HL7_IG_DS4P_R1_CH1_CONTENT

cda Privacy Segmented Document

[ClinicalDocument: templateId 2.16.840.1.113883.3.3251.1.1]

This CDA document template may be applied to any document type that is the result of
          segmentation.  Is specifies that the document may contain sections and entries
          modified to specify the  privacy annotations intended to assist a receiving
          systems to process the information  contained in the document in a way consistent
          with applicable privacy policies. If the information does not contain any additional
          section or entry-level annotations, the sender needs ot enforce the requirements to
          identify the author of the document, section, or entry if the context conduction requires
          it (i.e. if the author of the section is different than the author of the document or the
          author of the entry is different than the author of the section).

  1. SHALL contain exactly one [1..1] templateId ( CONF-DS4P-1 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.3.3251.1.1"
  2. SHALL conform to Consol General Header Constraints template (templateId: 2.16.840.1.113883.10.20.22.1.1) (CONF:9051)
  3. SHALL contain [1..*] author1 (CONF:5444)
    • The author of the document is the individual provider or the organization
                  that  originates the document. If the document is an aggregate of several
                  provider's input,  then this author information will be overwritten at the
                  section and entry level to  identify the actual author of the section or entry.
                  This constrain is intended ensure  this element is not null. This information is
                  necessary to establish the provenance of the document.

    1. Contains exactly one [1..1] cda Mandatory Document Provenance (templateId: 2.16.840.1.113883.3.3251.1.2)
  4. SHOULD contain [1..*] component (CONF:16789)
    • This association specifies the Privacy and Security Markings section. This may be
                  the first section of a segmented document, if policy requires it. In those cases when
                  the policy requires that the user view and/or acknowledge specific prohibitions against
                  redisclosure, the receiving system capabilities to display and use these marking will be
                  validated in addition to its interoperability.

    1. Contains exactly one [1..1] cda Privacy Markings Section (templateId: 2.16.840.1.113883.3.3251.1.5)
  5. MAY contain [0..*] component (CONF:16790)
    • The document may contain several sections constrained specifically to
                  support  protected information. If the information does not require privacy
                  annotations different than those already specified in the document header, then a
                  document instance may not include segmented sections.

