code='' displayName='' codeSystem='' codeSystemName=''/>
      <time>
        <low value=''/>
        <high value=''/>
      </time>
      <assignedEntity>
        <id root='' extension=''/>
        <code code='' displayName='' codeSystem='' codeSystemName=''/>
        <addr></addr>
        <telecom value='' use=''/>
        <assignedPerson><name></name></assignedPerson>
        <representedOrganization><name></name></representedOrganization>
        <sdtc:patient>
          <sdtc:id root='' extension=''/>
        </sdtc:patient>
      </assignedEntity>
    </performer>
  </serviceEvent>
<documentationOf>


<documentationOf>

The <documentationOf> element records the service events that were performed. This element shall be present.

<serviceEvent classCode="PCPR">

The <serviceEvent> element describes the activity being documented. This element shall be present, and shall have a classCode attribute of 'PCPR'.

<effectiveTime><low value=""/><high value=""/></effectiveTime>

The <effectiveTime> element records the time over which care provision activities are recorded in the document. There shall be a <low> element which records the starting date of care provision, and a <high> element which records the ending date of care provision. The ending date may extend into the future in the document describes care that is intended to be provided, but that has not actually occurred.

<performer typeCode="PRF">

The <performer> elements in the <serviceEvent> identify the providers of care. At least one <performer> element should be present. When a provider gives care over two distinct time intervals (e.g., as in the case of a specialist who treats the patient for short periods of time in different years), the provider may be recorded multiple times as a performer.

<functionCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The function of the provider in the care of the patient should be present, and will be described in the <functionCode> element. This may be used for example, to identify the primary care provider.

<time><low value=' '/><high value=' '/></time>

The

<assignedEntity classCode='ASSIGNED'>

The <assignedEntity> element contains elements that identify the individual provider, and shall be present.

<id root=' ' extension=' '/>

The <id> element may be present and identifies the provider.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element describes the type of provider and can be used to distinguish pharmacies from other providers.

<addr></addr>

The <addr> element gives the address of the provider.

<telecom value=' ' use=' '/>

The <telecom> element gives the telephone number of the provider.

<assignedPerson><name></name></assignedPerson>

The providers name should be present. If not present, then the <scopingOrganization> shall be present (see below).

<representedOrganization><name></name></representedOrganization>

This element should be present, and shall provide the name of the organization.

<sdtc:patient><sdtc:id root=' ' extension=' '/></sdtc:patient>

The <sdtc:patient> element may be present to represent the patient's medical record number with the given provider. The root attribute of <sdtc:id> element shall be present and identifies the namespace used for the identifier. The extension attribute shall be present and is the patient's medical record or account number with the provider. This element is an HL7 extension to CDA Release 2.0.

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 Patient Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.4

Patient contacts are recorded as described in HL7 CCD: 3.3


Uses

See Templates using Patient Contacts

Specification
Patient Contacts Example
<guardian classCode='GUARD'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
  <code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
  <addr></addr>
  <telecom />
  <guardianPerson>
    <name></name>
  </guardianPerson>
</guardian>
Guardians
<participant typeCode='IND'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
  <time value='20070213'/>
  <associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>
    <code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
    <addr></addr>
    <telecom value='' use=''/>
    <assignedPerson><name></name></assignedPerson>
  </associatedEntity>
</participant>


<guardian classCode='GUARD'>

The guardians of a patient shall be recorded in the <guardian> element beneath the <patient> element.

<participant typeCode='IND'>

Other contacts are recorded as <participant> elements appearing in the document header. The classCode attribute shall be set to 'IND'.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>

The <templateId> element identifies this person as a patient contact and must be recorded exactly as shown above.

<time value=' '>

The <time> element may be present and indicates the time of the participation.

<associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>

The <associatedEntity> element identifies the type of contact. The classCode attribute shall be present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or other relations respectively.

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The relationship between the patient and the guardian or other contact should be recorded in the <code> element. The code attribute is required and comes from the HL7 PersonalRelationshipRoleType vocabulary. The codeSystem attribute is required and shall be represented exactly as shown above.

<addr>

The address of the guardian or other contact should be present, and shall be represented as any other address would be in CDA.

<telecom>

The phone number of the guardian or other contact should be present, and shall be represented as any other phone number would be in CDA.

<guardianPerson><name/> or <assignedPerson><name/>

The name of the guardian or other contact shall be present, and shall be represented as any other name would be in CDA.

