cdaefa:Document Reference Entry (Template)

Dieses Material ist Teil des Leitfadens CDA für die elektronische Fallakte. 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 .

A Document Reference Entry refers to a single information object (e.g. within an eCR or another type of health record).

Standards

• IHE PCC External References (1.3.6.1.4.1.19376.1.5.3.1.4.4)

Template

   <entry>
      <act classCode='ACT' moodCode='EVN'> 
         <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         <templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>
         <id root='' extension=''/>
         <code nullFlavor='NA' />
         <text><reference value='#...'/></text>
         <effectiveTime value='YYYYMMDD'/>
         <reference typeCode='REFR'>
            <externalDocument classCode='DOC' moodCode='EVN'>
               <!-- required if known classification of the document -->
               <code code="..." codeSystem="2.16.840.1.113883.6.1"
                       codeSystemName="LOINC" displayName="..."/>
               <id extension='' root=''/>
               <text mediaType='mime-type'><reference value='&#104;ttp://....'></text>
            </externalDocument>
         </reference>
      </act>
   </entry>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
<templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>

The <templateId> elements shown above MUST be present, and indicated that this is an eCR Document Reference entry that implements an IHE PCC External Document entry.

<id root= extension=/>

The object reference is an entity on its own and therefore needs an identifier that MUST NOT be the identifier of the object itself.

<text><reference value='#...'/></text>

SHOULD contain a reference to the narrative description of the document that is provided in the section’s <text> element. Alternatively the description of the document MAY be directly given within this element.

<effectiveTime value='YYYYMMDD'/>

This element holds the <effectiveTime> value as given in the CDA header of the referenced document.

<externalDocument ....>
   <code code="..." codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="..."/>

If known, this element MUST record the LOINC code of the document. If the LOINC code of the document is not known a NullFlavor of ‘UNK’ MUST be set.

<externalDocument ....>
   ...
   <id root= extension=/>

This element MUST record an identifier that can be used to retrieve the document from a Document Repository.

<externalDocument ....>
   ...
   <text mediaType='mime-type'><reference value='https://....'/></text>

The MIME-Type of the external document MUST be given in the @mediaType-attribute of the <text> element. A reference value MAY be provided to record additional information that is needed by the document managing system to retrive the document. If given, the reference value MUST be coded as an URL. If no additional information is provided, the reference MUST be nullified with a nullFlavor of “NI”.

For fetching the external document, the content of the URL together with the external document identifier MUST be sent to the connected storage as provided. Therefore this information MUST be sufficient for the document store to discover and provide the document.

Example

   <entry>
      <act classCode='ACT' moodCode='EVN'> 
         <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         <templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>
    
         <id root='..' extension='..'/>
    
         <code nullFlavor='NA' />
    
         <text><reference value='#doc159382919223'/></text>
    
         <reference typeCode='REFR'>
            <externalDocument classCode='DOC' moodCode='EVN'>
               <id root='...'/>
               <code code="11522-0" codeSystem="2.16.840.1.113883.6.1"
                        codeSystemName="LOINC" displayName="Radiology report"/>
               <text mediaType='mime-type'><reference value=
                     'http://ecrDocRep.ecrProvider.de?node=cluster4'/></text>
            </externalDocument>
         </reference>
      </act>
   </entry>