電子紹介状 ( 診療情報提供書 ) 厚生労働省標準規格 HS007,HS008

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1 HL7 CDA(ISO 27932:2009) 電子紹介状 ( 診療情報提供書 ) 厚生労働省標準規格 HS007,HS008 HL7 Japan CDA WG1 平井正明 2010 年 5 月 27 日

2 診療情報提供書 2

3 XML での記述 <?xml version="1.0" encoding="utf-8"?> <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi=" xsi:schemalocation="urn:hl7-org:v3 CDA.xsd"> <typeid extension="pocd_hd000040jp00" root=" " /> <templateid root=" " /> <id root=" " extension=" " displayable="true" /> <code code="md " codesystem=" " codesystemname="jmix" displayname="referralnote" /> <title> 診療情報提供書 </title> <effectivetime value=" " /> <confidentialitycode code="n" codesystem=" " /> <languagecode code="ja-jp" /> <setid extension="123456" root=" " /> <versionnumber value="1" /> <recordtarget> <patientrole classcode="pat"> <id extension=" " root=" " assigningauthorityname=" 紹介元 " /> <id extension=" " root=" " assigningauthorityname=" 紹介先 " /> <id extension=" " root=" " assigningauthorityname=" 地域 " /> 3

4 XML とは XML (extensible Markup Language): 拡張可能な情報記述言語 XML は SGML (Standard Generalized Markup Language) から発展 1979 年 IBM の Charles Goldfarb は Edward Mosher および Raymond Lorie らとともに GML (Generalized Markup Language) を発表 1986 年 SGML として ISO になる XML は SGML のサブセットとして規定されたが 独自に発展を遂げている 最たるものは DTD のみならず XML で書かれた仕様書 Schema である HL7 V3 の実装技術 (ITS: Implementation Technology Specification) の ITS- XML 等で規定されている CDA は XML で記述される 4

5 XML extensible Markup Language 互換性 記述性 ( 変換が ) 容易性 SGML DTD HTML XML Schema XHTML XSL 5

6 XML の基礎 < と > で括られたタグで記述される < 名前 > 平井正明 </ 名前 > のように記述される < 要素 > 内容 データ等 </ 要素 > 開始タグ終了タグ { 内容 データ が無いときは < 要素 /> と記述できる } という風に記述される さらに一般的には < 要素名属性 属性...> 内容 データ等 </ 要素名 > この要素名 属性名は HL7 V3 で決められた名称が使用される 6

7 XML 記述 <?xml version= 1.0 encoding= UTF-8?> <!-- XML 宣言が必要 (XML 文章の先頭にコメントは書けない )--> < 人 > コメントの開始 < 姓名 ID= > 平井正明 </ 姓名 > 属性値属性名 < 性別 > 要素名男 </ 性別 > < 年齢 /> 内容が空の場合 <XXXX/> と記述できます < 住所 > 東京都港区虎ノ門 1 丁目 19 番 9 号 </ 住所 > </ 人 > コメントの終了 7

8 XML (extensible Markup Language) < 名前 > 平井正明 </ 名前 > 開始タグ終了タグ < 要素名 > データ </ 要素名 > データが無いときは < 要素名 /> と記述できます一般型 < 要素名属性名 = 属性値 属性名 = 属性値 > データ </ 要素名 > CDA では <name use="ide"> <family> 平井 </family> <given> 正明 </given> </name> 8

9 整形式 (Well Formed) XML 文書 XML 宣言がある ルート要素を一つだけ持つ CDA 文書 (R2) は <ClinicalDocument... で始まり </ClinicalDocument> で終わる 開始タグと終了タグがある 例 <name/> は可能 要素はネスト構造で 入れ子構造は使用できない 要素名 属性名は大文字と小文字は区別する 属性値は で囲む 9

10 検証済み (Valid) XML 文書 Schema(XML):XML 文書の内容 構造 構文 記述ルールを説明した仕様書 Schema により検証された文書 原則として V3 の XML 文書はスキーマ (Schema) により検証される例 :CDA のスキーマは先頭に CDA.xsd として記述されている <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi=" xsi:schemalocation="urn:hl7-org:v3 CDA.xsd"> スキーマ CDA.xsd は次のように記述されている本スキーマは日本向け診療情報提供書用に定義された CDA スキーマ POCD_MT000040JP00.xsd が Include する必要があることを示している <?xml version="1.0" encoding="utf-8" standalone="no"?> <xs:schema targetnamespace="urn:hl7-org:v3" xmlns:mif="urn:hl7-org:v3/mif" xmlns="urn:hl7-org:v3" xmlns:xs=" elementformdefault="qualified"> <xs:include schemalocation="../schemas/pocd_mt000040jp00.xsd" /> <xs:element name="clinicaldocument" type="pocd_mt000040jp00.clinicaldocument" /> </xs:schema> さらに V3 共通の用語 データタイプや CDA の Narrative 部のスキーマが用意されている 2006 年 Normative Edition では次の 5 つスキーマが共通定義されている datatypes.xsd datatypes-base.xsd infrastructureroot.xsd voc.xsd NarrativeBlock.xsd 10

11 XML 宣言 XML 処理を行うための宣言 : 必ず XML 文書の先頭に書く必要がある 例 : <?xml version="1.0" encoding="utf-8"?> <?xml で始まり?> 終わります < 及び > と? の間に空白などは許されない version= 1.0 バージョン番号を示します 通常 1.0 で問題はない encoding= UTF-8 文字コードを示しめす 日本語では Shift ー JIS ISO-2022-JP 等が使えるが フォントのインターナショナルな互換性を考えると UTF-8 を推奨する その他 外部参照ファイルの有無 standalone があるが デフォルトは yes として使用される 11

12 名前空間 (Namespace) <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi=" xsi:schemalocation="urn:hl7-org:v3 CDA.xsd"> 要素名が異なったグループで重複する名前が必要なとき 空間 ( 名前空間 ) を分けて使用する xmlns= 名前空間 で記述する HL7 のデフォルト空間 ( 名前空間を明示しない ) は urn:hl7-org:v3 CDA ではスキーマの名前空間 xsi を定義している 名前空間名は一般に URI が使用されるが 実在の URI である必要はない 12

13 XML 記述 コメント <!-- と --> の間に記述する 例 :<!-- コメントです --> 文字 記述 特殊文字 & と ; で括って書く & & < < > > &apos; " 10 進コード &# 数字 ; 16 進コード &#x 数字 ; 13

14 診療情報提供書のボトムアップ的記述と CDA 記述 ボトムアップ記述 <?xml version= 1.0 encoding= Shift-JIS?> < 診療情報提供書 > < 患者情報 > < 氏名形式 = 姓名 > < 姓 > 日本 </ 姓 > < 名 > 次郎 </ 名 > </ 氏名 > < 氏名形式 = フリガナ > < 姓 > ニホン </ 姓 > < 名 > ジロウ </ 名 > </ 氏名 > < 生年月日 > < 年号 > 昭和 </ 年号 > < 月日 >27 年 7 月 17 日 </ 月日 > < 年齢 >50</ 年齢 > </ 生年月日 > </ 患者情報 > </ 診療情報提供書 > CDA 記述 <?xml version="1.0" encoding="utf-8"?> <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi=" xsi:schemalocation="urn:hl7-org:v3 CDA.xsd"> <typeid extension="pocd_hd000040jp00" root=" " /> <templateid root=" " /> <title> 診療情報提供書 </title> <recordtarget> <patientrole classcode="pat"> <id extension=" " root=" " /> <patient> <name use="ide"> <family> 日本 </family> <given> 次郎 </given> </name> <name use="syl"> <family> ニホン </family> <given> ジロウ </given> </name> </ClinicalDocument > 14

