cdaefa:1.2.276.0.76.3.1.81.81.6.3.1

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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.

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>