Ehscda:CDA-CH-SCDO (specification)

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Identifikation dieses Dokuments
Abkürzung: CDA-CH-SCDO
OID: 2.16.756.5.30.1.1.1.1.3.11.1

Autoren Hilary Ramanantsalama (IHE Europe)

Zweck und Positionierung

Gleichstellung von Mann und Frau

Elektronische Version

Scdo:Zusammenfassung


Einleitung

Scdo:AusgangslageMotivation

Status und Zweck

Angesprochene Leserschaft


Ziele und Abgrenzungen

Voraussetzungen Interoperabilität

Scdo:Ziele Scdo:Abgrenzungen

Grundlagen und Basistechnologien

Scdo:Verantwortlichkeiten


Formelle Grundlagen

Scdo:BezugStandards

IHE Integrationsprofile

HL7 V3

HL7 Clinical Document Architecture (CDA)

Gesetzgebung Elektronisches Patientendossier (EPDG)

Übersetzungen


Anwendungsfälle

Dieses Material ist Teil

des Leitfadens eHealth Suisse Implementierungsleitfaden.

  • Direkt im Wiki geändert werden sollten Schreibfehler, ergänzende Hinweise.
  • Offene Fragen, die der Diskussionen bedürfen, sollten auf der Diskussionsseite aufgenommen werden.
  • Liste der Seiten dieses Leitfadens: hier, Liste der Seiten, in denen dieses Material verwendet (transkludiert) siehe hier .

Die hier skizzierten Anwendungsfälle (UC = Use Case) beziehen sich auf Beispiele, wie sie heute bei den verschiedenen Akteuren im Schweizer Gesundheitswesen vorkommen, die mit dem vorliegenden Thema zu tun haben. Einige Anwendungsfälle werden erst möglich, wenn durch Import/Export-Mechanismen alle relevanten Informationen interoperabel fliessen können.

Ziel ist einerseits die Bereitstellung von Informationen zum Gesundheitszustand des Patienten in einer menschlich lesbaren Form für die am Behandlungspfad beteiligten Personen. Andererseits sollen durch die elektronische Verarbeitung der Informationen Prozesse in den ICT-Systemen optimiert werden können.
Nachfolgend beschriebene Anwendungsfälle verdeutlichen diese Zusammenhänge im vorliegenden Kontext.

Scdo:AnwendungsfaelleEinfuehrung Scdo:AnwendungsfaelleStoryboard


Empfehlungen

Dieses Kapitel enthält Empfehlungen, welche im Sinne einer Harmonisierung hilfreich sind. Die nachfolgend genannten Empfehlungen können auch als "Best practices" betrachtet werden. Die nachfolgend genannten Empfehlungen sind nicht normativ und deren Umsetzung somit freiwillig.

Transportmechanismus

Umgang mit Metadaten

Wie bei den Empfehlungen zum Umgang mit Metadaten in CDA-CH V2 (2017) genannt, ist im Zusammenhang mit dem elektronischen Patientendossier ist ein harmonisierter Umgang mit Metadaten zu den Dokumenten, welche mit CDA-CH V2 erstellt werden wichtig.

Empfehlung zum Umgang mit Metadaten

Wenn ein CDA Dokument, welches der vorliegenden Spezifikation entspricht, in das elektronische Patientendossier eingestellt wird, sollen die Metadaten gemäss dieser Beschreibung zugeordnet werden: Metadaten gemäss EPDV

Ausserdem enthält die vorliegende Spezifikation eine konkret Vorgabe für das Metadaten-Attribut typeCode (siehe dazu Template 'Document Code'). Das Metadaten-Attribut classCode lässt sich davon gemäss der Tabelle "2.11 Typ des Dokumentes (2.16.756.5.30.1.127.3.10.1.27)" in Anhang 3 der Verordnung des EDI über das elektronische Patientendossier (Metadaten)[Anmerkung 2] ableiten (Spalte 4, 'Gehört zu Dokumentenklasse aus 2.3').

Scdo:SpezifikationIntro

Allgemeines

Scdo:HierarchieSpezifikationen Scdo:Szenario

CDA Struktur

CDA Document Level Templates

CDA-CH-SCDO-ScannedDocument

Id2.16.756.5.30.1.1.10.1.20Effective Date2018‑06‑08 13:36:50
StatusKyellow.png DraftVersion Label2017
NameCDA-CH-SCDO-ScannedDocumentDisplay NameCDA-CH - Scanned document
DescriptionCDA-CH - Scanned document
ContextPathname //
Label5.2.3
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 7 templates
Uses as NameVersion
2.16.756.5.30.1.1.10.2.1IncludeKyellow.png Patient - recordTarget (2020)DYNAMIC
2.16.756.5.30.1.1.10.2.72IncludeKyellow.png SCDO Data Enterer (2017)DYNAMIC
2.16.756.5.30.1.1.10.9.23IncludeKyellow.png Author (2020)DYNAMIC
2.16.756.5.30.1.1.10.9.52IncludeKyellow.png SCDO Author (2017)DYNAMIC
2.16.756.5.30.1.1.10.2.3IncludeKyellow.png Custodian (2020)DYNAMIC
2.16.756.5.30.1.1.10.2.5IncludeKgreen.png Legal Authenticator (2017)DYNAMIC
2.16.756.5.30.1.1.10.2.46IncludeKyellow.png Health Service - documentationOf (2019)DYNAMIC
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.2.20 Scanned document (XDS-SD) (2017‑02‑06 15:07:09)
ref
XDS-SD-