15 CDA CDA Clinical Document Architecture Release 2 ISO 27932:2009 として制定 HL7 の診療文書アーキテクチャ (Clinical Document Architecture:CDA) は 診療文書の交換を目的として 診療文書 の構造とセマンティックを定める文書マークアップ標準 ヘッダ部 ( 文書レベル ) と本文 ( セクション ) で構成される 15

16 CDA は HL7 V3 に基づいている V3 HDF RIM Reference Information Model 基本仕様書 設計書 D-MIM Domain Message Information Model 部門別設計書 R-MIM Refined Message Information Model 詳細設計書 HMD メッセージ表 Hierarchical Message Description Schema 診療情報提供書 XML インスタンス 16

17 17 V3 RIM (Reference Information Model)

18 V3 RIM (Reference Information Model) 18

19 クロン化 ( 患者属性 RIM R-MIM XML) <patient> <name use="ide"> <family> 日本 </family> <given> 次郎 </given> </name> <name use="syl"> <family> ニホン </family> <given> ジロウ </given> </name> <desc> 職業会社員 </desc> <administrativegendercode code="m" codesystem=" " /> <birthtime value=" " /> </patient> 19

20 患者情報は recordtarget 0..1 patient Patient id: II [0..1] (Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity 0..1 provider PatientRole classcode*: <= PAT id: SET<II> [1..*] 1..* patientrole recordtarget typecode*: <= RCT <recordtarget> <patientrole classcode="pat"> <!-- 患者 ID --> <!-- id extension=" " root=" "/ --> <id nullflavor="oth" /> <!-- 患者住所 --> <addr> <country>jp</country> <postalcode> </postalcode> <streetname> 西片 1 丁目 17 番 8 号 </streetname> <city> 文京区 </city> <state> 東京都 </state> </addr> <!-- 患者連絡電話番号 --> <telecom use="h" value="tel: " /> <patient> <!-- 患者名 --> <name use="ide"> <family> 日本 </family> <given> 次郎 </given> </name> <name use="syl"> <family> ニホン </family> <given> ジロウ </given> </name> <!-- 職業など諸情報 --> <desc> 職業会社員 </desc> <!-- 性別 --> <administrativegendercode code="m" codesystem=" " /> <!-- 誕生日 --> <birthtime value=" " /> </patient> </patientrole> </recordtarget> 20

21 R-MIM V3 データタイプ XML <birthtime value=" " /> 21

22 R-MIM V3 用語 (Vocabulary) XML <administrativegendercode code="m" codesystem=" " /> 22

23 HMD (Hierarchical Message Description) 23

24 診療情報提供書 24

25 CDA 詳細設計書 (CDA R2 R-MIM) (POCD_RM000040) The Organizer clone can be the source of the relationship or the reference relationship, but not the entryrelationship relationship. entryrelationship name: SET<PN> [] AuthorChoice Place classcode*: <= PLC name: EN [0..1] addr: AD [0..1] 0..1 received Patient id: II [0..1](Deprecated) name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity GuardianChoice 0..1 informationrecipient 0..1 represented AuthoringDevice classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 1..1 place Birthplace classcode*: <= BIRTHPL classcode*: <= ORG name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 birthplace 1..1 guardianchoice 0..1 whole 0..1 represented 0..1 assigned 1..1 maintaining 0..1 related 0..1 patient 0..1 scoping 0..1 aspartof asmaintainedentity 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian MaintainedEntity classcode*: <= MNT 0..1 represented 0..1 assigned 0..1 provider guardian PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus PatientRole classcode*: <= PAT id: SET<II> [1..*] languagecommunication Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 1..1 assignedcustodian custodian typecode*: <= CST Custodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] 1..* patientrole recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity participant typecode*: <= ParticipationType ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] confidentialitycode*: CE CWE [1..1] copytime: TS [0..1](Deprecated) parentdocument relateddocument typecode*: <= x_actrelationshipdocument documentationof typecode*: <= DOC infulfillmentof typecode*: <= FLFS ization typecode*: <= AUTH serviceevent Of 0..1 encompassingencounter Constraint: relateddocument.typecode A conformant CDA document can have a single relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and "RPLC"; or two relateddocuments with typecodes "XFRM" and "APND". HealthCareFacility classcode*: <= SDLOC code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType 0..1 serviceprovider CDA R-MIM order consent This RMIM is used to generate the CDA specification. ParentDocument classcode*: <= DOCCLIN code: CD CWE [0..1] <= DocumentType ServiceEvent classcode*: <= ACT code: CE CWE [0..1] Order classcode*: <= ACT moodcode*: <= RQO code: CE CWE [0..1] <= ActCode Consent classcode*: <= CONS code: CE CWE [0..1] <= ActCode statuscode*: CS CNE [1..1] <= completed EncompassingEncounter responsibleparty classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= ActEncounterCode assignedentity effectivetime*: IVL<TS> [1..1] encounterparticipant dischargedispositioncode: CE CWE [0..1] typecode*: <= x_encounterparticipant <= EncounterDischargeDisposition location typecode*: <= LOC 0..1 healthcarefacility 0..1 location Place RelatedSubject 0..1 classcode*: <= x_documentsubject code: CE CWE [0..1] <= alrelationshiproletype 0..1 subject Constraint: ParentDocument.text ParentDocument.text can be used to indicate the MIME type of the related document. It is not to be used to embed the related document, and thus ParentDocument.text.BIN is precluded from use. assignedentity performer typecode*: <= x_serviceeventperformer 1..1 bodychoice 0..1 relatedsubject subject typecode*: <= SBJ awarenesscode: CE CWE [0..1] <= TargetAwareness Subject name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] 0..1 represented 0..1 assigned 0..1 represented 0..1 assigned informant bodychoice NonXMLBody classcode*: <= DOCBODY text: ED [1..1] StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] section entry typecode*: <= x_actrelationshipentry DrugOrOtherMaterial LabeledDrug classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= DrugEntity name: EN [0..1] Material classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= MaterialEntityClassType name: EN [0..1] lotnumbertext: ST [0..1] PlayingEntity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode quantity: SET<PQ> [] name: SET<PN> [] desc: ED [0..1] Constraint: Section.text Section.text.mediaType fixed as "text/x-hl7-text+xml". See section "Section Narrative Block" for details. EntityChoice Device classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 0..1 manufacturer 1..1 manufactureddrugorothermaterial 0..1 playingentitychoice 0..1 scopingentity Entity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode desc: ED [0..1] 0..1 assigned ManufacturedProduct classcode*: <= MANU ParticipantRole classcode*: <= ROL 0..1 represented SpecimenRole classcode*: <= SPEC 0..1 specimenplayingentity typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] informant 0..1 subject 1..1 manufacturedproduct consumable typecode*: <= CSM clinicalstatement assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode 0..1 manufacturedproduct * product typecode*: <= PRD specimenrole specimen typecode*: <= SPC participantrole participant typecode*: <= ParticipationType awarenesscode: CE CWE [0..1] <= TargetAwareness clinicalstatement clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] RegionOfInterest classcode*: <= ROIOVL code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] ObservationMedia value*: ED [1..1] SubstanceAdministration classcode*: <= SBADM moodcode*: <= x_documentsubstancemood code: CD CWE [0..1] <= SubstanceAdministrationActCode effectivetime: GTS [0..1] routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite dosequantity: IVL<PQ> [0..1] ratequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] administrationunitcode: CE CWE [0..1] <= AdministrableDrugForm Supply classcode*: <= SPLY moodcode*: <= x_documentsubstancemood effectivetime: GTS [0..1] prioritycode: SET<CE> CWE [] <= ActPriority independentind: BL [0..1] quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] Procedure classcode*: <= PROC moodcode*: <= x_documentproceduremood code: CD CWE [0..1] methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] Encounter classcode*: <= ENC moodcode*: <= x_documentencountermood code: CD CWE [0..1] <= ActEncounterCode Organizer classcode*: <= x_actclassdocumententryorganizer statuscode*: CS CNE [1..1] <= ActStatus Act classcode*: <= x_actclassdocumententryact moodcode*: <= x_documentactmood code*: CD CWE [1..1] <= ActCode observationrange referencerange typecode*: <= REFV Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference clinicalstatement sequencenumber: INT [0..1] ObservationRange.CRT interpretationcode: CE CNE [0..1] <= ObservationInterpretation Criterion.CRT Constraint: Organizer externalactchoice externalactchoice ExternalAct classcode*: <= ACT ExternalObservation ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType ヘッダ部变述部エントリー部 外部参照部 25

