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# Template International Patient Summary

Id | 2.16.840.1.113883.10.22.1.2 | Effective Date | 2024‑08‑02 13:02:39
Status | Draft | Version Label | 2024
Name | HL7-IPS | Display Name | International Patient Summary
Description
The International Patient Summary is a "Minimal and non-exhaustive Patient Summary, specialty-agnostic, condition-independent, but readily usable by all clinicians for the unscheduled (cross-border) care of a patient." The IPS templates aim to: Serve for both cross-jurisdictional (through adaptation/extension for multi-language and realm scenarios, including translation) and national (through localization) patient summaries. Support emergency care and unplanned care in any country (home and foreign), regardless of language Define value sets based on international vocabularies that are usable and understandable in any country
Context | Pathname /
Classification | CDA Document Level Template
Open/Closed | Open (other than defined elements are allowed)
Used by / Uses |
Used by 1 transaction and 0 templates, Uses 23 templates
Used by | as | Name | Version
--- | --- | --- | ---
hl7ips-transaction-3 | Transaction | IPS Created (2024) | 2024‑08‑02
Uses | as | Name | Version
2.16.840.1.113883.10.22.2.1 | Include | IPS CDA recordTarget (2021) | DYNAMIC
2.16.840.1.113883.10.22.2.2 | Include | IPS CDA author (STU1) | DYNAMIC
2.16.840.1.113883.10.22.2.3 | Include | IPS CDA custodian (2021) | DYNAMIC
2.16.840.1.113883.10.22.2.4 | Include | IPS CDA legalAuthenticator (STU1) | DYNAMIC
2.16.840.1.113883.10.22.2.5 | Include | IPS Patient Contacts (STU1) | DYNAMIC
2.16.840.1.113883.10.22.2.6 | Include | IPS CDA documentationOf (STU1) | DYNAMIC
2.16.840.1.113883.10.22.2.7 | Include | IPS CDA relatedDocument (STU1) | DYNAMIC
2.16.840.1.113883.10.22.3.1 | Containment | IPS Medication Summary Section (STU1) | DYNAMIC
2.16.840.1.113883.10.22.3.2 | Containment | IPS Allergies and Intolerances Section (STU2) | DYNAMIC
2.16.840.1.113883.10.22.3.3 | Containment | IPS Problems Section (STU1) | DYNAMIC
2.16.840.1.113883.10.22.3.4 | Containment | IPS History of Procedures Section (STU1) | DYNAMIC
2.16.840.1.113883.10.22.3.5 | Containment | IPS Immunizations Section (STU1) | DYNAMIC
2.16.840.1.113883.10.22.3.6 | Containment | IPS Medical Devices Section (2021) | DYNAMIC
2.16.840.1.113883.10.22.3.14 | Containment | IPS Results Section (STU1) | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 | Containment | eHDSI Vital Signs | DYNAMIC
2.16.840.1.113883.10.22.3.7 | Containment | IPS History of Past Illness Section (STU1) | DYNAMIC
2.16.840.1.113883.10.22.3.8 | Containment | IPS Functional Status Section (TI-2020) | DYNAMIC
2.16.840.1.113883.10.22.3.9 | Containment | IPS Plan of Care Section (TI-2020) | DYNAMIC
2.16.840.1.113883.10.22.3.10 | Containment | IPS Social History Section (TI-2020) | DYNAMIC
2.16.840.1.113883.10.22.3.11 | Containment | IPS History of Pregnancy Section (TI-2020) | DYNAMIC
2.16.840.1.113883.10.22.3.12 | Containment | IPS Advance Directives Section (TI-2020) | DYNAMIC
2.16.840.1.113883.10.22.3.17 | Containment | IPS Alerts Section | DYNAMIC
2.16.840.1.113883.10.22.3.18 | Containment | IPS Patient Story Section | DYNAMIC
Relationship | Specialization: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2020‑07‑14 16:08:21) Version: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2020‑05‑08 12:30:59) Version: template 2.16.840.1.113883.10.22.1.1 International Patient Summary (2017‑04‑11) Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 epSOS-Patient Summary (2013‑12‑20) ref epsos- Adaptation: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07) ref ad1bbr-
Example |
Example