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 Authorization 1.3.6.1.4.1.19376.1.5.3.1.2.5

Each <authorization> element in the CDA Header represents an informed consent. When the document being shared represents the informed consent to a policy expressed by the XDS Affinity Domain within the document, it shall do so in an <authorization> element. More than one <authorization> element may be present. The consent to share informaiton shall have a unique identifier contained in the <id> element, representing the patient consent to that policy. The policy being consented to shall be represented in the <code> element. Note that other <authorization> elements may be present representing other sorts of consents associated with the document.


Uses

See Templates using Authorization

Specification
Authorization Example
<authorization typeCode='AUTH'>
  <consent classCode='CONS' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.5'/>
    <id root=''/>
    <code code='' codeSystem='' codeSystemName='' displayName=''/>
    <statusCode code='completed'/>
  </consent>
</authorization>


Policies are identified using an Affinity Domain specified coding system. Each coded value in that vocabulary represents one affinity domain specific policy.

<authorization typeCode='AUTH'>

At least one <authorization> element must be present in a consent medical document in documents shared by Document Source actors that implement the privacy option. The typeCode attribute shall be present and be valued with AUTH, indicating that this is an authorization act related to the document.

<consent classCode='CONS' moodCode='EVN'>

Each authorization element shall have one <consent> element. The classCode shall be present and be valued with CONS, indicating that the related act is an informed consent. The moodCode shall be EVN, indicating that this element represents and act that has occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.5'/>

The <templateId> element shall be recorded as shown above and identifies this consent as an authorization entry.

<id root=' '/>

The <consent> element shall have one identifier that is used to uniquely identify the consent act. This identifier shall contain a root attribute, and shall not contain an extension attribute.

<code code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '/>

The <consent> element shall have one <code> element that is used to identify the consent policy that was agreed to by the patient.

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 Consent Service Events 1.3.6.1.4.1.19376.1.5.3.1.2.6

Within a consent document, the effective time of the consent shall be specified within the documentationOf/serviceEvent element.


Uses

See Templates using Consent Service Events

Specification
Consent Service Events Example
<documentationOf typeCode='DOC'>
  <serviceEvent classCode='ACT' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.6'/>
    <id root=''/>
    <code code='' displayName='' codeSystem='' codeSystemName=''/>
    <effectiveTime>
      <low value=''/>
      <high value=''/>
    </effectiveTime>
  </serviceEvent>
</documentationOf>


<documentationOf typeCode='DOC'>

At least one <documentationOf> element shall exist within a consent to share information, describing the service event of provision of consent. This element shall have a typeCode attribute with the value DOC.

<serviceEvent classCode='ACT' moodCode='EVN'>

One <serviceEvent> shall exist for each consent to share information given, describing the duration of the provision of consent. This element shall have a classCode attribute set to ACT, and a moodCode attribute of EVN.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.6'/>

The <templateId> element shall be recorded exactly as shown above, and identifies this <serviceEvent> as recording consent to share information.

<id root=' ' />

The service event shall have one <id> element, providing an identifier for the service event. The root attribute of this element shall be present, and shall be a GUID or OID. The extension attribute shall not be present.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element shall be present, and shall indicate the consent given. The code attribute indicates the consent given, and the codeSystem attribute indicates the code system from which this consent is given. The displayName attribute may be present, and describes the consent given. The codeSystemName attribute may be present, and describes the code system.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> element shall be present, and shall indicated the effective time range over which consent is given. The low value must be provided . The high value may be present. If present, is shall indicate the maximum effective time of the consent.

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 Related Document 1.3.6.1.4.1.19376.1.5.3.1.2.7

The relatedDocument element using this templateId shall refer to a document conforming to the PHR Extract Content module. All XML content with the exception of the <id> element must appear exactly as shown below.


Uses

See Templates using Related Document

Specification
Related Document Example

<relatedDocument typeCode='APND'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.7'/>
 <parentDocument classCode='DOCCLIN' moodCode='EVN'>
   <id root=' ' extension=' '/>
 </parentDocument>
</relatedDocument>


<relatedDocument typeCode='APND'>

Indicates that this CDA document is an addendum to a preceeding CDA document. The typeCode attribute shall have the value APND.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.7'/>

This template identifier indicates that the <relatedDocument> entry conforms to the rules of this specification.

<parentDocument classCode='DOCCLIN' moodCode='EVN'>
<id root=' ' extension=' '/>

The related document shall be recorded in the <parentDocument> document element by identifying the the PHR Extract that is being updated in the <id> element.