26 診療情報提供書と R-MIM の関係 (POCD_RM000040JP00) entryrelationship PartOf classcode*: <= PART id*: SET<II> [] 0..1 whole statuscode: CS CNE [0..1] <= RoleStatus classcode*: <= ORG 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 represented 0..1 assigned 0..1 received assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] ParentDocument parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument code: CD CWE [0..1] <= DocumentType typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] ObservationRange.CRT observationrange referencerange typecode*: <= REFV interpretationcode: CE CNE [0..1] <= ObservationInterpretation Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN IntendedRecipient 0..1 informationrecipient 0..1 represented AuthorChoice classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 0..1 represented 0..1 assigned assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode ObservationMedia value*: ED [1..1] name: SET<PN> [] 0..1 assignedauthorchoice AssignedCustodian 0..1 assignedcustodian custodian typecode*: <= CST Custodian 1..1 representedcustodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] 0..1 represented 0..1 assigned dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] bodychoice externalactchoice 0..1 provider 0..1 patient Patient PatientRole classcode*: <= PAT id: SET<II> [1..*] id: II [0..1](Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity 1..* patientrole recordtarget typecode*: <= RCT PREF RMIM This RMIM is used for patient referral document 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..* section reference typecode*: <= x_actrelationshipexternalreference externalactchoice ExternalObservation GuardianChoice guardian Guardian classcode*: <= GUARD Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind section ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType 1..1 guardianchoice entry typecode*: <= x_actrelationshipentry clinicalstatement 0..1 scoping 0..1 associated associatedentity AssociatedEntity participant classcode*: <= RoleClassAssociative typecode*: <= ParticipationType ヘッダ部变述部エントリー部 外部参照部 26

27 診療情報提供書の本文の記述 (POCD_RM000040JP00) entryrelationship PartOf classcode*: <= PART id*: SET<II> [] 0..1 whole statuscode: CS CNE [0..1] <= RoleStatus classcode*: <= ORG 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 represented 0..1 assigned 0..1 received assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] ParentDocument parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument code: CD CWE [0..1] <= DocumentType typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] ObservationRange.CRT observationrange referencerange typecode*: <= REFV interpretationcode: CE CNE [0..1] <= ObservationInterpretation Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN IntendedRecipient 0..1 informationrecipient 0..1 represented AuthorChoice classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 0..1 represented 0..1 assigned assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode ObservationMedia value*: ED [1..1] name: SET<PN> [] 0..1 assignedauthorchoice AssignedCustodian 0..1 assignedcustodian custodian typecode*: <= CST Custodian 1..1 representedcustodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] 0..1 represented 0..1 assigned dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] bodychoice externalactchoice 0..1 provider 0..1 patient Patient PatientRole classcode*: <= PAT id: SET<II> [1..*] id: II [0..1](Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity 1..* patientrole recordtarget typecode*: <= RCT PREF RMIM This RMIM is used for patient referral document 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..* section reference typecode*: <= x_actrelationshipexternalreference externalactchoice ExternalObservation GuardianChoice guardian Guardian classcode*: <= GUARD Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind section ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType 1..1 guardianchoice entry typecode*: <= x_actrelationshipentry clinicalstatement 0..1 scoping 0..1 associated associatedentity AssociatedEntity participant classcode*: <= RoleClassAssociative typecode*: <= ParticipationType ヘッダ部变述部エントリー部 外部参照部 27