<ClinicalDocument> <realmCode code="ES"/> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="2.16.840.1.113883.10.22.1.1"/> <id root="2.16.724.4.8.10.200.10" extension="PSCTD0160f274530a031"/> <code displayName="Patient Summary" code="60591-5" codeSystem="2.16.840.1.113883.6.1"> <title>Patient Summary</title> <effectiveTime value="20111113125600+0200"/> <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="es-ES"/> <setId root="2.16.724.4.8.10.200.10" extension="PSCTD0160f274530a031S"/> <versionNumber value="2"/> <!-- include template 2.16.840.1.113883.10.22.2.1 'IPS CDA recordTarget' (dynamic) 1..1 M --> <!-- include template 2.16.840.1.113883.10.22.2.2 'IPS CDA author' (dynamic) 1..* M --> <!-- include template 2.16.840.1.113883.10.22.2.3 'IPS CDA custodian' (dynamic) 1..1 M --> <!-- include template 2.16.840.1.113883.10.22.2.4 'IPS CDA legalAuthenticator' (dynamic) 0..1 R --> <!-- include template 2.16.840.1.113883.10.22.2.5 'IPS Patient Contacts' (dynamic) 0..* O --> <!-- include template 2.16.840.1.113883.10.22.2.6 'IPS CDA documentationOf ' (dynamic) 1..1 M --> <!-- include template 2.16.840.1.113883.10.22.2.7 'IPS CDA relatedDocument' (dynamic) 0..* R --> <component> <structuredBody classCode="DOCBODY"> <component> <!-- template 2.16.840.1.113883.10.22.3.1 'IPS Medication Summary Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.2 'IPS Allergies and Intolerances Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.3 'IPS Problems Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.4 'IPS History of Procedures Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.5 'IPS Immunizations Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.6 'IPS Medical Devices Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.7 'IPS History of Past Illness Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.14 'IPS Results Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.8 'IPS Functional Status Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.9 'IPS Plan of Treatment Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.10 'IPS Social History Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.11 'IPS History of Pregnancy Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.3.12 'IPS Advance Directives Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.15 'IPS Alerts Section' (dynamic) --> </component> <component> <!-- template 2.16.840.1.113883.10.22.16 'IPS Patient Story Section' (dynamic) --> </component> </structuredBody> </component> </code></ClinicalDocument>
Item | DT | Card | Conf | Description | Label
--- | --- | --- | --- | --- | ---
hl7:ClinicalDocument |  |  | R | CDA header |
hl7:realmCode | CS | 0 … 1 | R |  |
hl7:typeId | II | 1 … 1 | M | The clinical document typeId identifies the constraints imposed by CDA R2 on the content, essentially acting as a version identifier. |
@root | uid | 1 … 1 | F | 2.16.840.1.113883.1.3
@extension | st | 1 … 1 | F | POCD_HD000040
| Example | <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
hl7:templateId | II | 1 … 1 | M |  |
@root | uid | 1 … 1 | F | 2.16.840.1.113883.10.22.1.1
hl7:id | II | 1 … 1 | M | Unique identifier of this instance of the Patient Summary. |
hl7:code | CE.IPS | 1 … 1 | M | Determines the document type that is the "Patient Summary" document |
@displayName |  | 1 … 1 | R |
@code | CONF | 1 … 1 | F | 60591-5
@codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.1 (LOINC)
| Example | <code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/>
hl7:translation | CD.IPS | 0 … * | R | This element can be here used either to provide the originally used document code if this IPS is the result of a transformation. |
hl7:title | ST | 1 … 1 | M | ClinicalDocument/title is used for display purposes. |
hl7:effectiveTime | TS.IPS.TZ | 1 … 1 | M | Time of creation of the Patient Summary |
| Example | <effectiveTime value="20111113125600+0200"/>
hl7:confidentialityCode | CE.IPS | 1 … 1 | R |  |
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
| Example | <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal"/>
hl7:languageCode | CS | 1 … 1 | M | Document Language Code |
| Constraint | The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)
| Example | <languageCode code="en-GB"/>
| Example | <languageCode code="fil-PH"/>
| Schematron assert | role | error |
| test | matches(@code,'[a-z]{2,3}-[A-Z]{2,3}') |
| Message | The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code) |
hl7:setId | II | 0 … 1 | R | This attribute “represents an identifier that is common across all document revisions”. In the case the IPS instance is generated as result of one or more transformations (translation/transcoding) the setId is supposed to remain unchanged across all those transformations. Implementers are recommended to use this attribute. |
