1.2.276.0.76.3.1.81.81.6.2.1

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Template ID	1.2.276.0.76.3.1.81.81.6.2.1
Genutztes Template	cdaab2:Patient_(recordTarget)_(Template)
Abgeleitete Templates	keines
Generelle Beschreibung	Template für efa
Erweiterbarkeit	geschlossen

For 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 stated otherwise the Patient Role MUST be encoded according to the general rules of CDA Medical Documents.

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>

Schematron

This Schematron can be used for verifying that a given CDA document does follow the rules as defined in this content module specification.

   <?xml version="1.0" encoding="UTF-8"?>

   <schema xmlns="http://purl.oclc.org/dsdl/schematron" queryBinding="xslt2">
      <title>CDA Schematron Rule Definitions</title>

      <ns prefix="cda" uri="urn:hl7-org:v3" />
      <!--<ns prefix="xs" uri="http://www.w3.org/2001/XMLSchema" />-->

      <pattern id="patient-role-header-content-module">
         <title>Patient Role Header Content Module</title>

         <rule context="cda:patientRole[cda:templateId/@root = '1.2.276.0.76.3.1.81.81.6.2.1']">

            <report flag="description" test="true()">
               Checks the correctness (in patientRole) of the id and that raceCode, ethnicGroupCode
               and religiousAffiliationCode are not set. The latter CAN be set if explicitly
               requested by the patient.
            </report>

            <assert flag="warning" 
                    test="cda:id/@root = '1.2.276.0.76.4.8' or cda:id/@root = '1.2.276.0.76.4.1'">
               Root OID MUST be 1.2.276.0.76.4.8 or 1.2.276.0.76.4.1 or a local root OID (ordered 
               by preference). A local root OID cannot be checked for correctness (yet?).
            </assert>

            <assert flag="warning" test="cda:id/@root = '1.2.276.0.76.4.8'">
               Root OID is not the preferred one: 1.2.276.0.76.4.8
            </assert>

            <assert test="not(cda:patient/cda:raceCode)">
               The patient raceCode MUST NOT be used.
            </assert>

            <assert test="not(cda:patient/cda:ethnicGroupCode)">
               The patient ethnicGroupCode MUST NOT be used.
            </assert>

            <assert flag="warning" test="not(cda:patient/cda:religiousAffiliationCode)">
               The patient religiousAffiliationCode MUST NOT be used EXCEPT explicitly requested 
               by the patient.
            </assert>

            <report flag="todo" test="true()">
               Find out how to check if religiousAffiliationCode was requested (maybe in a 
               schematron on the document level where other entries may refer to the patient's consent.
            </report>
         </rule>
      </pattern>
   </schema>