cdaefa:1.2.276.0.76.3.1.81.81.6.2.2

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 .

The Assigned Human Entity content module defines the recording of human entities. It can be used with the document header or within document body entries for the instantiation of <assignedEntity> and <assignedAuthor> elements.

With the context of eCR three different flavors of this content module are defined:

• the human entity is acting under the legal umbrella of a medical practice, a pharmacy, etc.
• the human entity is acting under the legal umbrella of a hospital
• the human entity is acting solely as a person without any organizational background

In the following section it is specified how each of these settings MUST be encoded.

Person without Organizational Background

The following figure shows how a person without an organizational background is recorded as a <assignedEntity> or <assignedAuthor>.

Template

   <assignedAuthor> <!-- or <assignedEntity> -->
      <templateId root='1.2.276.0.76.3.1.81.81.6.2.2' />
      <id extension='' root=''/>
      <code code='...' displayName='...' codeSystem='...' codeSystemName='...' />
      <telecom value='.... '/>
      <addr></addr>
      <assignedPerson><name> ... </name></assignedPerson>
   </assignedAuthor> <!-- or </assignedEntity> -->

<id extension= root=/>

The <id> element MUST uniquely identify the human entity. See table Healthcare Professional Instance Identifiers for a list of valid identification schemes.

This element records the structural role of the human entity. It is used depending on the context and SHOULD encode the job role of the healthcare professional, e.g. physician, nurse, etc.

For the German healthcare system job roles of pharmacists and phyiscians MUST be encoded according to the respective definitions for Health Professional Cards (Heilberufsausweis, HBA):

• For physicians the job role MUST be encoded as

• For pharmacists the job role MUST be encoded as

• For all other job roles the job role SHOULD be encoded by using the ASTM E1986-98 (2005) role catalogue (OID: 1.2.840.10065.1986.7).

<telecom value=’...’/><addr></addr>

These elements should record the address and contact data of the person. While the address is optional, at least an eMail-Address or a phone number for getting in contact with the author MUST be provided.

<assignedPerson> <name>

At least family name and given name of the author/entity MUST be recorded.

If given, an academic title such as a medical doctor MUST be recorded as:

<prefix qualifier="AC">Dr. med.</prefix>

Example

<assignedEntity>
   <templateId root='1.2.276.0.76.3.1.81.81.6.2.2'/>
   <id extension='midwife-id-1' root='1.1.1.1.1.1'/>

   <code code='nurse midwife' 
         codeSystem='1.2.840.10065.1986.7' codeSystemName='ASTM structural roles'/>
   <addr>
      <streetName>Lange Straße</streetName>
      <houseNumber>4</houseNumber>
      <postalCode>11111</postalCode>
      <city>Berlin</city>
   </addr>
   <telecom value='tel:+49(30)234-5678'/>
   <assignedPerson>
      <name><given>Gerline</given><family>Maier</family></name>
   </assignedPerson>
</assignedEntity>

Person under the Legal Umbrella of a Practice, Pharmacy, etc.

The following figure shows how a person who acts under the legal umbrella of a medical practice or pharmacy is recorded as a <assignedEntity> or <assignedAuthor>.

Template

   <assignedAuthor> <!—or <assignedEntity> -->
      <templateId root='1.2.276.0.76.3.1.81.81.6.2.2' />
      <id extension='' root=''/>
      <code code='...' displayName='...' codeSystem='...' codeSystemName='...' />
      <telecom value='.... '/>
      <addr></addr></code><code>
      <assignedPerson><name> ... </name></assignedPerson>
      <representedOrganization>
         <id extension='...' root='...'/>
         <name> ... </name>
         <telecom value='...'/>
         <addr> ... </addr>
      </representedOrganization>
   </assignedAuthor> <!—or </assignedEntity> -->

Elements not highlited in the template MUST be used as defined for human entities who act without an organizational scope.

<telecom value=’...’/><addr></addr>

These elements should record the job address and contact data of the person. While the address is optional, at least an eMail-Address or a phone number for getting in contact with the human entity MUST be provided. Telecommunication addresses SHOULD be classified by the @use attribute if the address is not the work place (@use=”WP”) of the entity. Public addresses (@use=”PUB”) SHOULD not be recorded with the person but with the represented organization.

<representedOrganization>

This element holds the unique identifier of the medical organization, its name and preferred contact data. For identifying the organization an identifier from one of the identification schemes listed in table Healthcare Professional Organization Instance Identifiers MUST be used. Multiple Identifiers MAY be given.

