cdaefa:1.2.276.0.76.3.1.81.81.6.2.1

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CDA documents that are used for encoding part of the eCR information model, the following constraints apply wrt the identification of the patient who is subject to the documented healthcare event.

Patient Role Header Content Module

Unless states otherwise the Patient Role MUST be encoded according to the general rules of CDA Medical Documents (1.3.6.1.4.1.19376.1.5.3.1.1.1).

The following patient demographics MUST NOT be used:

• raceCode
• ethnicGroupCode

A <religiousAffiliationCode> MUST NOT be provided except explicitly requested by the patient (a respective clause MUST be included with the patient’s initial consent).

These constraints are declared by adding <templateId root=’1.2.276.0.76.3.1.81.81.6.2.1’ /> to the <patientRole> element.

Patient Identification Schemes

Only the following identification schemes MUST be used. If multiple schemes are available for a practice, the order in the table denotes the order of preference.

Person Role	Scheme	Root OID
Patient	Fixed part of unique health insurance number (KVNR).	1.2.276.0.76.4.8
Patient	Full health insurance number (KVNR)	1.2.276.0.76.4.1
Patient	Local identifier within the healthcare organization. Local identifiers MUST NOT be directly derived from personal id numbers that are assigned by non-healthcare authorities.	Local Root OID

Example

<patientRole>
	<templateId root="1.2.276.0.76.3.1.81.81.6.2.1"/>

<!-- German Profile: Healthcare Patient Identifer -->
	<id extension="..." root="1.2.276.0.76.4.8"/>

	<addr>
		<streetName>Steinplatz</streetName>
		<houseNumber>2</houseNumber>
		<postalCode>11111</postalCode>
		<city>Berlin</city>
	</addr>
	<patient>
		<name>
			<given>Hans</given>
			<family>Mustermann</family>
		</name>
		<administrativeGenderCode code="M" 	codeSystem="2.16.840.1.113883.5.1"/>
		<birthTime value="19700908"/>
		<birthplace>
			<place><addr><city>Bielefeld</city></addr></place>
		</birthplace>
	</patient>
</patientRole>