Материал: part20

8.1.3 effectiveTime​

The effectiveTime signifies the document creation time, when the document first came into being. Where the CDA document is a​ transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is​ created. The time when the transform occurred is not represented in CDA.​

8.1.4 setID and versionNumber​

ThesetIDandversionNumberelementsmaybeusedbythedocumentcreationsystemtomanagedocumentrevisions,inaccordance​ with the CDA specification sections 4.2.1.7 and 4.2.1.8.​

COND: If and only if the setID element is present, the versionNumber element SHALL be present.​

8.1.5 recordTarget/patientRole​

The recordTarget records the patient whose health information is described by the clinical document; it must contain at least one​ patientRole element.​

Multiple recordTarget elements should be used only in the case of conjoined twins/triplets who are the subject of a single imaging​ procedure, or for special cases (e.g., pre-natal surgery, where a medical record has been established for the fetus).​

Example 8.1.5-1. Header example​

<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/> <!-- DICOM Imaging Report Template -->

<templateId root="1.2.840.10008.9.1"/> <!-- General Header Template --> <templateId root="1.2.840.10008.9.20"/>

<id extension="999021" root="2.16.840.1.113883.19"/> <code codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" code="18748-4" displayName="Diagnostic Imaging Report"/>

<title>Radiology Report</title> <effectiveTime value="20150329171504+0500"/>

<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="en-US" codeSystem="2.16.840.1.113883.6.121"/> <setId extension="111199021" root="2.16.840.1.113883.19"/> <versionNumber value="1"/>

8.1.6 legalAuthenticator​

The legalAuthenticator identifies the single person legally responsible for the correctness of the content of the document and SHALL​ be present if the document has been legally authenticated. In the context of an imaging report, this means the radiologist, cardiologist,​ or other professional who signed or validated the report.​

Note​

Per the CDA Standard, the legal authenticator, if present, must be a person, and the authentication applies to the human-​ readable narrative in section/text and any renderMultiMedia referenced content. Structured entries and external images​ referenced through linkHtml are not attested by the legal authentication.​

Based on local practice, clinical documents may be released before legal authentication. This implies that a clinical document that​ does not contain this element has not been legally authenticated.​

The legalAuthenticator SHALL contain exactly one [1..1] time representing the time of signature.​

- Standard -​

The legalAuthenticator MAY contain zero or one [0..1] sdtc:signatureText extension element. This provides a textual or multimedia​ depictionofthesignaturebywhichtheparticipantendorsesandacceptsresponsibilityforhisorherparticipationintheAct.Theelement​ is described in the HL7 CDA Digital Signature Standard.​

Example 8.1.6-1. legalAuthenticator example​

<legalAuthenticator>

<time value="20050329224411+0500"/> <signatureCode code="S"/> <assignedEntity>

<id extension="KP00017" root="2.16.840.1.113883.19"/> <addr>

<streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city>

<state>MA</state>

<postalCode>02368</postalCode>

<country>US</country>

</addr>

<telecom use="WP" value="tel:(555) 555-1003"/> <assignedPerson>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedEntity>

</legalAuthenticator>

8.1.7 recordTarget/patientRole/Patient/birthTime​

Patient birthTime SHALL be precise to year, SHOULD be precise to day.​

Example 8.1.7-1. recordTarget example​

<recordTarget>

<patientRole>

<id extension="12345" root="2.16.840.1.113883.19"/> <!-Example ID using fake assigning authority OID. ->

<id extension="111-00-1234" root="2.16.840.1.118975.4.1"/> <!-Fake Social Security Number using the actual SSN OID. -> <addr use="HP">

<!-HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -> <streetAddressLine>17 Daws Rd.</streetAddressLine>

<city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country>

<!-US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -> </addr>

<telecom value="tel:(781) 555-1212" use="HP"/>

<!-HP is "primary home" from AddressUse 2.16.840.1.113883.5.1119 -> <patient>

<name use="L">

<!-L is "Legal" from EntityNameUse 2.16.840.1.113883.5.45 ->

- Standard -​

<prefix>Mr.</prefix>

<given>Adam</given>

<given qualifier="CL">Frankie</given>

<!-CL is "Call me" from EntityNamePartQualifier 2.16.840.1.113883.5.43 -> <family>Everyman</family>

</name>

<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>

<birthTime value="19541125"/> </patient> <providerOrganization>

<id root="2.16.840.1.113883.19"/> <name>Good Health Clinic</name>

<telecom use="WP" value="tel:(781) 555-1212"/> <addr>

<streetAddressLine>21 North Ave</streetAddressLine> <city>Burlington</city>

<state>MA</state>

<postalCode>02368</postalCode>

<country>US</country>

</addr>

</providerOrganization>

</patientRole>

</recordTarget>

8.1.8 author/assignedAuthor​

The author element represents the creator of the clinical document. This template restricts the author to be a person.​

SuchauthorSHALLcontainexactlyone[1..1]timerepresentingthestarttimeoftheauthor'sparticipationinthecreationofthecontent​ of the clinical document.​

Example 8.1.8-1. Person author example​

<author>

<time value="20050329224411+0500"/> <assignedAuthor>

<id extension="KP00017" root="2.16.840.1.113883.19.5"/> <addr>

<streetAddressLine>21 North Ave.</streetAddressLine> <city>Burlington</city>

<state>MA</state>

<postalCode>02368</postalCode>

<country>US</country>

</addr>

<telecom use="WP" value="tel:(555) 555-1003"/> <assignedPerson>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedAuthor>

</author>

- Standard -​

8.1.9 InformationRecipient/intendedRecipient​

The informationRecipient participation elements record the intended recipients of the information at the time the document is created.​ Anintendedrecipientmaybeaperson(aninformationRecipiententity),withorwithoutanorganizationaffiliation(receivedOrganization​ scoping entity), or simply an organization. If an organization, the document is expected to be incorporated into an information system​ of that organization (e.g., the electronic medical record for the patient).​

Example 8.1.9-1. informationRecipient example​

<informationRecipient>

<intendedRecipient classCode="ASSIGNED"> <informationRecipient>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</informationRecipient>

<receivedOrganization>

<name>Good Health Clinic</name> </receivedOrganization>

</intendedRecipient>

</informationRecipient>

8.2 Imaging Header​

- Standard -​

- Standard -​