1.2.276.0.76.3.1.81.81.6.2.2
Dieses Material ist Teil des Leitfadens CDA für die elektronische Fallakte.
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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.
Inhaltsverzeichnis
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>
Diskussion: Bei der Profilierung des PN-Typs durch HL7-D erfolgt nur eine minimale Normierung der Syntax. Wenn Personennamen aus einem CDA Dokument für eine MPI-Query (o.ä.) nutzbar sein sollen, sollten typische Kodierungsfehler und potenzielle Mehrdeutigkeiten ausgeschlossen werden. Von daher soll für die EFA sowohl Moxed Content als auch Freitext ausgeschlossen werden. Wäre es nicht sinnvoll, diese Beschränkungen zumindest als Empfehlung auch in den deutschen CDA Datentypen Leitfaden aufzunehmen? |
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>
<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>Dr. Klaus Muster</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>
<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=/>
- <name>...</name> <addr>...</addr> <telecom />
- <asOrganizationPartOf>
- <wholeOrganization>
- <id extension= root=/>
- <name></name>
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>Dr. John Musterarzt</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>