28 患者情報は recordtarget で記述 (POCD_RM000040) The Organizer clone can be the source of the relationship or the reference relationship, but not the entryrelationship relationship. PartOf classcode*: <= PART 0..1 whole id*: SET<II> [] desc: ED [0..1] statuscode: CS CNE [0..1] <= classcode*: <= ORG RoleStatus 0..1 aspartof name: SET<ON> [] birthtime: TS [0..1] standardindustryclasscode: CE CWE [0..1] <= IndustryClass maritalstatuscode: 0..1 represented CE CWE [0..1] <= assignedentity MaritalStatus authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature racecode: CE CWE [0..1] telecom: SET<TEL> <= [] Race legalauthenticator typecode*: <= LA 0..1 assigned ethnicgroupcode: CE CWE [0..1] <= time*: Ethnicity TS [1..1] signaturecode*: CS CNE [1..1] <= ParticipationSignature name: SET<PN> [] AuthorChoice Place classcode*: <= PLC name: EN [0..1] addr: AD [0..1] 0..1 received Patient Patient id: II [0..1] (Deprecated) id: II [0..1](Deprecated) name: SET<PN> [] name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity ethnicgroupcode: CE CWE [0..1] <= Ethnicity GuardianChoice 0..1 informationrecipient 0..1 represented AuthoringDevice classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 1..1 place Birthplace classcode*: <= BIRTHPL Patient id: II [0..1] (Deprecated) name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation 0..1 birthplace 1..1 guardianchoice 1..1 maintaining 0..1 related 0..1 patient 0..1 patient 0..1 scoping asmaintainedentity 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian MaintainedEntity classcode*: <= MNT 0..1 represented 0..1 assigned 0..1 provider guardian PatientRole classcode*: <= PAT id: SET<II> [1..*] 患者情報 languagecommunication Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 1..1 assignedcustodian custodian typecode*: <= CST Custodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] 1..* patientrole recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity participant typecode*: <= ParticipationType 0..1 patient ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] confidentialitycode*: CE CWE [1..1] copytime: TS [0..1](Deprecated) parentdocument relateddocument typecode*: <= x_actrelationshipdocument documentationof typecode*: <= DOC infulfillmentof typecode*: <= FLFS ization typecode*: <= AUTH 0..1 provider serviceevent Of 0..1 encompassingencounter HealthCareFacility classcode*: <= SDLOC code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType 0..1 serviceprovider CDA R-MIM order consent PatientRole classcode*: <= PAT id: SET<II> [1..*] This RMIM is used to generate the CDA specification. Constraint: relateddocument.typecode A conformant CDA document can have a single relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and "RPLC"; or two relateddocuments with typecodes "XFRM" and "APND". ParentDocument classcode*: <= DOCCLIN code: CD CWE [0..1] <= DocumentType ServiceEvent classcode*: <= ACT code: CE CWE [0..1] Order classcode*: <= ACT moodcode*: <= RQO code: CE CWE [0..1] <= ActCode Consent classcode*: <= CONS code: CE CWE [0..1] <= ActCode statuscode*: CS CNE [1..1] <= completed EncompassingEncounter responsibleparty classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= ActEncounterCode assignedentity effectivetime*: IVL<TS> [1..1] encounterparticipant dischargedispositioncode: CE CWE [0..1] typecode*: <= x_encounterparticipant <= EncounterDischargeDisposition location typecode*: <= LOC 0..1 healthcarefacility 0..1 location Place RelatedSubject 0..1 classcode*: <= x_documentsubject code: CE CWE [0..1] <= alrelationshiproletype 0..1 subject Constraint: ParentDocument.text ParentDocument.text can be used to indicate the MIME type of the related document. It is not to be used to embed the related document, and thus ParentDocument.text.BIN is precluded from use. assignedentity performer typecode*: <= x_serviceeventperformer 1..1 bodychoice 0..1 relatedsubject subject typecode*: <= SBJ awarenesscode: CE CWE [0..1] <= TargetAwareness Subject name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] 0..1 represented 0..1 assigned 0..1 represented 0..1 assigned informant 1..* patientrole recordtarget typecode*: <= RCT bodychoice NonXMLBody classcode*: <= DOCBODY text: ED [1..1] StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] section entry typecode*: <= x_actrelationshipentry DrugOrOtherMaterial LabeledDrug classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= DrugEntity name: EN [0..1] Material classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= MaterialEntityClassType name: EN [0..1] lotnumbertext: ST [0..1] PlayingEntity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode quantity: SET<PQ> [] name: SET<PN> [] desc: ED [0..1] Constraint: Section.text Section.text.mediaType fixed as "text/x-hl7-text+xml". See section "Section Narrative Block" for details. EntityChoice Device classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 0..1 manufacturer 1..1 manufactureddrugorothermaterial 0..1 playingentitychoice 0..1 scopingentity Entity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode desc: ED [0..1] 0..1 assigned ManufacturedProduct classcode*: <= MANU ParticipantRole classcode*: <= ROL 0..1 represented SpecimenRole classcode*: <= SPEC 0..1 specimenplayingentity entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] informant 0..1 subject 1..1 manufacturedproduct consumable typecode*: <= CSM clinicalstatement assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode 0..1 manufacturedproduct * product typecode*: <= PRD specimenrole specimen typecode*: <= SPC participantrole participant typecode*: <= ParticipationType awarenesscode: CE CWE [0..1] <= TargetAwareness clinicalstatement clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] RegionOfInterest classcode*: <= ROIOVL code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] ObservationMedia value*: ED [1..1] 患者情報 SubstanceAdministration classcode*: <= SBADM moodcode*: <= x_documentsubstancemood code: CD CWE [0..1] <= SubstanceAdministrationActCode effectivetime: GTS [0..1] routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite dosequantity: IVL<PQ> [0..1] ratequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] administrationunitcode: CE CWE [0..1] <= AdministrableDrugForm Supply classcode*: <= SPLY moodcode*: <= x_documentsubstancemood effectivetime: GTS [0..1] prioritycode: SET<CE> CWE [] <= ActPriority independentind: BL [0..1] quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] Procedure classcode*: <= PROC moodcode*: <= x_documentproceduremood code: CD CWE [0..1] methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] Encounter classcode*: <= ENC moodcode*: <= x_documentencountermood code: CD CWE [0..1] <= ActEncounterCode Organizer classcode*: <= x_actclassdocumententryorganizer statuscode*: CS CNE [1..1] <= ActStatus Act classcode*: <= x_actclassdocumententryact moodcode*: <= x_documentactmood code*: CD CWE [1..1] <= ActCode observationrange referencerange typecode*: <= REFV Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference clinicalstatement sequencenumber: INT [0..1] ObservationRange.CRT interpretationcode: CE CNE [0..1] <= ObservationInterpretation Criterion.CRT Constraint: Organizer externalactchoice externalactchoice ExternalAct classcode*: <= ACT ExternalObservation ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType ヘッダ部变述部エントリー部 外部参照部 28

29 患者情報 0..1 patient Patient id: II [0..1] (Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity 0..1 provider PatientRole classcode*: <= PAT id: SET<II> [1..*] 1..* patientrole recordtarget typecode*: <= RCT <recordtarget> <patientrole classcode="pat"> <id extension=" " root=" "/ > <addr> <country>jp</country> <postalcode> </postalcode> <streetname> 西片 1 丁目 17 番 8 号 </streetname> <city> 文京区 </city> <state> 東京都 </state> </addr> <telecom use="h" value="tel: " /> <patient> <name use="ide"> <family> 日本 </family> <given> 次郎 </given> </name> <name use="syl"> <family> ニホン </family> <given> ジロウ </given> </name> <desc> 職業会社員 </desc> <administrativegendercode code="m" codesystem=" " /> <birthtime value=" " /> </patient> </patientrole> </recordtarget> 29