Specialization: template 2.16.756.5.30.1.1.10.1.12 CDA-CH v2.0 - nonXMLBody (DYNAMIC)
ref
hl7chcda-
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
5.2.3
Treetree.pnghl7:typeId
II1 … 1RFixed, per CDA R2 version in use
5.2.3.1
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
Treetree.pnghl7:templateId
II1 … 1RFixed, per the specification
5.2.3.1
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.2.205.2.3.1
Treetree.pnghl7:templateId
II1 … 1R5.2.3
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.1.12
Treetree.pnghl7:templateId
II1 … 1R5.2.3
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.1.20
Treetree.pnghl7:id
II1 … 1RComputable5.2.3
Treeblank.pngTreetree.png@root
uid1 … 1R5.2.3.1
Treetree.pnghl7:code
CE1 … 1REntered by operator or approprietely fixed for scanned content.5.2.3.1
Treeblank.pngTreetree.png@codeSystem
oid1 … 1R5.2.3.1
Treeblank.pngTreetree.png@code
cs1 … 1R5.2.3.1
Treetree.pnghl7:title
ST0 … 1REntered by operator, or possibly can be taken from the scanned content.5.2.3.1
Treetree.pnghl7:effectiveTime
TS1 … 1RComputed. This is the scan time.5.2.3.1
 Schematron assertroleKred.png error 
 see5.2.3.1 
 teststring-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))) 
 MessageThe time shall include the time zone offset from GMT (5.2.3.1) 
 Schematron assertroleKred.png error 
 seeXDSSDVAL-017 
 teststring-length(@value) >= 8 
 MessageAt a minimum, the time shall be precise to the day (5.2.3.1) 
Treetree.pnghl7:confidentialityCode
CE1 … 1RAssigned by the operator.5.2.3.1
Treeblank.pngTreetree.png@code
cs1 … 1R5.2.3.1
Treeblank.pngTreetree.png@codeSystem
oid1 … 1R5.2.3.1
Treetree.pnghl7:language​Code
CS1 … 1REntered by operator5.2.3.1
Treeblank.pngTreetree.png@code
cs1 … 1R5.2.3.1
Included1 … *R from 2.16.756.5.30.1.1.10.2.1 Patient - recordTarget (DYNAMIC)
Taken from scanned content, supplemented by operator.
Treetree.pnghl7:recordTarget
1 … *R A human patient for whom this CDA document instance was created.
  • Target patient
    The HL7 CDA R2 (2005) standard allows multiple patients.
    In order to ensure that the information in a CDA document is unambiguously assigned to one and only patient, a CDA-CH V2 based document MUST contain exactly one patient.
    Special cases: In exceptional cases (e.g., new-born twins, both having jaundice), multiple documents MUST be created (all of the same content, but each with a unique patient).

  • Patient identifiers
    Multiple ids (patient identification number) MAY be declared.
    If multiple ids are known, it is highly recommended to declare all known ids. Especially in cases where the CDA document instance is kind of an answer to a preceding order (independent of its data format), all ids specified by the ordering system SHALL be declared in the CDA document instance. This allows the receiver to assign its internal patient identification.
    The patient identification number MUST be grouped with the OID of its assigning system. The patient identification number MUST be unique within the system identified by the OID.
    The declared OID MUST be found in one of the public OID registries, such as oid.refdata.ch (preferred), oid-info.com, hl7.org/oid, www.dimdi.de/static/de/klassi/oid/, gesundheit.gv.at/OID_Frontend/ etc.
    OIDs that can't be found in a public OID registry are NOT ALLOWED.

  • Pseudonymizing
    In special cases, the demographic data of the patient are not allowed to be transmitted or they have to be pseudonymized.
    While HL7 CDA or its derivatives like CDA-CH or Swiss exchange formats nevertheless require these elements in the XML structure, the affected values MUST be replaced by a nullFlavor of type "MSK" (masked), in order to support the required data format structure and simultaneously to shield the real data.

