HL7_IG_DS4P_R1_CH1_CONTENT

cda Privacy Segmented Section

[Section: templateId 2.16.840.1.113883.3.3251.1.10]

This CDA template may apply to any section of a C-CDA document if that section
          metadata is  different than the document's overall. For instance, this template
          may be used to ensure  that confidentiality levels and provenance information are
          specified correctly for each  section in the document.

  1. SHALL contain exactly one [1..1] templateId ( CONF-DS4P-10 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.3.3251.1.10"
  2. SHOULD contain exactly one [1..1] confidentialityCode (CONF:16834), where the @code SHALL be selected from ValueSet HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC (CONF:16833)
    • The value may apply a different level of confidentiality to the section than
                  the  document itself; thus, it may not agree with the
                  clinicalDocument/confidentialityCode  element's value. This code should be set
                  of the level of confidentiality of a section  differs from the overall level of
                  confidentiality of the document. For instance, if the  document is set as
                  "Restricted" but the section contains
                  "Normal" content, then the section confidentiality code will be set
                  to  "N" -thus indicating content with normal level of
                  confidentiality. The  confidentialityCode shall be assigned by the provider or
                  system in accordance with  jurisdictional and organizational policy. To support
                  scenarios within the use case,  there will need to be some level of
                  organizational policy hierarchy or a policy catalog  at some point in the future
                  that would specify how a system would assign confidentiality  codes to
                  particular data.   Prior to any disclosure, the sending system shall be
                  capable of executing stored procedures based upon request type, destination
                  authorizations, environmental factors and confidentiality codes to perform
                  privacy  enhancing functions of marking, masking, redaction, anonymization and
                  application of  handling instructions

  3. SHOULD contain [0..*] author (CONF:5460)
    • If the provenance of the section is different than the provenance of the document,
                  there should be at least one occurence is needed. This information is necessary to establish the provenance of
                  the section if the author of the section is different than the author of the
                document.

    1. Contains exactly one [1..1] cda Mandatory Entry Provenance (templateId: 2.16.840.1.113883.3.3251.1.6)

cda Privacy Segmented Section example

 
 
<!-- 
					********************************************************
					
					Allergies and Alerts section
					********************************************************
				-->
				<section>
					<!-- Segmented Section template -->
					<templateId root="2.16.840.1.113883.3.3251.1.10"
						assigningAuthorityName="HL7 Security"/>
					<!-- root="2.16.840.1.113883.10.20.1.2" assigningAuthorityName="CCD"-->
					<templateId root="2.16.840.1.113883.10.20.1.2" assigningAuthorityName="CCD"/>					
					<!-- code="10160-0" displayName="Alerts" codeSystem="2.16.840.1.113883.6.1"
						codeSystemName="LOINC" -->
					<code code="10160-0" displayName="Alerts" codeSystem="2.16.840.1.113883.6.1"
						codeSystemName="LOINC"/>
					<!--  AllergySectionTitle =  Allergies and Alert Problems-->
					<title>Allergies and Alert Problems</title>
					<text>
						<table>
							<thead>
								<tr>
									<!--  AllergySubstanceHeading -->
									<th>Substance</th>
									<!--  AllergyReactionHeading -->
									<th>Reactions</th>
									<!--  AllergySeverityHeading -->
									<th>Severity</th>
									<!--  AllergyOnsetHeading -->
									<th>Date of onset</th>
									<!--  AllergyCommentHeading -->
									<th>Comments</th>
								</tr>

							</thead>
							<tbody>
								<tr>
									<!--  AllergySubstanceDisplayName -->
									<td>IVP dye</td>
									<!--  AllergyReactionDisplayName  -->
									<td>anaphylaxis</td>
									<!--  AllergySeverityDisplayName -->
									<td>High</td>
									<!--  AllergyOnsetDate -->
									<td>2010</td>
									<!--  AllergyComment -->
									<td>Allergy is is very severe...</td>
								</tr>
							</tbody>
						</table>
					</text>
					<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"
						codeSystemName="HL7 Confidentiality"/>
					<author>
						<templateId root="2.16.840.1.113883.3.3251.1.6"
							assigningAuthorityName="HL7 Security"/>
						<!--  DateTimeCreated (timezone added -0500)-->
						<time value="20131021120500-0500"/>
						<assignedAuthor>
							<!-- Mandatory Assigned Author -->
							<templateId root="2.16.840.1.113883.3.3251.1.7"/>
							<!-- 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"/>
							<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>

					<entry>
						<act classCode="ACT" moodCode="EVN">
							<!--CCD Problem act - Required-->
							<templateId root="2.16.840.1.113883.10.20.1.27"
								assigningAuthorityName="CCD"/>
							<id nullFlavor="NI"/>
							<!--  Must be NA -->
							<code nullFlavor="NA"/>
							<entryRelationship typeCode="SUBJ">
								<!--classCode="OBS" moodCode="EVN"-->
								<observation classCode="OBS" moodCode="EVN">
									<!-- root="2.16.840.1.113883.10.20.1.18"
										assigningAuthorityName="CCD" -->
									<templateId root="2.16.840.1.113883.10.20.1.18"
										assigningAuthorityName="CCD"/>
									<!-- code="420134006"
										displayName="Propensity to adverse reactions"
										codeSystemName="SNOMED CT"
										codeSystem="2.16.840.1.113883.6.96" -->
									<code code="420134006"
										displayName="Propensity to adverse reactions"
										codeSystemName="SNOMED CT"
										codeSystem="2.16.840.1.113883.6.96"> </code>
									<!-- code="completed" -->
									<statusCode code="completed"/>
									<!-- @value= AllergyOnsetDate(date?) -->
									<effectiveTime value="2010"/>
									<!-- typeCode="CSM" -->
									<participant typeCode="CSM">
										<!-- classCode="MANU"  -->
										<participantRole classCode="MANU">
											<!-- Address and telecom should be present for H&P documents
												NIST warning reported-->
											<!-- nullFlavor="NA" -->
											<addr nullFlavor="NA"/>
											<!-- nullFlavor="NA" -->
											<telecom nullFlavor="NA"/>
											<!-- classCode="MMAT" -->
											<playingEntity classCode="MMAT">
												<!-- @code AllergySubstanceCode, @displayName=  AllergySubstanceDisplayName @codeSystemName="Example" -->
												<code code="AllergyCode1" displayName="IVP dye"
												codeSystemName="Example">
												<!--  AllergyComment -->
												<originalText>Allergy is very
												severe...</originalText>
												</code>
											</playingEntity>
										</participantRole>
									</participant>
									<!-- typeCode="MFST"  -->
									<entryRelationship typeCode="MFST">
										<!-- classCode="OBS" moodCode="EVN" -->
										<observation classCode="OBS" moodCode="EVN">
											<!-- Reaction template root="2.16.840.1.113883.10.20.1.54" -->
											<templateId root="2.16.840.1.113883.10.20.1.54"/>
											<code code="ASSERTION"
												codeSystem="2.16.840.1.113883.5.4"/>
											<statusCode code="completed"/>
											<!-- @xsi:type="CE" @code= AllergyReactionCode, @displayName= AllergyReactionDisplayName,  @codeSystem='Example'  -->
											<value xsi:type="CE" code="ReactionCode1"
												codeSystemName="Example" displayName="anaphylaxis"/>
											<!--@code= AllergySeverityCode, @displayName= AllergySeverityDisplayName, @codeSystem='Example' -->
											<interpretationCode code="H" codeSystem="Example"
												displayName="High"/>
										</observation>
									</entryRelationship>
								</observation>
							</entryRelationship>
						</act>
					</entry>
				</section>