30 診療情報提供書記載者 ( 紹介元 ) (POCD_RM000040) The Organizer clone can be the source of the relationship or the reference relationship, but not the entryrelationship relationship. PartOf classcode*: <= PART 0..1 whole id*: SET<II> [] statuscode: CS CNE [0..1] <= classcode*: <= ORG RoleStatus 0..1 aspartof name: SET<ON> [] classcode*: standardindustryclasscode: CE CWE [0..1] <= PSN <= IndustryClass 0..1 represented assignedentity authenticator determinercode*: <= classcode*: INSTANCE <= ASSIGNED typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature name: SET<PN> [] legalauthenticator typecode*: <= LA 0..1 assigned signaturecode*: CS CNE [1..1] <= ParticipationSignature name: SET<PN> [] AuthorChoice Place classcode*: <= PLC name: EN [0..1] addr: AD [0..1] 0..1 received Patient id: II [0..1](Deprecated) name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity GuardianChoice 0..1 informationrecipient 0..1 represented AuthoringDevice classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 1..1 place Birthplace classcode*: <= BIRTHPL 0..1 birthplace 1..1 guardianchoice 1..1 maintaining 0..1 related 0..1 patient 0..1 scoping asmaintainedentity 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor classcode*: <= <= ASSIGNED 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian MaintainedEntity classcode*: <= MNT 0..1 represented 0..1 assigned 0..1 provider guardian PatientRole classcode*: <= PAT id: SET<II> [1..*] languagecommunication Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AuthorChoice 作成者 AssociatedEntity classcode*: <= RoleClassAssociative intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= <= AUT functioncode: CE CWE [0..1] <= <= ParticipationFunction contextcontrolcode*: CS CNE [1..1] <= <= "OP" 1..1 assignedcustodian custodian typecode*: <= CST Custodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] 1..* patientrole recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity participant typecode*: <= ParticipationType 0..1 represented ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] confidentialitycode*: CE CWE [1..1] copytime: TS [0..1](Deprecated) parentdocument relateddocument typecode*: <= x_actrelationshipdocument documentationof typecode*: <= DOC infulfillmentof typecode*: <= FLFS ization typecode*: <= AUTH serviceevent Of 0..1 encompassingencounter Constraint: relateddocument.typecode A conformant CDA document can have a single relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and "RPLC"; or two relateddocuments with typecodes "XFRM" and "APND". HealthCareFacility classcode*: <= SDLOC code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType 0..1 serviceprovider CDA R-MIM order consent This RMIM is used to generate the CDA specification. ParentDocument classcode*: <= DOCCLIN code: CD CWE [0..1] <= DocumentType ServiceEvent classcode*: <= ACT code: CE CWE [0..1] Order classcode*: <= ACT moodcode*: <= RQO code: CE CWE [0..1] <= ActCode Consent classcode*: <= CONS code: CE CWE [0..1] <= ActCode statuscode*: CS CNE [1..1] <= completed EncompassingEncounter responsibleparty classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= ActEncounterCode assignedentity effectivetime*: IVL<TS> [1..1] encounterparticipant dischargedispositioncode: CE CWE [0..1] typecode*: <= x_encounterparticipant <= EncounterDischargeDisposition location typecode*: <= LOC 0..1 healthcarefacility 0..1 location Place RelatedSubject 0..1 classcode*: <= x_documentsubject code: CE CWE [0..1] <= alrelationshiproletype 0..1 subject Constraint: ParentDocument.text ParentDocument.text can be used to indicate the MIME type of the related document. It is not to be used to embed the related document, and thus ParentDocument.text.BIN is precluded from use. assignedentity performer typecode*: <= x_serviceeventperformer AssignedAuthor 0..1 assignedauthorchoice 1..1 bodychoice 0..1 relatedsubject subject typecode*: <= SBJ awarenesscode: CE CWE [0..1] <= TargetAwareness Subject name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] 0..1 represented 0..1 assigned 0..1 represented 0..1 assigned informant bodychoice NonXMLBody classcode*: <= DOCBODY text: ED [1..1] StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] section entry typecode*: <= x_actrelationshipentry DrugOrOtherMaterial LabeledDrug classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= DrugEntity name: EN [0..1] Material classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= MaterialEntityClassType name: EN [0..1] lotnumbertext: ST [0..1] PlayingEntity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode quantity: SET<PQ> [] name: SET<PN> [] desc: ED [0..1] Constraint: Section.text Section.text.mediaType fixed as "text/x-hl7-text+xml". See section "Section Narrative Block" for details. EntityChoice Device classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 0..1 manufacturer 1..1 manufactureddrugorothermaterial 0..1 playingentitychoice 0..1 scopingentity Entity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode desc: ED [0..1] 0..1 assigned ManufacturedProduct classcode*: <= MANU ParticipantRole classcode*: <= ROL 1..* assignedauthor typecode*: <= AUT 0..1 represented SpecimenRole classcode*: <= SPEC 0..1 specimenplayingentity entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] informant 0..1 subject 1..1 manufacturedproduct consumable typecode*: <= CSM clinicalstatement assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode 0..1 manufacturedproduct * product typecode*: <= PRD specimenrole specimen typecode*: <= SPC participantrole participant typecode*: <= ParticipationType awarenesscode: CE CWE [0..1] <= TargetAwareness clinicalstatement clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] RegionOfInterest classcode*: <= ROIOVL code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] ObservationMedia value*: ED [1..1] SubstanceAdministration classcode*: <= SBADM moodcode*: <= x_documentsubstancemood code: CD CWE [0..1] <= SubstanceAdministrationActCode effectivetime: GTS [0..1] routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite dosequantity: IVL<PQ> [0..1] ratequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] administrationunitcode: CE CWE [0..1] <= AdministrableDrugForm Supply classcode*: <= SPLY moodcode*: <= x_documentsubstancemood effectivetime: GTS [0..1] prioritycode: SET<CE> CWE [] <= ActPriority independentind: BL [0..1] quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] Procedure classcode*: <= PROC moodcode*: <= x_documentproceduremood code: CD CWE [0..1] methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] Encounter classcode*: <= ENC moodcode*: <= x_documentencountermood code: CD CWE [0..1] <= ActEncounterCode Organizer classcode*: <= x_actclassdocumententryorganizer statuscode*: CS CNE [1..1] <= ActStatus Act classcode*: <= x_actclassdocumententryact moodcode*: <= x_documentactmood code*: CD CWE [1..1] <= ActCode observationrange referencerange typecode*: <= REFV Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference clinicalstatement sequencenumber: INT [0..1] ObservationRange.CRT interpretationcode: CE CNE [0..1] <= ObservationInterpretation Criterion.CRT Constraint: Organizer externalactchoice externalactchoice ExternalAct classcode*: <= ACT ExternalObservation ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType ヘッダ部变述部エントリー部 外部参照部 30

31 診療情報提供書記載者 ( 紹介元 ) name: SET<PN> [] AuthorChoice 0..1 represented AssignedAuthor 0..1 assignedauthorchoice 1..* assignedauthor typecode*: <= AUT <> <time value=" " /> <assignedauthor> <id extension="12345" root=" " /> <addr> <country>jp</country> <streetname> 虎ノ門 1 丁目 19 番 9 号 </streetname> <city> 港区 </city> <state> 東京都 </state> <postalcode> </postalcode> </addr> <telecom use="wp" value="tel: " /> <assigned> <name use="ide"> <family> 東京 </family> <given> 太郎 </given> </name> </assigned> <represented> <id extension="93" root=" " /> <name>jahis 病院内科 </name> </represented> </assignedauthor> </> 31