CDA‑CH V2
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.1
Treeblank.pngTreetree.pnghl7:patientRole
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RThe patient's id.CDA‑CH V2
 
Target.png
cdachemed-data​element-13Kyellow.png Identification number Kyellow.png Dataset 1
hl7chcda-data​element-162Kyellow.png personIdentification Kyellow.png CDA-CH V2 2017
hl7chcda-data​element-228Kyellow.png Identification number Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1RThe OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 The id itself. It MUST be unique within the issuing system.
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *The patient's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
 
Target.png
cdachemed-data​element-14Kyellow.png Address (es) Kyellow.png Dataset 1
hl7chcda-data​element-47Kyellow.png addressInformation Kyellow.png CDA-CH V2 2017
hl7chcda-data​element-229Kyellow.png Address (es) Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *The patient's means of communication (phone, eMail, ...).CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
1 … 1RContains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)CDA‑CH V2
 
Target.png
cdachemed-data​element-5Kyellow.png Patient/Patientin Kyellow.png Dataset 1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE1 … 1RThe patient's genderCDA‑CH V2
 
Target.png
cdachemed-data​element-12Kyellow.png Gender Kyellow.png Dataset 1
hl7chcda-data​element-227Kyellow.png Gender Kyellow.png CDA-CH V2 2017
hl7chcda-data​element-183Kyellow.png sex Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st1 … 1FHL7 AdministrativeGender
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS.CH.TZ1 … 1RThe patient's birthdate.CDA‑CH V2
 
Target.png
cdachemed-data​element-11Kyellow.png Date of birth Kyellow.png Dataset 1
hl7chcda-data​element-181Kyellow.png dateOfBirth Kyellow.png CDA-CH V2 2017
hl7chcda-data​element-226Kyellow.png Date of birth Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:marital​Status​Code
CE0 … 1The patient's marital status.CDA‑CH V2
 
Target.png
hl7chcda-data​element-186Kyellow.png maritalStatus Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.1.11.12212
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st1 … 1FHL7 MaritalStatus
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12212 MaritalStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
0 … *A translation of the code to another coding systemCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:religious​Affiliation​Code
CE0 … 1The patient's religion.CDA‑CH V2
 
Target.png
hl7chcda-data​element-184Kyellow.png religion Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNAV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1 
Included0 … 1C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED0 … 1CCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL1 … 1MThe reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx']CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1RReference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding <content></content> element.
 Schematron assertroleKred.png error 
 teststarts-with(@value,'#') 
 MessageThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertroleKred.png error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MessageNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
 Schematron assertroleKred.png error 
 testparent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text() 
 MessageThe originalText content MUST be identical to the narrative text for this reference. 
 Schematron assertroleKred.png error 
 test(@nullFlavor='NAV' and originalText and not(@codeSystem or @codeSystemName or @code or @displayName)) or (@codeSystem and @codeSystemName and @code and @displayName) 
 MessageEither a code described by code, codeSystem, codeSystemName and displayName or originalText and nullFlavor="NAV" is REQUIRED. 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian
0 … *The patient's guardian.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *The guardian's id.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1RThe OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 The id itself. It MUST be unique within the issuing system.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1The guardian's role.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0 … 1F2.16.840.1.113883.5.111
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st0 … 1FHL7RoleCode
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1 
 Schematron assertroleKred.png error 
 test(not(@nullFlavor) and @displayName and @code and @codeSystem and @codeSystemName) or (@nullFlavor and not(@displayName or @code or @codeSystem or @codeSystemName)) 
 MessageEither nullFlavor or a valid code is required. 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *The guardian's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
 
Target.png
hl7chcda-data​element-47Kyellow.png addressInformation Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *The guardian's means of communication (phone, eMail, ...).CDA‑CH V2
Choice1 … 1Elements to choose from:
  • hl7:guardian​Person containing template 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
  • hl7:guardian​Organization containing template 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian​Person
The guardian's as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian​Organization
The guardian's as an organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthplace
0 … 1The patient's birthplace.CDA‑CH V2
 
Target.png
hl7chcda-data​element-182Kyellow.png placeofBirth Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:place
1 … 1CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
EN0 … 1The patient's birthplace name.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … 1RThe patient's birthplace address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Communication
0 … *The patient's language skills.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Code
CS1 … 1CDA‑CH V2
 