hl7:versionNumber |  | 0 … 1 | R |  |
Included | 1 … 1 | M | from 2.16.840.1.113883.10.22.2.1 IPS CDA recordTarget (DYNAMIC)
hl7:recordTarget |  | 1 … 1 | M |  |
@typeCode | cs | 0 … 1 | F | RCT
@contextControlCode | cs | 0 … 1 | F | OP
| Example | <recordTarget typeCode="RCT" contextControlCode="OP"> <patientRole classCode="PAT"> <id root="1.2.3.999" extension="__example only__"/> <addr> <streetAddressLine>HSE M CASSAR STR</streetAddressLine> <city>ISLA</city> <country>MT</country> </addr> <telecom use="HP" value="tel:+356124567891"/> <telecom use="WP" value="mailto:elif@foo.too.mt"/> <patient> <name> <family>BORG</family> <given>TANIA</given> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/> <birthTime value="19430130"/> <!-- Optional guardian information ; see example below--> <!-- Optional languageCommunication information see example below --> </patient> </patientRole></recordTarget>
hl7:patientRole |  | 1 … 1 | M |  |
hl7ips-dataelement-2.1 | Patient Attributes | CEN/TC 251 prEN 17269
@classCode | cs | 0 … 1 | F | PAT
hl7:id | II | 1 … * | R | Patient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number) |
hl7ips-dataelement-202 | Healthcare related Identifiers | CEN/TC 251 prEN 17269
hl7ips-dataelement-7 | Insurance identifier | CEN/TC 251 prEN 17269
hl7:addr | AD.IPS | 1 … * | R | The patient address. |
hl7ips-dataelement-162 | Address | CEN/TC 251 prEN 17269
| Constraint | When used for cross-border exchange the country address part has to be provided.
Included |  |  | from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | SHALL NOT have mixed content except for white space If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
| Schematron assert | role | error |
| test | @nullFlavor or hl7:* |
| Message | If addr is not nullflavored at least one sub element has to be provided |
hl7:streetAddressLine | ADXP | 0 … * | C | Subject's or Organization's Street Address Line |
| Schematron assert | role | error |
| test | hl7:streetAddressLine and (hl7:city or hl7:postalCode) |
| Message | If the address line is included either the city or the zip code has to be provided |
hl7:city | ADXP | 0 … 1 | C | Subject's or Organization's City |
hl7:postalCode | ADXP | 0 … 1 | C | Subject's or Organization's Postal Code |
hl7:state | ADXP | 0 … 1 | C | Subject's or Organization's State or Province |
hl7:country | ADXP | 0 … 1 | C | Subject's Country. |
| Constraint | The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom | TEL | 1 … * | R | Patient’s telecom information : e.g. telephone number, e-mail address. |
hl7ips-dataelement-100 | Telecoms | CEN/TC 251 prEN 17269
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
| Example | <telecom use="HP" value="tel:+356124567891"/>
| Example | <telecom use="WP" value="mailto:elif@foo.too.mt"/>
| Example | <telecom nullFlavor="NI"/>
hl7:patient |  | 1 … 1 | M |  |
@classCode | cs | 0 … 1 | F | PSN
@determinerCode | cs | 0 … 1 | F | INSTANCE
| Example | Japanese example (Person Name) <patient> <name use="IDE"> <family>木村</family> <given>通男</given> </name> <name use="SYL"> <family>きむら</family> <given>みちお</given> </name> <name use="ABC"> <family>KIMURA</family> <given>MICHIO</given> </name> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/> <birthTime nullFlavor="UNK"/></patient>
hl7:name | PN | 1 … * | M | Patient Name |
hl7ips-dataelement-3 | Patient's name | CEN/TC 251 prEN 17269
| Constraint | The Alphabetic representation of the name SHALL be always provided
hl7:family |  | 1 … * | R | Patient's Family Name/Surname |
hl7:given |  | 1 … * | R | Patient's Given Name |
hl7:administrativeGenderCode | CE.IPS | 1 … 1 | R | Patient's Gender |
hl7ips-dataelement-4 | Administrative gender | CEN/TC 251 prEN 17269
@nullFlavor | cs | 0 … 1 | F | UNK
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
| Example | <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"> <translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>
hl7:birthTime | TS | 1 … 1 | R | Patient's Date of Birth. The patient date of birth may be a partial date such as only the year. |