32 診療情報提供書記載者 ( 紹介先 ) (POCD_RM000040) The Organizer clone can be the source of the relationship or the reference relationship, but not the entryrelationship relationship received name: SET<PN> [] AuthorChoice Place classcode*: <= PLC name: EN [0..1] addr: AD [0..1] 0..1 received Patient id: II [0..1](Deprecated) name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity GuardianChoice 0..1 informationrecipient 0..1 represented AuthoringDevice classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 1..1 place Birthplace classcode*: <= BIRTHPL classcode*: <= ORG name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 birthplace 1..1 guardianchoice 0..1 whole 0..1 represented 0..1 assigned 1..1 maintaining 0..1 related 0..1 patient 0..1 scoping 0..1 aspartof asmaintainedentity 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian MaintainedEntity classcode*: <= MNT 0..1 represented 0..1 assigned 0..1 provider guardian PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus 紹介先 PatientRole classcode*: <= PAT id: SET<II> [1..*] languagecommunication Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 1..1 assignedcustodian custodian typecode*: <= CST Custodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] 1..* patientrole recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity participant typecode*: <= ParticipationType 0..1 informationrecipient ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] confidentialitycode*: CE CWE [1..1] copytime: TS [0..1](Deprecated) parentdocument relateddocument typecode*: <= x_actrelationshipdocument documentationof typecode*: <= DOC infulfillmentof typecode*: <= FLFS ization typecode*: <= AUTH serviceevent Of 0..1 encompassingencounter Constraint: relateddocument.typecode A conformant CDA document can have a single relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and "RPLC"; or two relateddocuments with typecodes "XFRM" and "APND". HealthCareFacility classcode*: <= SDLOC code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType 0..1 serviceprovider CDA R-MIM order consent This RMIM is used to generate the CDA specification. ParentDocument classcode*: <= DOCCLIN code: CD CWE [0..1] <= DocumentType ServiceEvent classcode*: <= ACT code: CE CWE [0..1] Order classcode*: <= ACT moodcode*: <= RQO code: CE CWE [0..1] <= ActCode Consent classcode*: <= CONS code: CE CWE [0..1] <= ActCode statuscode*: CS CNE [1..1] <= completed EncompassingEncounter responsibleparty classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= ActEncounterCode assignedentity effectivetime*: IVL<TS> [1..1] encounterparticipant dischargedispositioncode: CE CWE [0..1] typecode*: <= x_encounterparticipant <= EncounterDischargeDisposition location typecode*: <= LOC 0..1 healthcarefacility 0..1 location Place IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] RelatedSubject 0..1 classcode*: <= x_documentsubject code: CE CWE [0..1] <= alrelationshiproletype 0..1 subject Constraint: ParentDocument.text ParentDocument.text can be used to indicate the MIME type of the related document. It is not to be used to embed the related document, and thus ParentDocument.text.BIN is precluded from use. assignedentity performer typecode*: <= x_serviceeventperformer 1..1 bodychoice 0..1 relatedsubject subject typecode*: <= SBJ awarenesscode: CE CWE [0..1] <= TargetAwareness Subject name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] 0..1 represented 0..1 assigned 0..1 represented 0..1 assigned informant bodychoice NonXMLBody classcode*: <= DOCBODY text: ED [1..1] StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] section entry typecode*: <= x_actrelationshipentry DrugOrOtherMaterial LabeledDrug classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= DrugEntity name: EN [0..1] Material classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= MaterialEntityClassType name: EN [0..1] lotnumbertext: ST [0..1] PlayingEntity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode quantity: SET<PQ> [] name: SET<PN> [] desc: ED [0..1] Constraint: Section.text Section.text.mediaType fixed as "text/x-hl7-text+xml". See section "Section Narrative Block" for details. entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] intendedrecipient sequencenumber: INT [0..1] informationrecipient clinicalstatement typecode*: <= x_informationrecipient EntityChoice Device classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 0..1 manufacturer 1..1 manufactureddrugorothermaterial 0..1 playingentitychoice 0..1 scopingentity Entity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode desc: ED [0..1] 0..1 assigned ManufacturedProduct classcode*: <= MANU ParticipantRole classcode*: <= ROL 0..1 represented SpecimenRole classcode*: <= SPEC 0..1 specimenplayingentity informant 0..1 subject 1..1 manufacturedproduct consumable typecode*: <= CSM clinicalstatement assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode 0..1 manufacturedproduct * product typecode*: <= PRD specimenrole specimen typecode*: <= SPC participantrole participant typecode*: <= ParticipationType awarenesscode: CE CWE [0..1] <= TargetAwareness clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] RegionOfInterest classcode*: <= ROIOVL code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] ObservationMedia value*: ED [1..1] SubstanceAdministration classcode*: <= SBADM moodcode*: <= x_documentsubstancemood code: CD CWE [0..1] <= SubstanceAdministrationActCode effectivetime: GTS [0..1] routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite dosequantity: IVL<PQ> [0..1] ratequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] administrationunitcode: CE CWE [0..1] <= AdministrableDrugForm Supply classcode*: <= SPLY moodcode*: <= x_documentsubstancemood effectivetime: GTS [0..1] prioritycode: SET<CE> CWE [] <= ActPriority independentind: BL [0..1] quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] Procedure classcode*: <= PROC moodcode*: <= x_documentproceduremood code: CD CWE [0..1] methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] Encounter classcode*: <= ENC moodcode*: <= x_documentencountermood code: CD CWE [0..1] <= ActEncounterCode Organizer classcode*: <= x_actclassdocumententryorganizer statuscode*: CS CNE [1..1] <= ActStatus Act classcode*: <= x_actclassdocumententryact moodcode*: <= x_documentactmood code*: CD CWE [1..1] <= ActCode observationrange referencerange typecode*: <= REFV Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference clinicalstatement sequencenumber: INT [0..1] ObservationRange.CRT interpretationcode: CE CNE [0..1] <= ObservationInterpretation Criterion.CRT Constraint: Organizer externalactchoice externalactchoice ExternalAct classcode*: <= ACT ExternalObservation ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType ヘッダ部变述部エントリー部 外部参照部 32

33 紹介先 0..1 received 0..1 informationrecipient IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] intendedrecipient informationrecipient typecode*: <= x_informationrecipient <informationrecipient typecode="prcp"> <intendedrecipient classcode="assigned"> <id extension="1234" root=" " /> <!-- 紹介先医療機関住所 --> <addr> <country>jp</country> <postalcode> </postalcode> <streetname> 西落合 1 丁目 31 番 4 号 </streetname> <city> 新宿区 </city> <state> 東京都 </state> </addr> <!-- 紹介先医療機関電話番号 --> <telecom use="wp" value="tel: " /> <informationrecipient> <!-- 紹介先医師名 --> <name use="ide"> <family> 港 </family> <given> 次郎 </given> </name> </informationrecipient> <!-- 紹介先医療機関名 --> <received> <id extension="111111" root=" " /> <name>hl7 病院内科 </name> </received> </intendedrecipient> </informationrecipient> 33

34 診療情報提供書と R-MIM の関係 ( ヘッダ部 ) (POCD_RM000040JP00) entryrelationship PartOf classcode*: <= PART id*: SET<II> [] 0..1 whole statuscode: CS CNE [0..1] <= RoleStatus classcode*: <= ORG 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 represented 0..1 assigned 0..1 received IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] 0..1 informationrecipient 0..1 represented AssignedAuthor AuthorChoice assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature 受取者 intendedrecipient informationrecipient typecode*: <= x_informationrecipient 0..1 assignedauthorchoice 0..1 assignedcustodian AssignedCustodian custodian name: SET<PN> [] typecode*: <= CST 1..* assignedauthor typecode*: <= AUT 作成者 文書情報 ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] ParentDocument parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument code: CD CWE [0..1] <= DocumentType 0..1 represented 0..1 assigned typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] clinicalstatement assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] ObservationMedia value*: ED [1..1] ObservationRange.CRT observationrange referencerange typecode*: <= REFV interpretationcode: CE CNE [0..1] <= ObservationInterpretation Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN Custodian 1..1 representedcustodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] 0..1 represented 0..1 assigned dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] bodychoice externalactchoice 0..1 patient Patient id: II [0..1](Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity 0..1 provider PatientRole classcode*: <= PAT id: SET<II> [1..*] 患者情報 1..* patientrole recordtarget typecode*: <= RCT PREF RMIM This RMIM is used for patient referral document 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..* section reference typecode*: <= x_actrelationshipexternalreference externalactchoice ExternalObservation GuardianChoice guardian Guardian classcode*: <= GUARD Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind section ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType 1..1 guardianchoice entry typecode*: <= x_actrelationshipentry clinicalstatement 0..1 scoping 0..1 associated associatedentity AssociatedEntity participant classcode*: <= RoleClassAssociative typecode*: <= ParticipationType ヘッダ部变述部エントリー部 外部参照部 34

35 診療情報提供書の本文の記述 (POCD_RM000040JP00) entryrelationship PartOf classcode*: <= PART id*: SET<II> [] 0..1 whole statuscode: CS CNE [0..1] <= RoleStatus classcode*: <= ORG 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 represented 0..1 assigned 0..1 received assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] ParentDocument parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument code: CD CWE [0..1] <= DocumentType typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] ObservationRange.CRT observationrange referencerange typecode*: <= REFV interpretationcode: CE CNE [0..1] <= ObservationInterpretation Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN IntendedRecipient 0..1 informationrecipient 0..1 represented AuthorChoice classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 0..1 represented 0..1 assigned assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode ObservationMedia value*: ED [1..1] name: SET<PN> [] 0..1 assignedauthorchoice AssignedCustodian 0..1 assignedcustodian custodian typecode*: <= CST Custodian 1..1 representedcustodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] 0..1 represented 0..1 assigned dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] bodychoice externalactchoice 0..1 provider 0..1 patient Patient PatientRole classcode*: <= PAT id: SET<II> [1..*] id: II [0..1](Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity 1..* patientrole recordtarget typecode*: <= RCT PREF RMIM This RMIM is used for patient referral document 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..* section reference typecode*: <= x_actrelationshipexternalreference externalactchoice ExternalObservation GuardianChoice guardian Guardian classcode*: <= GUARD Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind section ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType 1..1 guardianchoice entry typecode*: <= x_actrelationshipentry clinicalstatement 0..1 scoping 0..1 associated associatedentity AssociatedEntity participant classcode*: <= RoleClassAssociative typecode*: <= ParticipationType ヘッダ部变述部エントリー部 外部参照部 35