Target.png
hl7chcda-data​element-164Kyellow.png languageOfCorrespondance Kyellow.png CDA-CH V2 2017
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:modeCode
CE0 … 1CDA‑CH V2
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:proficiency​Level​Code
CE0 … 1CDA‑CH V2
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:preference​Ind
BL0 … 1In case of @value=true it is the patient's correspondence language.CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:providerOrganization
0 … 1The organization who took care of the patient in the same context with the current CDA document. E.g. entry of the Medreg, FMH Index or the Health Organisation Index (HOI) of the Swiss EPR.
Contains 2.16.756.5.30.1.1.10.9.30 Organization Compilation with GLN and name (DYNAMIC)
CDA‑CH V2
Included1 … *R from 2.16.756.5.30.1.1.10.2.72 SCDO Data Enterer (DYNAMIC)
Can be computed or fixed based on the scanning device and software. This is the information about the scanning device. 
Treetree.pnghl7:dataEnterer
1 … *RInformation about the person that entered information in this CDA document. It SHALL be declared, when data recorded in this document has been entered by a person other than the author but only when this is relevant for some reason.CDA‑CH V2
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.7
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.72
Treeblank.pngTreetree.pnghl7:time
TS.CH.TZ1 … 1R
Time shall denote the time at which the original content was scanned. This value shall be equal to that of ClinicalDocument/effectiveTime. At a minimum, the time shall be precise to the day and shall include the time zone offset from GMT. 
CDA‑CH V2
 Schematron assertroleKyellow.png hint 
 test@value=parent::node()/parent::node()/hl7:effectiveTime/@value 
 MessageThis value shall be equal to that of ClinicalDocument/effectiveTime 
 Schematron assertroleKred.png error 
 teststring-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))) 
 MessageThe time shall include the time zone offset from GMT. 
 Schematron assertroleKred.png error 
 teststring-length(@value) >= 8 
 MessageAt a minimum, the time shall be precise to the day 
Treeblank.pngTreetree.pnghl7:assignedEntity
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st1 … 1R
Included0 … * from 2.16.756.5.30.1.1.10.9.23 Author (DYNAMIC)
Taken from scanned content, supplemented by operator. This is the original author.
Treetree.pnghl7:author
0 … *RInformation about the author of a CDA document, section or entry. An author MAY be a person or a device.CDA‑CH V2
 
Target.png
cdachemed-data​element-2Kyellow.png Autorin/Autor Kyellow.png Dataset 1
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.9.23
Treeblank.pngTreetree.pnghl7:functionCode
CE0 … 1CDA‑CH V2
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
Treeblank.pngTreetree.pnghl7:time
TS.CH.TZ1 … 1RTimestamp of the authorship.CDA‑CH V2
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1RCDA‑CH V2
 Schematron assertroleKred.png error 
 testnot(assignedAuthoringDevice/softwareName) or (representedOrganization) 
 MessageFor device authors the element representedOrganization is REQUIRED. 
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1R The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared.
CDA‑CH V2
 
Target.png
cdachemed-data​element-7Kyellow.png Identifier Kyellow.png Dataset 1
hl7chcda-data​element-233Kyellow.png Identifier Kyellow.png CDA-CH V2 2017
hl7chcda-data​element-162Kyellow.png personIdentification Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNAV
 Temporarily unknown, will be filled later.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
cs0 … 1F2.51.1.3
 OID for GS1 GLN.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 The GS1 GLN.
 Schematron assertroleKred.png error 
 test(@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') 
 MessageEither the GS1 GLN or nullFlavor='NAV' is REQUIRED 
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *Other ids are allowed.CDA‑CH V2
 
Target.png
hl7chcda-data​element-162Kyellow.png personIdentification Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
cs1 … 1RThe OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 Contains the ID itself. The ID MUST be unique within the system that issued the ID.
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *The author's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *The author's means of communication (phone, eMail, ...).CDA‑CH V2
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person containing template 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
  • hl7:assigned​Authoring​Device containing template 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1The author as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
 
Target.png
cdachemed-data​element-3Kyellow.png Name Kyellow.png Dataset 1
cdachemed-data​element-6Kyellow.png First names Kyellow.png Dataset 1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1The author's organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
 
Target.png
cdachemed-data​element-8Kyellow.png Health facility Kyellow.png Dataset 1
hl7chcda-data​element-234Kyellow.png Health facility Kyellow.png CDA-CH V2 2017
Included1 … 1R from 2.16.756.5.30.1.1.10.9.52 SCDO Author (DYNAMIC)
Can be computed by the scanner or supplemented by operator. This is the information about the scanner operator.
Treetree.pnghl7:author
1 … 1RInformation about the author of a CDA document, section or entry. An author MAY be a person or a device.CDA‑CH V2
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.9.23
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.9.52
Treeblank.pngTreetree.pnghl7:functionCode
CE1 … 1R

The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.

If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, nullFlavor='NAV' MUST be used. In this case, the originalText element MUST contain the description of the role.

Translations to other vocabularies are allowed.

CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
st0 … 1FNAV
Treeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreetree.png@codeSystemName
st0 … 1FSNOMED CT
Treeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1 
 CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 DocumentEntry.authorRole (DYNAMIC)
 Example
Patient
<functionCode code="116154003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Patient"/>
 Example
Nurse
<functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
 Example
Home helper
<functionCode nullFlavor="NAV">
  <originalText>Home helper</originalText></functionCode>
 Example
Laboratory technician
<functionCode nullFlavor="NAV">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
 Schematron assertroleKred.png error 
 test(@code and @codeSystem) or (@nullFlavor='NAV') 
 MessageEither a code with its code system or nullFlavor='NAV' is required. 
 Schematron assertroleKred.png error 
 testnot(@nullFlavor) or (hl7:originalText) 
 MessageOther Caregivers description MUST be declared in the originalText element in case of nullFlavor. 
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
0 … *A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7)CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
Treeblank.pngTreetree.pnghl7:time
TS.CH.TZ1 … 1RTimestamp of the authorship.CDA‑CH V2
 Schematron assertroleKyellow.png hint 
 test@value=parent::node()/parent::node()/hl7:effectiveTime/@value 
 MessageThis value shall be equal to that of ClinicalDocument/effectiveTime 
 Schematron assertroleKred.png error 
 teststring-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))) 
 MessageThe time shall include the time zone offset from GMT 
 Schematron assertroleKred.png error 
 teststring-length(@value) >= 8 
 MessageAt a minimum, the time shall be precise to the day 
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1RCDA‑CH V2
 Schematron assertroleKred.png error 
 testnot(assignedAuthoringDevice/softwareName) or (representedOrganization) 
 MessageFor device authors the element representedOrganization is REQUIRED. 
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1R The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared.
CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNAV
 Temporarily unknown, will be filled later.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
cs0 … 1F2.51.1.3
 OID for GS1 GLN.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 The GS1 GLN.
 Schematron assertroleKred.png error 
 test(@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') 
 MessageEither the GS1 GLN or nullFlavor='NAV' is REQUIRED 
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *Other ids are allowed.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
cs1 … 1RThe OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 Contains the ID itself. The ID MUST be unique within the system that issued the ID.
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *The author's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *The author's means of communication (phone, eMail, ...).CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RXDSSD‑44
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.840.10008.2.16.4
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.2.20.11.1 DICOM Vocabulary (2017‑02‑06 14:01:56)
 Schematron assertroleKyellow.png hint 
 test(@code = 'CAPTURE' and parent::node()/parent::node()/parent::node()/parent::node()/hl7:component/hl7:nonXMLBody/text/@mediaType = 'application/pdf') or (@code = 'WSD' and contains('parent::node()/parent::node()/parent::node()/parent::node()/hl7:component/hl7:nonXMLBody/text/@mediaType', 'text/plain') 
 MessageClinicalDocument/component/nonXMLBody/text@mediaType shall be "application/pdf" for PDF, or "text/plain" for plaintext 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1The author's organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
Included1 … 1R from 2.16.756.5.30.1.1.10.2.3 Custodian (DYNAMIC)
Retains original HL7 CDA Context. To be computed or fixed appropriately to denote guardianship of the scanned and wrapped content.
Treetree.pnghl7:custodian
1 … 1RThe organization in whose name this CDA document has been created (corresponds to the sender of a letter).CDA‑CH V2
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.3
Treeblank.pngTreetree.pnghl7:assignedCustodian
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MThe custodian's id.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1RThe OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 Contains the ID itself. The ID MUST be unique within the system that issued the ID.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1RThe custodian's name.CDA‑CH V2
 
Target.png
hl7chcda-data​element-73Kyellow.png organisationName Kyellow.png CDA-CH V2 2017
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1The custodian's means of communication (phone, eMail, ...).CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1The custodian's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
 
