1.2.276.0.76.3.1.81.81.6.3.1

Aus Hl7wiki
(Teildokument von CDA für die elektronische Fallakte)
Wechseln zu: Navigation, Suche
Zeile 1: Zeile 1:
<!--
+
{{DocumentPart}}
 
 
    Implementierungsleitfaden "CDA für die elektronische Fallakte"
 
 
 
-->
 
{{Infobox Dokument
 
|Title    = 1.2.276.0.76.3.1.81.81.6.2.2
 
|Short    = Consents and Contracts Section
 
|Namespace = cdaefa
 
|Type      = Implementierungsleitfaden
 
|Version  = 0.9
 
|Submitted = March 2012
 
|Author    = Jörg Caumanns
 
|Date      = March 2012
 
|Copyright = 2011-2012
 
|Status    = Draft
 
|Period    = xxx
 
|OID      = n.n.
 
|Realm    = Deutschland
 
}}
 
  
 
The Consents and Contracts section provides an overview about  
 
The Consents and Contracts section provides an overview about  

Version vom 14. März 2012, 22:02 Uhr

Dieses Material ist Teil des Leitfadens CDA für die elektronische Fallakte.
  • Direkt im Wiki geändert werden sollten Schreibfehler, ergänzende Hinweise.
  • Offene Fragen, die der Diskussionen bedürfen, sollten auf der Diskussionsseite aufgenommen werden.
  • Liste der Seiten dieses Leitfadens: hier, Liste der Seiten, in denen dieses Material verwendet (transkludiert) siehe hier .

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. See section xxxx for the definition of the respective 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>