Example

   <assignedEntity>
	<templateId root='1.2.276.0.76.3.1.81.81.6.2.2'/>

   <!-- German Profile: HBA Certificate Number and gematik role code -->
	<id extension='HPC-Physician-1' root='1.2.276.0.76.4.75'/>

	<code code='1.2.276.0.76.4.30' displayName='arzt-ghcs'/>

	<telecom value='tel:+49(30)234-5678'/>
	<assignedPerson>
		<name><prefix qualifier="AC">Dr. med.</prefix><given>Klaas</given><family>Muster</family></name>
	</assignedPerson>
	<representedOrganization>
		<templateId root='1.2.276.0.76.3.1.81.81.6.2.5'/>
		<id extension='SMC-Pracitice-1' root='1.2.276.0.76.4.77'/>
		<name>Onkologische Gemeinschaftspraxis Schulz Meier Muster</name>
		<telecom value=' tel:+49(30)234-5600'/>
		<addr>
			<streetName>Kurze Straße</streetName>
			<houseNumber>4</houseNumber>
			<postalCode>11111</postalCode>
			<city>Berlin</city>
		</addr>
	</representedOrganization>
   </assignedEntity>

Person under the Legal Umbrella of a Hospital

The following figure shows how a person who acts under the legal umbrella of a hospital is recorded as a <assignedEntity> or <assignedAuthor>.

Template

   <assignedAuthor> <!—or <assignedEntity> -->
      <templateId root='1.2.276.0.76.3.1.81.81.6.2.2' />
      <id extension='' root=''/>
      <id extension="..." root="1.2.276.0.76.3.1.81.81.4.2.1"/>
      <code code='...' displayName='...' codeSystem='...' codeSystemName='...' />
      <telecom value='.... '/>
      <addr></addr>
      <assignedPerson><name> ... </name></assignedPerson>
      <representedOrganization>
         <id extension='' root=''/>
         <name> ... </name>
         <addr> ... </addr>
         <telecom value='...'/>
         <asOrganizationPartOf>
            <!-- this template signals the German profile -->
            <templateId root='1.2.276.0.76.3.1.81.81.6.4.2'/>
            <code code='...' displayName='...' codeSystem='...' codeSystemName='...' />
      	    <wholeOrganization>
                <id extension='' root=''/>
                <name> ... </name>
            </wholeOrganization>
         </asOrganizationPartOf>
      </representedOrganization>
   </assignedAuthor> <!—or </assignedEntity> -->

Elements not highlited in the template MUST be used as defined for human entities who act without an organizational scope.

<representedOrganization>

<id extension= root=/>

The represented organization records the hospital department or faculty to which the human entity is assigned. Identifiers for hospital departments MUST NOT be given unless (1) the department is assigned its own SMC-B and (2) the identifier can be discovered through public directory services. In all other cases the healthcare provider entity identifier of a hospital department MUST be recorded as unknown: <id nullFlavor=”UNK” />

<representedOrganization>...

<name>...</name> <addr>...</addr> <telecom />

Name, address and contact data of the hospital department or faculty.

<representedOrganization> ...

<asOrganizationPartOf>

A faculty or department MUST always be linked with a hospital. The code SHOULD record the structural role of the department within the hospital (e.g. “cardiology”, “laboratory”, etc.).

For the German healthcare system the <code> element SHOULD record the 4-letter »Fachbereichskennung« acc. to § 301 SGB V. The <asOrganizationPartOf> element MUST be classified with the respective template id (1.2.276.0.76.3.1.81.81.6.4.2).

<wholeOrganization>

<id extension= root=/>

<name></name>

The organization the department/faculty belongs to MUST be identified by a unique identifier and its name.

For identifying the organization an identifier from one of the identification schemes listed in table Healthcare Professional Organization Instance Identifiers MUST be used. Multiple Identifiers MAY be given.

Example

   <assignedEntity>
	<templateId root='1.2.276.0.76.3.1.81.81.6.2.2'/>
	<id extension='HPC-Physician-1' root='1.2.276.0.76.4.75'/>
	<code code='1.2.276.0.76.4.30' displayName='arzt-ghcs'/>
	<addr>Kardiologie, Klinikum Berlin</addr>
	<telecom value='tel:+49(30)234-5678'/>
	<assignedPerson>
		<name><prefix qualifier="AC">Dr. med.</prefix><given>Klaas</given><family>Muster</family></name>
	</assignedPerson>
	<representedOrganization>
		<templateId root='1.2.276.0.76.3.1.81.81.6.2.5'/>
		<name>Kardiologie, Prof. Schulz</name>
		<telecom value=' tel:+49(30)234-5600'/>
		<addr>Muellerstr. 4</addr>
		<asOrganizationPartOf>
			<templateId root='1.2.276.0.76.3.1.81.81.6.4.2'/>
			<code code='P301'/>
        		<wholeOrganization>
				<id extension='SMC-Hospital-1' root='1.2.276.0.76.4.77'/>
				<name>Klinikum Berlin</name>
			</wholeOrganization>
   		</asOrganizationPartOf>    				
	</representedOrganization>
   </assignedEntity>