Target.png
hl7chcda-data​element-77Kyellow.png addressInformation Kyellow.png CDA-CH V2 2017
Included0 … 1 from 2.16.756.5.30.1.1.10.2.5 Legal Authenticator (DYNAMIC)
Most likely supplemented by the operator, when applicable or mandated
Treetree.pnghl7:legalAuthenticator
0 … 1Information about the legal authenticator of a CDA document. A legal authenticator MUST be a person.CDA‑CH V2
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.5
Treeblank.pngTreetree.pnghl7:time
TS.CH.TZ1 … 1RTimestamp of the signature.CDA‑CH V2
Treeblank.pngTreetree.pnghl7:signatureCode
CS1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FS
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0NPNP/not present
Treeblank.pngTreeblank.pngTreetree.png@codeSystemName
st0NPNP/not present
Treeblank.pngTreeblank.pngTreetree.png@displayName
st0NPNP/not present
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
Treeblank.pngTreetree.pnghl7:assignedEntity
1 … 1RContains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC)CDA‑CH V2
Included1 … *R from 2.16.756.5.30.1.1.10.2.46 Health Service - documentationOf (DYNAMIC)
Denotes the time/date range of the original content.
Treetree.pnghl7:documentationOf
1 … *RInformation about a health service describing the context of this CDA document.CDA‑CH V2
Treeblank.pngTreetree.png@typeCode
cs1 … 1FDOC
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.46
Treeblank.pngTreetree.pnghl7:serviceEvent
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FACT
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *Health service identifiers such as case number ([ge]: Fallnummer; [fr]: Numéro de cas), consultation id, episode id, etc.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1RThe OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 The id itself. It MUST be unique within the issuing system.
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE1 … 1RAs long as the eventCodeList for the Swiss EPR metadata is not defined yet by the FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), the nullFlavor='NAV' MUST be used in this template. Other codes MAY be declared as translation.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
st1 … 1FNAV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0NPNP/not present
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0NPNP/not present
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st0NPNP/not present
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0NPNP/not present
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
0 … *A translation of the code to another coding system.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
st1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS.CH.TZ1 … 1RDuration of the health service.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:low
TS.CH.TZ1 … 1RStart of the health service.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:high
TS.CH.TZ1 … 1REnd of the health service.CDA‑CH V2
Included0 … * from 2.16.756.5.30.1.1.10.9.31 Performer (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:performer
0 … *Information about a healthcare provider who was the primary performer of the act.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FPRF
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.9.31
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:templateId
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.1.24.3.5
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:templateId
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.12.323
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
IVL_TS.CH.TZ0 … 1Duration of the performance.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:low
TS.CH.TZ1 … 1RStart of the performance.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:high
TS.CH.TZ1 … 1REnd of the performance.CDA‑CH V2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1RContains 2.16.756.5.30.1.1.10.9.32 Assigned Entity Compilation with id, name, addr, telecom, person and organization (DYNAMIC)CDA‑CH V2
Treetree.pnghl7:component
1 … 1RThe scanned/encoded content.
5.2.3.9
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1 
Treeblank.pngTreetree.pnghl7:nonXMLBody
1 … 1R5.2.3.9
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED1 … 1R5.2.3.9
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@representation
cs1 … 1FB645.2.3.9
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@mediaType
cs1 … 1R5.2.3.9
Treeblank.pngTreeblank.pngTreetree.pnghl7:language​Code
CS0 … 15.2.3.9
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R5.2.3.9
 Schematron assertroleKyellow.png hint 
 see5.2.3.1 
 testcount(hl7:title) == 1 
 MessageThe ClinicalDocument/title element shall be present if known. (XDSSDVAL-016) 

CDA Header Level Templates

SCDO Data Enterer

Id2.16.756.5.30.1.1.10.2.72Effective Date2018‑06‑26 17:03:29
StatusKyellow.png DraftVersion Label2017
Namescdo_cdach_header_DataEntererDisplay NameSCDO Data Enterer
Description
Information about the person that entered information in this CDA document. It SHALL be declared, when data recorded in this document has been entered by a person other than the author but only when this is relevant for some reason. All CDA-CH V2 derivatives, i.e. Swiss exchange formats MUST reference this template.
LabelCDA‑CH V2
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.756.5.30.1.1.10.2.7 Data Enterer (2018‑04‑18)
ref
hl7chcda-

Specialization: template 2.16.840.1.113883.10.12.103 CDA dataEnterer (2005‑09‑07)
ref
ad1bbr-
Example
Example
<dataEnterer>
  <templateId root="2.16.756.5.30.1.1.10.2.7"/>  <time value="201709122029+0200"/>  <assignedEntity>
    <id root="2.999" extension="0812763"/>    <assignedPerson>
      <name>
        <given>Jean</given>        <family>Dupont</family>      </name>
    </assignedPerson>
  </assignedEntity>
</dataEnterer>
ItemDTCardConfDescriptionLabel
hl7:dataEnterer
0 … 1Information about the person that entered information in this CDA document. It SHALL be declared, when data recorded in this document has been entered by a person other than the author but only when this is relevant for some reason.CDA‑CH V2
Treetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.7
Treetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.2.72
Treetree.pnghl7:time
TS.CH.TZ1 … 1R
Time shall denote the time at which the original content was scanned. This value shall be equal to that of ClinicalDocument/effectiveTime. At a minimum, the time shall be precise to the day and shall include the time zone offset from GMT. 
CDA‑CH V2
 Schematron assertroleKyellow.png hint 
 test@value=parent::node()/parent::node()/hl7:effectiveTime/@value 
 MessageThis value shall be equal to that of ClinicalDocument/effectiveTime 
 Schematron assertroleKred.png error 
 teststring-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))) 
 MessageThe time shall include the time zone offset from GMT. 
 Schematron assertroleKred.png error 
 teststring-length(@value) >= 8 
 MessageAt a minimum, the time shall be precise to the day 
Treetree.pnghl7:assignedEntity
1 … 1RCDA‑CH V2
Treeblank.pngTreetree.pnghl7:id
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1R
Treeblank.pngTreeblank.pngTreetree.png@extension
st1 … 1R