36 診療情報提供書本文例レベル 1 2 での記述 (POCD_RM000040JP00) bodychoice classcode*: <= ORG name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 whole 0..1 aspartof 0..1 represented 0..1 assigned 0..1 received PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] parentdocument relateddocument typecode*: <= x_actrelationshipdocument ParentDocument classcode*: <= DOCCLIN code: CD CWE [0..1] <= DocumentType entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] clinicalstatement 1..1 bodychoice clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] StructuredBody classcode*: <= DOCBODY Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. criterion precondition typecode*: <= PRCN ObservationRange.CRT interpretationcode: CE CNE [0..1] <= ObservationInterpretation observationrange referencerange typecode*: <= REFV Criterion.CRT contextconductionind*: value: ANY BL [0..1] [1..1] "true" IntendedRecipient name: SET<PN> [] AuthorChoice 0..1 informationrecipient 0..1 represented classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian 0..1 represented 0..1 assigned intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 0..1 assignedcustodian custodian typecode*: <= CST Custodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] bodychoice 0..1 represented 0..1 assigned assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode ObservationMedia value*: ED [1..1] 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind externalactchoice 0..1 provider 0..1 patient Patient PatientRole classcode*: <= PAT id: SET<II> [1..*] id: II [0..1](Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity 1..* patientrole recordtarget typecode*: <= RCT typecode*: <= <= COMP COMP contextconductionind*: BL BL [1..1] [1..1] "true" "true" PREF RMIM This RMIM is used for patient referral document 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..* section reference typecode*: <= x_actrelationshipexternalreference externalactchoice ExternalObservation GuardianChoice guardian Guardian classcode*: <= GUARD Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind section ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType 1..1 guardianchoice entry typecode*: <= x_actrelationshipentry clinicalstatement 0..1 scoping 0..1 associated associatedentity AssociatedEntity participant classcode*: <= RoleClassAssociative typecode*: <= ParticipationType ヘッダ部变述部エントリー部 外部参照部 36

37 診療情報提供書本文例レベル 1 2 での記述 <!-- ********** CDA Body ********** --> bodychoice < contextconductionind="true"> <structuredbody> <!-- 目的 ( 区分 ) --> < contextconductionind="true"> <section> <code code="md " codesystem=" " displayname=" 目的 " /> <title> 目的 </title> <text> 胃潰瘍投薬治療後の経過観察 </text> </section> </> <!-- 連絡 ( 留意 ) 事項 --> < contextconductionind="true"> <section> <code code="md " codesystem=" " displayname=" 連絡事項 " /> <title> 連絡事項 </title> <text> 平成 17 年 9 月 8 日当科入院 投薬治療 胸腹部 CT 施行いたしました 投薬治療により 潰瘍が消滅しました ご本人の希望もあり 今後の経過観察につき御高診の程 よろしくお願い申し上げます </text> </section> </> 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind 37

38 診療情報提供書本文例レベル 1 2 での記述 < typecode="comp" contextconductionind="true"> <section classcode="docsect" moodcode="evn"> <code code="md " codesystem=" " codesystemname="jmix" displayname=" 現投与 " /> <title> 現在の処方 </title> <text> <table> <tbody> <tr> <td> 実施済 </td> <td> 処方 </td> <td> 皮膚科 </td> <td> 康裕 </td> <td> 外来 </td> <td> 昼 </td> <td> 院内 </td> <td> 会計済 </td> </tr> </tbody> </table> <table> <tbody> <tr> <td>rp1</td> <td> ジルテック錠 10mg</td> <td>1 錠 </td> <td>1 日 1 回朝食後 </td> <td>14 日 </td> </tr> 1..1 bodychoice bodychoice StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] <= x_basicconfidentialitykind 39