hl7ips-dataelement-5 | Date of birth | CEN/TC 251 prEN 17269
hl7:guardian |  | 0 … * | R | The guardians of a patient. Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact. |
@classCode | cs | 1 … 1 | F | GUARD
| Example | <guardian classCode="GUARD"> <code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/> <addr nullFlavor="NI"/> <telecom use="MC" value="tel:+33-12345678"/> <guardianPerson> <name> <family>Curie</family> <given>Marie</given> </name> </guardianPerson></guardian>
hl7:code | CD.IPS | 0 … 1 | R | The relationship between the patient and the guardian or other contact may be recorded in the `element.` |
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr | AD.IPS | 1 … * | R |  |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
Included |  |  | from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | SHALL NOT have mixed content except for white space If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
| Schematron assert | role | error |
| test | @nullFlavor or hl7:* |
| Message | If addr is not nullflavored at least one sub element has to be provided |
hl7:streetAddressLine | ADXP | 0 … * | C | Subject's or Organization's Street Address Line |
| Schematron assert | role | error |
| test | hl7:streetAddressLine and (hl7:city or hl7:postalCode) |
| Message | If the address line is included either the city or the zip code has to be provided |
hl7:city | ADXP | 0 … 1 | C | Subject's or Organization's City |
hl7:postalCode | ADXP | 0 … 1 | C | Subject's or Organization's Postal Code |
hl7:state | ADXP | 0 … 1 | C | Subject's or Organization's State or Province |
hl7:country | ADXP | 0 … 1 | C | Subject's Country. |
| Constraint | The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom | TEL | 1 … * | R | Guardian’s telecom information: e.g. telephone number; e-mail address. |
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
hl7:guardianPerson |  | 1 … 1 | R |  |
hl7:name | PN | 1 … * | R | Patient Guardian's Name |
hl7:family | ENXP | 1 … * | R | Patient Guardian's Family Name/Surname |
hl7:given | ENXP | 1 … * | R | Patient Guardian's Given Name |
hl7:languageCommunication |  | 0 … * | R |  |
hl7:languageCode | CS | 1 … 1 | R | Patient’s language |
hl7ips-dataelement-135 | Patient’s preferred language | CEN/TC 251 prEN 17269
| Constraint | The two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.4.642.3.21 All Languages (DYNAMIC)
| Example | British English <languageCode code="en-GB"/>
| Example | Amurdak (Australia) <languageCode code="amg-AU"/>
| Schematron assert | role | error |
| test | matches(@code,'[a-z]{2,3}-[A-Z]{2,3}') |
| Message | The language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code) |
Included | 1 … * | M | from 2.16.840.1.113883.10.22.2.2 IPS CDA author (DYNAMIC)
hl7:author |  | 1 … * | M |  |
@typeCode | cs | 0 … 1 | F | AUT
@contextControlCode | cs | 0 … 1 | F | OP
| Example | <author> <time value="201212290600+0100"/> <assignedAuthor> <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/> <addr use="WP"> <streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country> </addr> <telecom use="WP" value="tel:+39-051-34343434"/> <assignedPerson> <name> <given>Paolo</given> <family>Rossi</family> </name> </assignedPerson> </assignedAuthor> <representedOrganization> <!-- template 'IPS CDA Organization' (dynamic) --> </representedOrganization></author>
hl7:functionCode | CE.IPS | 0 … 1 | R |  |
hl7:time | TS.IPS.TZ | 1 … 1 | R | The author/time element represents the start time of the author’s participation in the creation of the clinical document. |
| Example | <time value="201212290600+0100"/>
hl7:assignedAuthor |  | 1 … 1 | R |  |
@classCode | cs | 0 … 1 | F | ASSIGNED
hl7:id | II | 1 … * | R | Author Identifier(s) |
@nullFlavor | cs | 0 … 1 |  |
hl7:code | CE.IPS (extensible) | 0 … 1 | R | A code, which identifies the profession/competence/specialty of the author when it is a person. |
| CONF |
The value of @code SHOULD be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
| Example | <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>
hl7:addr | AD.IPS | 1 … * | R |  |
| Example | <addr use="WP"> <streetAddressLine>Viale della Cristallina 3</streetAddressLine> <city>Bologna</city> <state>BO</state> <postalCode>40121</postalCode> <country>IT</country></addr>