Other CDA Templates

SCDO Author

Id2.16.756.5.30.1.1.10.9.52Effective Date2018‑06‑26 18:00:12
StatusKyellow.png DraftVersion Label2017
Namescdo_cdach_other_AuthorDisplay NameSCDO Author
Description
Information about the author of a CDA document, section or entry. An author MAY be a person or a device. All CDA-CH V2 derivatives, i.e. Swiss exchange formats MUST use this template at least in the CDA Header by either reference or specialisation.
ContextParent nodes of template element with id 2.16.756.5.30.1.1.10.9.52
LabelCDA‑CH V2
ClassificationTemplate type not specified
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 3 templates
Uses as NameVersion
2.16.756.5.30.1.1.10.9.35ContainmentKgreen.png Address Information Compilation - eCH-0010 (2017)DYNAMIC
2.16.756.5.30.1.1.10.9.21ContainmentKgreen.png Device Compilation with name (2017)DYNAMIC
2.16.756.5.30.1.1.10.9.24ContainmentKgreen.png Organization Compilation with name (2017)DYNAMIC
RelationshipSpecialization: template 2.16.756.5.30.1.1.10.9.23 Author (2018‑04‑18)
ref
hl7chcda-

Specialization: template 2.16.840.1.113883.10.12.102 CDA author (2005‑09‑07)
ref
ad1bbr-
Example
Sample author
<author>
  <templateId root="2.16.756.5.30.1.1.10.9.23"/>  <functionCode code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>  <time value="20170905"/>  <assignedAuthor>
    <id root="2.51.1.3" extension="7608888888888"/>    <assignedPerson>
      <name>
        <prefix>Dr. med.</prefix>        <given>Allzeit</given>        <family>Bereit</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <id root="2.51.1.3" extension="7609999999999"/>      <name>Gruppenpraxis CH</name>      <telecom value="tel:+41.32.234.55.66" use="WP"/>      <telecom value="fax:+41.32.234.55.67" use="WP"/>      <telecom value="mailto:bereit@gruppenpraxis.ch" use="WP"/>      <telecom value="http:www.gruppenpraxis.ch" use="WP"/>      <addr use="WP">
        <streetName>Doktorgasse</streetName>        <houseNumber>2</houseNumber>        <city>Musterhausen</city>        <postalCode>8888</postalCode>        <country>CH</country>      </addr>
    </representedOrganization>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
1 … *RInformation about the author of a CDA document, section or entry. An author MAY be a person or a device.CDA‑CH V2
Treetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.9.23
Treetree.pnghl7:templateId
II1 … 1MCDA‑CH V2
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.756.5.30.1.1.10.9.52
Treetree.pnghl7:functionCode
CE1 … 1R

The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.

If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, nullFlavor='NAV' MUST be used. In this case, the originalText element MUST contain the description of the role.

Translations to other vocabularies are allowed.

CDA‑CH V2
Treeblank.pngTreetree.png@nullFlavor
st0 … 1FNAV
Treeblank.pngTreetree.png@code
cs0 … 1 
Treeblank.pngTreetree.png@codeSystem
oid0 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreetree.png@codeSystemName
st0 … 1FSNOMED CT
Treeblank.pngTreetree.png@displayName
st0 … 1 
 CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 DocumentEntry.authorRole (DYNAMIC)
 Example
Patient
<functionCode code="116154003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Patient"/>
 Example
Nurse
<functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
 Example
Home helper
<functionCode nullFlavor="NAV">
  <originalText>Home helper</originalText></functionCode>
 Example
Laboratory technician
<functionCode nullFlavor="NAV">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
 Schematron assertroleKred.png error 
 test(@code and @codeSystem) or (@nullFlavor='NAV') 
 MessageEither a code with its code system or nullFlavor='NAV' is required. 
 Schematron assertroleKred.png error 
 testnot(@nullFlavor) or (hl7:originalText) 
 MessageOther Caregivers description MUST be declared in the originalText element in case of nullFlavor. 
Treeblank.pngTreetree.pnghl7:translation
0 … *A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7)CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1R
Treeblank.pngTreeblank.pngTreetree.png@codeSystemName
st1 … 1R
Treeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
Treetree.pnghl7:time
TS.CH.TZ1 … 1RTimestamp of the authorship.CDA‑CH V2
 Schematron assertroleKyellow.png hint 
 test@value=parent::node()/parent::node()/hl7:effectiveTime/@value 
 MessageThis value shall be equal to that of ClinicalDocument/effectiveTime 
 Schematron assertroleKred.png error 
 teststring-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))) 
 MessageThe time shall include the time zone offset from GMT 
 Schematron assertroleKred.png error 
 teststring-length(@value) >= 8 
 MessageAt a minimum, the time shall be precise to the day 
Treetree.pnghl7:assignedAuthor
1 … 1RCDA‑CH V2
 Schematron assertroleKred.png error 
 testnot(assignedAuthoringDevice/softwareName) or (representedOrganization) 
 MessageFor device authors the element representedOrganization is REQUIRED. 
Treeblank.pngTreetree.pnghl7:id
II1 … 1R The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared.
CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNAV
 Temporarily unknown, will be filled later.
Treeblank.pngTreeblank.pngTreetree.png@root
cs0 … 1F2.51.1.3
 OID for GS1 GLN.
Treeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 The GS1 GLN.
 Schematron assertroleKred.png error 
 test(@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') 
 MessageEither the GS1 GLN or nullFlavor='NAV' is REQUIRED 
Treeblank.pngTreetree.pnghl7:id
II0 … *Other ids are allowed.CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.png@root
cs1 … 1RThe OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
Treeblank.pngTreeblank.pngTreetree.png@extension
st0 … 1 Contains the ID itself. The ID MUST be unique within the system that issued the ID.
Treeblank.pngTreetree.pnghl7:addr
AD0 … *The author's address.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreetree.pnghl7:telecom
TEL0 … *The author's means of communication (phone, eMail, ...).CDA‑CH V2
Treeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
CDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RXDSSD‑44
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.840.10008.2.16.4
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.2.20.11.1 DICOM Vocabulary (2017‑02‑06 14:01:56)
 Schematron assertroleKyellow.png hint 
 test(@code = 'CAPTURE' and parent::node()/parent::node()/parent::node()/parent::node()/hl7:component/hl7:nonXMLBody/text/@mediaType = 'application/pdf') or (@code = 'WSD' and contains('parent::node()/parent::node()/parent::node()/parent::node()/hl7:component/hl7:nonXMLBody/text/@mediaType', 'text/plain') 
 MessageClinicalDocument/component/nonXMLBody/text@mediaType shall be "application/pdf" for PDF, or "text/plain" for plaintext 
Treeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
1 … 1RCDA‑CH V2
Treeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
1 … 1RCDA‑CH V2
Treeblank.pngTreetree.pnghl7:represented​Organization
0 … 1The author's organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2