    1. Contains exactly one [1..1] cda Privacy Segmented Section (templateId: 2.16.840.1.113883.3.3251.1.10)

cda Privacy Segmented Document example

    
    <?xml version="1.0" encoding="UTF-8"?>
     <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3"
        xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
        xsi:schemaLocation="urn:hl7-org:v3 file:c32/C32_CDA.xsd" classCode="DOCCLIN" moodCode="EVN">
        <!-- @realcode="US" -->
        <realmCode code="US"/>
        <!-- @root="2.16.840.1.113883.1.3" @extension="POCD_HD000040" -->
        <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
        <!-- Segmented Document Profile Id -->
        <templateId root="2.16.840.1.113883.3.3251.1.1" assigningAuthorityName="HL7 Security"/>
        <!--  DocumentUid in @root  @assigningAuthorityName="Sample HIE Project"-->
        <id root="db734647-fc99-424c-a864-7e3cda82e703" assigningAuthorityName="Vrtua HIE Project"/>
        <code code="34133-9" displayName="Summarization of episode note"
            codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
        <title>Example Continuity of Care Document</title>
        <!--  DateTimeCreated (timezone added)-->
        <effectiveTime value="20101021120500-0500"/>
        <!-- Restricted content based on HL7 BasicConfidentialityKind value set -->
        <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="R"/>
        <languageCode code="en-US"/>
        <recordTarget>
            <patientRole>
                <!--  PatientMRN in @extension; @root="ExampleMRN" @assigningAuthorityName="Example"-->
                <id extension="080980" root="ExampleMRN" assigningAuthorityName="Example"/>
                <!--  PatientAddressType - hardcoded @use="HP" -->
                <addr use="HP">
                    <!--  PatientHomeAddressStreetLine,  PatientHomeAddressCityName,  PatientHomeAddressStateCode,  PatientHomeAddressZipCode -->
                    <streetAddressLine>1 Main St</streetAddressLine>
                    <city>Anytown</city>
                    <state>NH</state>
                    <postalCode>99999</postalCode>
                </addr>
                <!--  PatientHomePhone preceded by "tel:" with @use="HP"-->
                <telecom value="tel:+1-999-999-9999" use="HP"/>
                <!--  PatientWorkPhone preceded by "tel:" with @use="HP"-->
                <telecom value="tel:+1-999-999-9999" use="WP"/>
                <!--  PatientEmailAddress -->
                <telecom value="mailto:EmailName@DomainName"/>
                <patient>
                    <name>
                        <!--  PatientFirstName,  PatientMiddleInitial,  PatientFamilyName-->
                        <given>Mary</given>
                        <given>A</given>
                        <family>Everyperson</family>
                    </name>
                    <!--  GenderCode  GenderDisplayName -->
                    <administrativeGenderCode code="F" displayName="Female"
                        codeSystemName="HL7 AdministrativeGenderCodes"
                        codeSystem="2.16.840.1.113883.5.1"> </administrativeGenderCode>
                    <!--  PatientDOB -->
                    <birthTime xsi:type="TS" value="19430704"/>
                    <!--  MaritalStatusCode,  MaritalStatusDisplayName -->
                    <maritalStatusCode code="S" displayName="Single" codeSystem="2.16.840.1.113883.5.2"/>
                    <!--  RaceCode,  RaceDisplayName -->
                    <raceCode code="P" displayName="Pacific Islander"
                        codeSystem="2.16.840.1.113883.6.238"/>
                    <!--  PreferredLanguage i -->
                    <languageCommunication>
                        <languageCode code="us-en"/>
                    </languageCommunication>
                </patient>
            </patientRole>
        </recordTarget>
        <author>
            <!-- Mandatory Document Author -->
            <templateId root="2.16.840.1.113883.3.3251.1.2" assigningAuthorityName="HL7 Security"/>
            <!--  DateTimeCreated (timezone added -0500)-->
            <time value="20131021120500-0500"/>
            <assignedAuthor>
                <!-- Mandatory Document Provenance - assigned author -->
                <templateId root="2.16.840.1.113883.3.3251.1.3" assigningAuthorityName="HL7 Security"/>
                <!-- auhorId -->
                <id root="4d0c8e77-ea1d-4f41-9858-88806852e774"/>
                <addr>
                    <!--  AuthorAddressLine,  AuthorCity,  AuthorState,  AuthorZipCode -->
                    <streetAddressLine>Example Address Line</streetAddressLine>
                    <city>ExampleCity</city>
                    <state>NH</state>
                    <postalCode>99999</postalCode>
                </addr>
                <!--  AuthorTelephone preceded by "tel:" with @use="WP"-->
                <telecom value="tel:+1-301-555-1212" use="WP"/>
                <telecom value="mailto:Hippocrates@Clinic.org" use="EC"/>
                <assignedPerson>
                    <!--  AuthorProviderName -->
                    <name>
                        <prefix>Dr.</prefix>
                        <family>Hippocrates</family>
                        <given>Harold</given>
                    </name>
                </assignedPerson>
                <representedOrganization>
                    <!--  AuthorOrganizationName -->
                    <name>Example Organization</name>
                    <!--  AuthorTelephone preceded by "tel:" with @use="WP"-->
                    <telecom value="tel:+1-301-555-1212" use="WP"/>
                    <addr>
                        <!--  AuthorAddressLine,  AuthorCity,  AuthorZipCode -->
                        <streetAddressLine>Example Organization Address Line</streetAddressLine>
                        <city>ExampleCity</city>
                        <state>NH</state>
                        <postalCode>99999</postalCode>
                    </addr>
                </representedOrganization>
            </assignedAuthor>
        </author>
        ...