hl7:telecom | TEL.IPS | 1 … * | R |  |
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@value | url | 0 … 1 |  |
| Example | <telecom use="WP" value="tel:+39-051-34343434"/>
| Example | <telecom nullFlavor="NI"/>
Choice | 1 … 1 |  | Elements to choose from: hl7:assignedPerson hl7:assignedAuthoringDevice
hl7:assignedPerson |  | 0 … 1 | C |  |
@classCode | cs | 0 … 1 | F | PSN
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:name | PN | 1 … * | R | Name of the person (e.g. the Healthcare Professional) authoring this document |
| Example | <name> <given>John</given> <family>Español Smith</family></name>
hl7:family |  | 1 … * | R |  |
hl7:given |  | 1 … * | R |  |
hl7:assignedAuthoringDevice |  | 0 … 1 | C |  |
| Example | <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included |  |  | from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
@classCode | cs | 0 … 1 | F | DEV
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:code | CE | 0 … 1 |  |  |
hl7:manufacturerModelName | SC | 0 … 1 |  |  |
hl7:softwareName | SC | 0 … 1 |  |  |
hl7:representedOrganization |  | 0 … 1 | R |  |
Included |  |  | from 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
@classCode | cs | 1 … 1 | F | ORG
@determinerCode | cs | 1 … 1 | F | INSTANCE
hl7:id | II | 1 … * | R |  |
@nullFlavor | cs | 0 … 1 |  |
hl7:name | ON | 1 … 1 | R |  |
@nullFlavor | cs | 0 … 1 |  |
hl7:telecom | TEL | 1 … * | R |  |
@use | set_cs | 1 … 1 | R |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor | cs | 0 … 1 |  |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
hl7:addr | AD.IPS | 1 … 1 | R |  |
Included |  |  | from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | SHALL NOT have mixed content except for white space If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
| Schematron assert | role | error |
| test | @nullFlavor or hl7:* |
| Message | If addr is not nullflavored at least one sub element has to be provided |
hl7:streetAddressLine | ADXP | 0 … * | C | Subject's or Organization's Street Address Line |
| Schematron assert | role | error |
| test | hl7:streetAddressLine and (hl7:city or hl7:postalCode) |
| Message | If the address line is included either the city or the zip code has to be provided |
hl7:city | ADXP | 0 … 1 | C | Subject's or Organization's City |
hl7:postalCode | ADXP | 0 … 1 | C | Subject's or Organization's Postal Code |
hl7:state | ADXP | 0 … 1 | C | Subject's or Organization's State or Province |
hl7:country | ADXP | 0 … 1 | C | Subject's Country. |
| Constraint | The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Included | 1 … 1 | M | from 2.16.840.1.113883.10.22.2.3 IPS CDA custodian (DYNAMIC)
hl7:custodian |  | 1 … 1 | M |  |
@typeCode | cs | 0 … 1 | F | CST
| Example | <custodian typeCode="CST"> <assignedCustodian classCode="ASSIGNED"> <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE"> <!-- template 'IPS CDA Organization' (dynamic) --> </representedCustodianOrganization> </assignedCustodian></custodian>
hl7:assignedCustodian |  | 1 … 1 | R |  |
@classCode | cs | 0 … 1 | F | ASSIGNED
hl7:representedCustodianOrganization |  | 1 … 1 | R |  |
@classCode | cs | 0 … 1 | F | ORG
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:id | II | 1 … * | R |  |
@nullFlavor | cs | 0 … 1 |  |
hl7:name | ON | 1 … 1 | R |  |
@nullFlavor | cs | 0 … 1 |  |
hl7:telecom | TEL | 1 … 1 | R |  |
@use | set_cs | 1 … 1 | R |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor | cs | 0 … 1 |  |
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
hl7:addr | AD.IPS | 1 … 1 | R |  |
Included |  |  | from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | SHALL NOT have mixed content except for white space If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
| Schematron assert | role | error |
| test | @nullFlavor or hl7:* |
| Message | If addr is not nullflavored at least one sub element has to be provided |
hl7:streetAddressLine | ADXP | 0 … * | C | Subject's or Organization's Street Address Line |
| Schematron assert | role | error |
| test | hl7:streetAddressLine and (hl7:city or hl7:postalCode) |