Validierung, Technologien und Tools


Anhang

Lizenzen

SNOMED Clinical Terms® (SNOMED CT®)

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of SNOMED International (former known as International Health Terminology Standards Development Organisation IHTSDO). All rights reserved. SNOMED CT®, was originally created by The College of American Pathologists. “SNOMED” and “SNOMED CT” are registered trademarks of SNOMED International.

Logical Observation Identifiers Names and Codes LOINC

This material contains content from LOINC® (http://loinc.org). The LOINC table, LOINC codes, and LOINC panels and forms file are copyright © 1995-2013, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and available at no cost under the license at http://loinc.org/terms-of-use.

Anmerkungen

  1. HL7 Interoperability Work Group. Coming To Terms - Scoping Interoperability for Health Care. 2007; Siehe auch: http://www.hln.com/assets/pdf/Coming-to-Terms-February-2007.pdf
  2. siehe Elektronisches Patientendossier (EPDG)

Referenzen

EPDG SR 816.11 Bundesgesetz über das elektronische Patientendossier https://www.bag.admin.ch/dam/bag/de/dokumente/nat-gesundheitsstrategien/strategie-ehealth/gesetzgebung-elektronisches-patientendossier/SR%20816.11.pdf.download.pdf/SR%20816.11_DE.pdf

EPDV SR 816.111 Verordnung über das elektronische Patientendossier https://www.bag.admin.ch/dam/bag/de/dokumente/nat-gesundheitsstrategien/strategie-ehealth/gesetzgebung-elektronisches-patientendossier/gesetze/SR%20816.111.pdf.download.pdf/SR%20816.111.pdf

EPDV-EDI SR 816.111.1 Verordnung des EDI über das elektronische Patientendossier https://www.bag.admin.ch/dam/bag/de/dokumente/nat-gesundheitsstrategien/strategie-ehealth/gesetzgebung-elektronisches-patientendossier/gesetze/SR%20816.111.1.pdf.download.pdf/SR%20816.111.1_DE.pdf

DSG Bundesgesetz vom 19. Juni 1992 über den Datenschutz (DSG) http://www.admin.ch/ch/d/sr/2/235.1.de.pdf

Strategie Gesundheit 2020 Nationale Strategie „eHealth” 27.06.2007 https://www.bag.admin.ch/bag/de/home/themen/strategien-politik/gesundheit-2020.html

ITI TF-2b IHE IT Infrastructure Technical Framework Volume 2b (ITI TF-2b), http://www.ihe.net/uploadedFiles/Documents/ITI/IHE_ITI_TF_Vol2b.pdf

HL7 CDA HL7 Clinical Document Architecture, Release 2.0 ANSI/HL7 CDA, R2-2005 4/21/2005 HL7 Version 3 Standard; Last Published: 03/27/2006 3:35 AM www.hl7.org

Abbildungen

Tabellen

  1. Notationen in diesem Dokument


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