1.2.276.0.76.3.1.81.81.6.3.1
(Teildokument von CDA für die elektronische Fallakte)
Dieses Material ist Teil des Leitfadens CDA für die elektronische Fallakte.
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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.
Inhaltsverzeichnis
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>