| Message | If the address line is included either the city or the zip code has to be provided |
hl7:city | ADXP | 0 … 1 | C | Subject's or Organization's City |
hl7:postalCode | ADXP | 0 … 1 | C | Subject's or Organization's Postal Code |
hl7:state | ADXP | 0 … 1 | C | Subject's or Organization's State or Province |
hl7:country | ADXP | 0 … 1 | C | Subject's Country. |
| Constraint | The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
Included | 0 … 1 | R | from 2.16.840.1.113883.10.22.2.4 IPS CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator |  | 0 … 1 | R |  |
| Example | <legalAuthenticator> <time value="20111013150937-0800"/> <signatureCode code="S"/> <assignedEntity> <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/> <assignedPerson> <name> <given>John</given> <family>Español Smith</family> </name> </assignedPerson> <representedOrganization> <name>Healthcare Facility's name</name> <addr> <country>NL</country> <streetName>Duinweg</streetName> <houseNumber>23</houseNumber> <postalCode>7364 RX</postalCode> <city>Amsterdam</city> </addr> </representedOrganization> </assignedEntity></legalAuthenticator>
hl7:time | TS.IPS.TZ | 1 … 1 | M | Time of signing the document |
hl7:signatureCode | CS | 0 … 1 | R | Signature code |
@code | CONF | 0 … 1 | F | S
hl7:assignedEntity |  | 0 … 1 | R | The entity that is responsible for the legal authentication of the CDA document |
hl7:id |  | 1 … * | R | Unique identification of legal authenticator |
hl7:addr | AD.IPS | 1 … * | R |  |
hl7:telecom | TEL.IPS | 1 … * | R |  |
hl7:assignedPerson |  | 1 … 1 | R |  |
@classCode | cs | 0 … 1 | F | PSN
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:name | PN | 1 … * | R | Name of the legal authenticator |
| Example | <name> <given>John</given> <family>Español Smith</family></name>
hl7:family |  | 1 … * | R | HP Family Name/Surname |
hl7:given |  | 1 … * | R | HP Given Name |
hl7:representedOrganization |  | 1 … 1 | M | Organization the legal authenticator is acting for Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) |
Included | 0 … * |  | from 2.16.840.1.113883.10.22.2.5 IPS Patient Contacts (DYNAMIC)
hl7:participant |  | 0 … * | R | Patient contacts or the Preferred Health Professional to contact in case of emergency. |
where [hl7:templateId/@root='2.16.840.1.113883.10.22.2.5'] |
hl7ips-dataelement-154 | Patient’s Address Book | CEN/TC 251 prEN 17269
hl7ips-dataelement-163 | Preferred Healthcare providers | CEN/TC 251 prEN 17269
@typeCode | cs | 1 … 1 | F | IND
| Example | <participant typeCode="IND"> <templateId root="2.16.840.1.113883.10.22.2.5"/> <associatedEntity classCode="NOK"> <addr> <streetAddressLine>Promenade des Anglais 111</streetAddressLine> <city>Lyon</city> <postalCode>69001</postalCode> <country>FR</country> </addr> <telecom value="tel:(+33)555-20036" use="WP"/> <associatedPerson> <name> <given>Martha</given> <family>Mum</family> </name> </associatedPerson> </associatedEntity></participant>
hl7:templateId | II | 1 … 1 | M |  |
@root | uid | 1 … 1 | F | 2.16.840.1.113883.10.22.2.5
hl7:functionCode |  | 0 … 1 | C | The element may be used to indicate that this participant is the preferred Health Professional to contact in case of emergency. |
@code | CONF | 0 … 1 | F | PCP
@codeSystem | 0 … 1 | F | 2.16.840.1.113883.5.88 (Participation Function)
hl7:associatedEntity |  |  | R | The element identifies the type of contact. |
@classCode | cs | 1 … 1 | R |
| CONF |
The value of @classCode SHALL be drawn from value set 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes (DYNAMIC)
| Example | <associatedEntity classCode="ECON"> <addr> <streetAddressLine>Karl Strasse</streetAddressLine> <city>Freiberg</city> <postalCode>09599</postalCode> <country>DE</country> </addr> <telecom value="tel:+49-761-11110000" use="WP"/> <associatedPerson> <name> <given>Arzt</given> <family>Guter</family> </name> </associatedPerson></associatedEntity>
hl7:code | CV.IPS | 0 … 1 | R | This element indicates the relationship between the patient and this participant. |
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.11.22.54 IPS Personal Relationship (DYNAMIC)
or
The value of @code SHALL be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
