cdaefa:1.2.276.0.76.3.1.81.81.6.3.1

1.2.276.0.76.3.1.81.81.6.2.2

Consents and Contracts Section

Implementierungsleitfaden

vorgelegt von:
March 2012
Jörg Caumanns

Draft

Version:	0.9
Datum:	March 2012
Status:	xxx
Verfahren:	{{{Verfahren}}}
Realm:	Deutschland

Copyright © 2011-2012: HL7 Deutschland

The Consents and Contracts section provides an overview about

• the consents given by the patient
• contracts among the care providers
• contracts between the care team and health insurance companies (e.g. for participation with a managed care program)

The CDA Level 3 coded Consent and Contracts section can as well manage digital consents or scanned documents as references to paper forms.

Standards

• IHE PCC Patient Education and Consents Section (1.3.6.1.4.1.19376.1.5.3.1.3.35)

Template

  <component>
     <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.35'/>
        <templateId root='1.2.276.0.76.3.1.81.81.6.3.1.1'/>
        <id root=' ' extension=' '/>
        <code code='34895-3' displayName='EDUCATION NOTE'
     		  codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
        <text>...</text>  
        <entry>
           ...
           <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
           <templateId root='1.2.276.0.76.3.1.81.81.6.4.1'/>
           ...
        </entry> 
     </section>
  </component>

Template Identifier

CDA Level	Content Module	templateId
3	IHE PCC Patient Education and Consents S.	1.3.6.1.4.1.19376.1.5.3.1.3.35
3	eCR Coded Consents and Contracts Section	1.2.276.0.76.3.1.81.81.6.3.3.1

Entries

• <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
• <templateId root='1.2.276.0.76.3.1.81.81.6.4.1'/>

Contracts and consents MUST comply with the IHE PCC Simple Observation Entry Content Module and the eCR Consent Directive Observation Entry Content Module. See section xxxx for the definition of the respective Entry Content Module.

CDA Level 3 Example

   <component>
      <section>
         <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.38'/>
         <templateId root='1.2.276.0.76.3.1.81.81.6.3.1.1'/>
         <id root='1.1.1.1' extension='section-2'/>
         <code code='34895-3' displayName='EDUCATION NOTE'
 	       codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

         <!-- Level 2 textual encoding -->
         <text>
            <list>
               <item ID='id-2'>Full Patient Consent given to 
                               Dr. Schulz on 09.09.2011</item>
            </list>
         </text>  

   <!—Level 3 coded representation of the consent -->
         <entry>
            <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
            <templateId root='1.2.276.0.76.3.1.81.81.6.4.1'/>
            <observation typeCode='OBS' moodCode='EVN'>
               <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
               <templateId root='1.2.276.0.76.3.1.81.81.6.4.1'/>
               <id root='1.1.1.1' extension='consent-1'/>

   <!-- the consent is active; documents may be registered and read -->
               <code code='P' displayName='Pending' 
                     codeSystem='2.16.840.1.113883.12.498' 
                     codeSystemName='HL7 Consent Status'/>

   <!-- the consent allows for regular eCR use and allows eCR participants to 
        autonomously link visits to the eCR -->
               <value xsi:type='CD' code='SETUP' displayName='Setup and Use' 
                                    codeSystem='1.2.276.0.76.3.1.81.81.5.1' 
                                    codeSystemName='eCR Consent Authorization Code'/>
               <value xsi:type='CD' code='ENCLINK' displayName='Encounter Linkage' 
                                    codeSystem='1.2.276.0.76.3.1.81.81.5.1' 
                                    codeSystemName='eCR Consent Authorization Code'/>
               <text><reference value='#id-2'/></text>
               <statusCode code='completed'/>

   <!-- the consent is valid for 2 years -->
               <effectiveTime>
                  <low value='20110909'/>
                  <high value='20130909'/>
               </effectiveTime>  

   <!-- the consent was given to the identified physician on Sept. 9. 2011 -->
               <author>
                  <time value="20110909"/>
                  <assignedAuthor>
                     <templateId root='1.2.276.0.76.3.1.81.81.6.2.2'/>
                     <id extension='HPC-Physician-2' root='1.2.276.0.76.4.75'/>
                     <code code='1.2.276.0.76.4.30' displayName='arzt-ghcs'/>
                     ...
                  </assignedAuthor>
               </author>

   <!-- the consent was scanned and stored as a document with the eCR Repository -->
               <reference typeCode='REFR'>
                  <templateId root='2.16.840.1.113883.10.20.1.36'/>
                  <externalDocument classCode='DOC' moodCode='EVN'>
                     <id extension="ecrdoc-1" root="1.2.3.4.5.6.7.8"/>
                  </externalDocument>
               </reference>
            </observation>
         </entry> 
      </section>
   </component>