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Taken from https://service.projectplace.com/pp/pp.cgi/r844355914
CDA Header
Template id:
<!-- conforms to epSOS HCER requirements -->
<templateId <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.1.4"/>
<id root="1.3.6.1.4.1.28284.6.2.4.75" extension="201304291013151234"/><code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
Title:
<title>Health Care Encounter Report</title>Time when the HCER document was generated (current time):
<effectiveTime value="20130429101315+0300"/>
Confidentiality code, value is N.
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="HL7:Confidentiality" displayName="normal"/>Language code, must be taken from portal configuration.
<languageCode code="et-EE"/>Author is to be filled with portal user's data (the logged in user's and its organization's details). Reuse eD implementation for this.
<author>
<time value="20120519234435+0300"/>
<assignedAuthor classCode="ASSIGNED">
<id root="1.3.6.1.4.1.28284.6.2.4.32"/>
<assignedPerson>
<name>
<given>Patient Summary</given>
<family>Fetcher</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="1.3.6.1.4.1.28284.6.2.4.1" extension="90009016"/>
<name>Eesti E-Tervise SA</name>
<telecom use="WP" value="tel:+3726943900"/>
<telecom use="WP" value="mailto:e-tervis@e-tervis.ee"/>
<addr>
<country>EE</country>
<city>Tallinn</city>
<postalCode>10134</postalCode>
<streetAddressLine>Uus-Tatari 25 / Veerenni 13</streetAddressLine>
<state nullFlavor="NI"/>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
Custodian data, from portal configuration:
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="1.3.6.1.4.1.28284.6.2.4.1" extension="90009016"/>
<name>Eesti E-Tervise SA</name>
<addr>
<country>EE</country>
<city>Tallinn</city>
<postalCode>10134</postalCode>
<streetAddressLine>Uus-Tatari 25 / Veerenni 13</streetAddressLine>
<state nullFlavor="NI"/>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
Legal authenticator data, from portal configuration:
<legalAuthenticator>
<time value="20120519234435+0300"/>
<signatureCode nullFlavor="NI"/>
<assignedEntity>
<id root="1.3.6.1.4.1.28284.6.2.4.32" assigningAuthorityName="Digilugu"/>
<assignedPerson nullFlavor="NI"/>
<representedOrganization>
<id root="1.3.6.1.4.1.28284.6.2.4.1" extension="90009016"/>
<name>Eesti E-Tervise SA</name>
<telecom use="WP" value="tel:+3726943900"/>
<telecom use="WP" value="mailto:e-tervis@e-tervis.ee"/>
<addr>
<country>EE</country>
<city>Tallinn</city>
<postalCode>10134</postalCode>
<streetAddressLine>Uus-Tatari 25 / Veerenni 13</streetAddressLine>
<state nullFlavor="NI"/>
</addr>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
The same data as in the author element is stored in the documentationOf section. In addition to that, values of <low> and <high> elements must be editable. Default values as suggested to the user by the UI: current time.
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20120519234435+0300"/>
<high value="20120619234435+0300"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="222" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Nursing and midwifery professionals"/>
<assignedEntity>
<id root="1.3.6.1.4.1.28284.6.2.4.32"/>
<assignedPerson>
<name>
<given>Patient Summary</given>
<family>Fetcher</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
The relatedDocument tag includes a XFRM reference to the PDF version of the HCER, if it is generated by the portal (optional).
<relatedDocument typeCode="XFRM">
<parentDocument>
<id root="1.3.6.1.4.1.28284.6.2.4.75" extension="201304291013151234"/>
</parentDocument>
</relatedDocument>
Another relatedDocument tag includes an APND reference to the XML version of the patient summary previously fetched by the portal.
<relatedDocument typeCode="APND">
<parentDocument>
<id root="2.16.17.710.820.1000.990.1.1.1" extension="201304290913154321"/>
</parentDocument>
</relatedDocument>
CDA Body (under work)
Specifications for the document sections are in D3.9.1 Appendix B1/B2, PS-related specifications for the sections.