| Example | <code code="AUNT" displayName="θεία" codeSystem="2.16.840.1.113883.5.111"/>
hl7:addr | AD.IPS | 1 … * | R | Patient Contact's / Preferred HP's Address |
| Schematron assert | role | error |
| test | @nullFlavor or hl7:* |
| Message | If addr is not nullflavored at least one sub element has to be provided |
Included |  |  | from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | SHALL NOT have mixed content except for white space If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
| Schematron assert | role | error |
| test | @nullFlavor or hl7:* |
| Message | If addr is not nullflavored at least one sub element has to be provided |
hl7:streetAddressLine | ADXP | 0 … * | C | Subject's or Organization's Street Address Line |
| Schematron assert | role | error |
| test | hl7:streetAddressLine and (hl7:city or hl7:postalCode) |
| Message | If the address line is included either the city or the zip code has to be provided |
hl7:city | ADXP | 0 … 1 | C | Subject's or Organization's City |
hl7:postalCode | ADXP | 0 … 1 | C | Subject's or Organization's Postal Code |
hl7:state | ADXP | 0 … 1 | C | Subject's or Organization's State or Province |
hl7:country | ADXP | 0 … 1 | C | Subject's Country. |
| Constraint | The content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300 DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom | TEL | 1 … * | R | Patient Contact's / Preferred HP's/Legal Organization telephone or e-mail element is required. |
hl7ips-dataelement-169 | Telecoms | CEN/TC 251 prEN 17269
hl7ips-dataelement-174 | Telecoms | CEN/TC 251 prEN 17269
@use | set_cs | 0 … 1 |  |
| CONF |
The value of @use SHALL be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor | cs | 0 … 1 | F | NI
| Constraint | If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present
| Example | <telecom use="WP" value="tel:+45 20 7025 6161"/><telecom use="HP" value="mailto:jsmith@myprovider.co.uk"/>
Choice | 1 … 2 |  | Elements to choose from: hl7:associatedPerson hl7:scopingOrganization
hl7:associatedPerson |  | 0 … 1 | C | Or the associatedPerson, or the scopingOrganization, or both elements shall be provided |
hl7ips-dataelement-165 | Healthcare Provider (person) | CEN/TC 251 prEN 17269
hl7:name | PN | 1 … * | R | Patient Contact's Name / Preferred HP's Name |
hl7ips-dataelement-121 | Name | CEN/TC 251 prEN 17269
| Example | <name> <given>John</given> <family>Español Smith</family></name>
hl7:family |  | 1 … * | R | Patient Contact's Family Name/Surname / Preferred HP's Family Name/Surname |
hl7:given |  | 1 … * | R | Patient Contact's Given Name / Preferred HP's Given Name |
hl7:scopingOrganization |  | 0 … 1 | C | Or the associatedPerson, or the scopingOrganization, or both elements shall be provided |
hl7ips-dataelement-166 | Healthcare Provider (organisation) | CEN/TC 251 prEN 17269
hl7:name | ON | 1 … * | R | Organization's Name |
hl7ips-dataelement-172 | Organisation’s Name | CEN/TC 251 prEN 17269
Included | 1 … 1 | M | from 2.16.840.1.113883.10.22.2.6 IPS CDA documentationOf (DYNAMIC)
hl7:documentationOf |  | 1 … 1 | M | The documentationOf relationship in an International Patient Summary contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. |
@typeCode | cs | 0 … 1 | F | DOC
| Example | <documentationOf> <serviceEvent classCode="PCPR"> <effectiveTime> <low nullFlavor="NI"/> <high value="20110308"/> </effectiveTime> <performer typeCode="PRF"> <!-- See example below --> </performer> </serviceEvent></documentationOf>
hl7:serviceEvent |  | 1 … 1 | R | The main activity being described by a IPS is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the low value should represent the date when the treatment relationship between the patient and the GP started; and the high value the date of the latest care event. |
@classCode | cs | 1 … 1 | F | PCPR
@moodCode | cs | 1 … 1 | F | EVN
hl7:id | II | 0 … * | R |  |
hl7:effectiveTime | IVL_TS | 1 … 1 | R |  |
hl7:low | TS | 1 … 1 | R |  |
hl7:high | TS | 1 … 1 | R |  |
hl7:performer |  | 0 … * | R | It represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors |
@typeCode | cs | 1 … 1 | R |
| CONF |
The value of @typeCode SHALL be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)
| Example | <performer typeCode="PRF"> <assignedEntity> <id assigningAuthorityName="MEF" displayable="false" extension="DVLMMG57R07F205G" root="2.16.840.1.113883.2.9.4.3.2"/> <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"> <translation codeSystem="2.16.840.1.113883.2.9.5.1.111" code="MMG" displayName="Medico di Medicina Generale"/> </code> <addr nullFlavor="NI"/> <telecom nullFlavor="NI"/> <assignedPerson> <name> <family>DVALUNO</family> <given>MMG</given> </name> </assignedPerson> <representedOrganization> <id assigningAuthorityName="A.S.L. DELLA PROVINCIA DI LECCO" extension="030305" root="2.16.840.1.113883.2.9.4.1.1"/> <name>A.S.L. DELLA PROVINCIA DI LECCO</name> <telecom nullFlavor="NI"/> <addr> <state>LECCO</state> <city>LECCO</city> <country>IT</country> <postalCode>23900</postalCode> <streetAddressLine>CORSO CARLO ALBERTO,120</streetAddressLine> </addr> </representedOrganization> </assignedEntity></performer>
hl7:functionCode | CE.IPS | 0 … 1 | R |  |
hl7:time | IVL_TS.IPS.TZ | 0 … 1 | R |  |
hl7:assignedEntity |  | 1 … 1 | M |  |
hl7:id | II | 1 … * | R | Healthcare provider ID number |
hl7:code | CE.IPS (extensible) | 0 … 1 | R | It describes the professional role of the healthcare provider involved in the current or pertinent historical care of the patient. |
| CONF |
The value of @code SHOULD be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
hl7:addr | AD.IPS | 1 … * | R |  |
hl7:telecom | TEL.IPS | 1 … * | R |  |
hl7:assignedPerson |  | 0 … 1 |  |  |
Included |  |  | from 2.16.840.1.113883.10.22.9.3 IPS CDA Person (DYNAMIC)
@classCode | cs | 0 … 1 | F | PSN
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:name | PN | 1 … * | R |  |
hl7:representedOrganization |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC) |
Included | 0 … 2 | R | from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)
| Constraint | A conformant CDA document can have: a single relatedDocument with typeCode "APND"; OR a single relatedDocument with typeCode "RPLC"; OR a single relatedDocument with typeCode "XFRM"; OR a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; OR a combination of two relatedDocuments with typeCodes "XFRM" and "APND". No other combinations are allowed.
hl7:relatedDocument |  | 0 … 2 | R |  |
@typeCode | cs | 1 … 1 | R |
| CONF |
The value of @typeCode SHALL be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument |  | 1 … 1 | R |  |
@classCode | cs | 0 … 1 | F | DOCCLIN
@moodCode | cs | 0 … 1 | F | EVN
hl7:id | II | 1 … * | R |  |
hl7:code | CD.IPS | 0 … 1 | R |  |
@codeSystem | CONF | 0 … 1 | F | 2.16.840.1.113883.6.1 (LOINC)
hl7:text | ED | 0 … 1 | R |  |
hl7:setId | II | 0 … 1 | R |  |
hl7:versionNumber | INT | 0 … 1 | R |  |
hl7:component |  | 1 … 1 | M |  |
hl7:structuredBody |  | 1 … 1 | M | Note: the proposed order of the sections hereafter indicated is not mandatory |
@classCode | cs | 0 … 1 | F | DOCBODY
hl7:component |  | 1 … 1 | M | Contains 2.16.840.1.113883.10.22.3.1 IPS Medication Summary Section (DYNAMIC) |
hl7:component |  | 1 … 1 | M | Contains 2.16.840.1.113883.10.22.3.2 IPS Allergies and Intolerances Section (DYNAMIC) |
hl7:component |  | 1 … 1 | M | Contains 2.16.840.1.113883.10.22.3.3 IPS Problems Section (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.4 IPS History of Procedures Section (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.5 IPS Immunizations Section (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.6 IPS Medical Devices Section (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 2.16.840.1.113883.10.22.3.14 IPS Results Section (DYNAMIC) |
hl7:component |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 eHDSI Vital Signs (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.8 IPS Functional Status Section (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.9 IPS Plan of Care Section (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.10 IPS Social History Section (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.12 IPS Advance Directives Section (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.17 IPS Alerts Section (DYNAMIC) |
hl7:component |  | 0 … 1 |  | Contains 2.16.840.1.113883.10.22.3.18 IPS Patient Story Section (DYNAMIC) |