39 CDA R2 Clinical Statement (POCD_RM000040) The Organizer clone can be the source of the relationship or the reference relationship, but not the entryrelationship relationship. entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] ObservationRange clinicalstatement.crt Observation observationrange moodcode*: <= x_actmooddocumentobservation referencerange typecode*: <= REFV interpretationcode: CE CNE [0..1] <= ObservationInterpretation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] entryrelationship Constraint: relateddocument.typecode typecode*: <= typecode*: <= x_actrelationshipentryrelationship A conformant CDA document can have a single inversionind: inversionind: BL BL [0..1] [0..1] PartOf relateddocument with typecode "APND"; a single clinicalstatement contextconductionind*: BL BL [1..1] [1..1] "true" "true" classcode*: <= PART relateddocument with typecode "RPLC"; a single sequencenumber: INT [0..1] sequencenumber: INT [0..1] 0..1 whole id*: SET<II> [] relateddocument with typecode "XFRM"; two negationind: negationind: BL BL [0..1] [0..1] relateddocuments with typecodes "XFRM" and statuscode: CS CNE [0..1] <= "RPLC"; or two relateddocuments with typecodes classcode*: <= ORG RoleStatus "XFRM" and "APND". clinicalstatement 0..1 aspartof interpretationcode: SET<CE> CNE [] Observation Observation name: SET<ON> [] methodcode: SET<CE> CWE [] Criterion moodcode*: <= x_actmooddocumentobservation Constraint: ParentDocument.text moodcode*: <= x_actmooddocumentobservation targetsitecode: SET<CD> CWE [] ParentDocument standardindustryclasscode: CE CWE [0..1] informant ParentDocument.text can be used to indicate code*: CD CWE [1..1] <= ObservationType parentdocument classcode*: <= DOCCLIN code*: CD CWE [1..1] <= ObservationType <= IndustryClass the MIME type of the related document. It is.crt 0..1 represented assignedentity ClinicalDocument relateddocument not to be used to embed the related document, derivationexpr: ST [0..1] authenticator classcode*: <= DOCCLIN and thus ParentDocument.text.BIN RegionOfInterest is precluded derivationexpr: ST [0..1] typecode*: <= x_actrelationshipdocument criterion code: CD CWE [0..1] <= DocumentType typecode*: <= AUTHEN from use. classcode*: <= ROIOVL id*: II [1..1] precondition statuscode: effectivetime: CS IVL<TS> CNE [0..1] [0..1] <= ActStatus clinicalstatement effectivetime: signaturecode*: CS CNE [1..1] <= ParticipationSignature code*: CE CWE [1..1] <= DocumentType prioritycode: IVL<TS> CE CWE [0..1] [0..1] 0..1 <= ActPriority typecode*: <= PRCN clinicalstatement prioritycode: repeatnumber: CE IVL<INT> CWE [0..1] [0..1] <= ActPriority effectivetime*: TS [1..1] subject repeatnumber: languagecode: IVL<INT> CS CNE [0..1] [0..1] <= legalauthenticator confidentialitycode*: CE CWE [1..1] assignedentity languagecode: CS CNE [0..1] <= ServiceEvent code*: CS CNE [1..1] <= ROIOverlayShape value: typecode*: <= LA interpretationcode: ANY [0..1] performer 0..1 represented SET<CE> CNE [] 0..1 assigned classcode*: <= ACT interpretationcode: serviceevent methodcode: SET<CE> SET<CE> CWE CNE [] [] typecode*: <= x_serviceeventperformer value*: LIST<INT> [1..*] signaturecode*: CS CNE [1..1] <= ParticipationSignature documentationof methodcode: targetsitecode: SET<CE> SET<CD> CWE CWE [] [] 0..1 represented 0..1 assigned informant targetsitecode: SET<CD> CWE [] typecode*: <= DOC code: CE CWE [0..1] informant 0..1 received copytime: TS [0..1](Deprecated) RegionOfInterest RegionOfInterest order assignedentity ObservationMedia classcode*: <= ROIOVL 0..1 classcode*: moodcode*: <= <= ROIOVL EVN infulfillmentof typecode*: <= FLFS Order performer 0..1subject moodcode*: id*: SET<II> <= [1..*] EVN IntendedRecipient subject id*: code*: SET<II> CS CNE [1..*][1..1] <= ROIOverlayShape 0..1 assigned classcode*: <= typecode*: ACT <= PRF code*: value*: CS LIST<INT> CNE [1..1] [1..*] <= ROIOverlayShape classcode*: <= intendedrecipient moodcode*: <= RQO 0..1 represented value*: LIST<INT> [1..*] x_informationrecipientrole informationrecipient 0..1 represented id*: SET<II> [] code: CE CWE modecode: [0..1] <= ActCodeCE CWE [0..1] <= ParticipationMode assignedentity ObservationMedia 0..1 informationrecipient typecode*: <= x_informationrecipient performer ObservationMedia value*: ED [1..1] assignedentity 0..1 assigned performer typecode*: <= PRF classcode*: moodcode*: <= <= OBS EVN 0..1 manufacturer consent Consent 0..1 assigned typecode*: time: IVL<TS> <= PRF [0..1] moodcode*: <= EVN time: modecode: IVL<TS> CE [0..1] CWE [0..1] <= ParticipationMode id: languagecode: SET<II> [] CS CNE [0..1] <= 0..1 represented 1..* assignedauthor ization classcode*: <= CONS modecode: CE CWE [0..1] <= ParticipationMode languagecode: value*: ED [1..1] CS CNE [0..1] <= SubstanceAdministration typecode*: <= AUTH 0..1 manufacturer value*: ED [1..1] AssignedAuthor DrugOrOtherMaterial typecode*: <= AUT code: CE CWE [0..1] <= ActCode classcode*: <= SBADM 0..1 manufacturer SubstanceAdministration statuscode*: CS CNE [1..1] <= completed DrugOrOtherMaterial SubstanceAdministration classcode*: <= SBADM LabeledDrug moodcode*: <= x_documentsubstancemood DrugOrOtherMaterial LabeledDrug classcode*: moodcode*: <= <= SBADM x_documentsubstancemood AuthorChoice EncompassingEncounter responsibleparty classcode*: <= MMAT moodcode*: <= x_documentsubstancemood classcode*: <= MMAT LabeledDrug code: CD CWE [0..1] <= SubstanceAdministrationActCode ManufacturedProduct code: 0..1 represented CD CWE [0..1] <= SubstanceAdministrationActCode ManufacturedProduct determinercode*: <= KIND classcode*: <= MMAT determinercode*: <= KIND classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= ManufacturedProduct classcode*: <= MANU code: CD CWE [0..1] <= SubstanceAdministrationActCode Of determinercode*: <= KIND DrugEntity 1..1 manufacturedproduct code: CE CWE [0..1] <= classcode*: <= MANU code: CE CWE [0..1] <= classcode*: <= MANU 0..1 assignedauthorchoice 1..1 assignedcustodian assignedentity name: EN [0..1] DrugEntity AssignedCustodian custodian 0..1 encompassingencounter code: CE CWE [0..1] <= ActEncounterCode 1..1 consumable manufacturedproduct effectivetime: GTS [0..1] DrugEntity 1..1 manufacturedproduct name: SET<PN> [] effectivetime*: IVL<TS> [1..1] encounterparticipant name: EN [0..1] consumable typecode*: <= CSM effectivetime: prioritycode: GTS CE CWE [0..1] [0..1] <= ActPriority typecode*: <= CST name: EN [0..1] dischargedispositioncode: CE CWE [0..1] typecode*: <= x_encounterparticipant consumable Material typecode*: <= CSM <= EncounterDischargeDisposition effectivetime: GTS [0..1] 0..1 assigned routecode: CE CWE [0..1] <= RouteOfAdministration Material classcode*: <= MMAT AuthoringDevice approachsitecode: SET<CD> CWE [] <= ActSite location typecode*: <= CSM classcode*: determinercode*: <= MMAT <= KIND routecode: CE CWE [0..1] <= RouteOfAdministration classcode*: <= DEV code: CE CWE [0..1] dosequantity: IVL<PQ> [0..1] typecode*: <= LOC determinercode*: <= KIND approachsitecode: SET<CD> CWE [] <= ActSite ratequantity: IVL<PQ> [0..1] Custodian Material 0..1 healthcarefacility <= MaterialEntityClassType code: CE CWE [0..1] <= EntityCode 1..1 representedcustodian code: CE CWE [0..1] dosequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] classcode*: <= ORG name: EN [0..1] ratequantity: IVL<PQ> [0..1] manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName classcode*: <= MMAT routecode: CE CWE [0..1] <= RouteOfAdministration <= MaterialEntityClassType administrationunitcode: CE CWE [0..1] <= lotnumbertext: ST [0..1] softwarename: SC CWE [0..1] <= SoftwareName HealthCareFacility name: EN [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] AdministrableDrugForm determinercode*: <= KIND approachsitecode: SET<CD> CWE [] <= ActSite classcode*: <= SDLOC lotnumbertext: ST [0..1] administrationunitcode: CE CWE [0..1] <= name: ON [0..1] 1..1 manufactureddrugorothermaterial 0..1 manufacturedproduct * AdministrableDrugForm asmaintainedentity MaintainedEntity telecom: TEL [0..1] code: CE CWE [0..1] dosequantity: IVL<PQ> [0..1] code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType 1..1 manufactureddrugorothermaterial 0..1 product manufacturedproduct * addr: AD [0..1] Supply 1..1 maintaining classcode*: <= MNT <= MaterialEntityClassType ratequantity: IVL<PQ> [0..1] typecode*: <= PRD product classcode*: <= SPLY name: EN [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] EntityChoice typecode*: <= PRD Supply moodcode*: <= x_documentsubstancemood classcode*: 0..1 serviceprovider <= SPLY lotnumbertext: ST [0..1] administrationunitcode: CE CWE [0..1] <= 0..1 location DeviceEntityChoice moodcode*: code: CD CWE <= x_documentsubstancemood [0..1] <= ActCode bodychoice Place AdministrableDrugForm classcode*: <= DEV Device specimenrole id: text: SET<II> ED [0..1] [] 0..1 represented dataenterer specimen code: statuscode: CD CWE CS [0..1] CNE <= [0..1] ActCode <= ActStatus typecode*: <= ENT (Transcriptionist) NonXMLBody classcode*: code: CE <= CWE DEV[0..1] <= EntityCode SpecimenRole specimenrole 1..1 manufactureddrugorothermaterial 0..1 manufacturedproduct * typecode*: <= SPC text: effectivetime: ED [0..1] GTS [0..1] determinercode*: Place classcode*: <= DOCBODY manufacturermodelname: <= INSTANCE SC CWE [0..1] 0..1 assigned classcode*: <= SPEC specimen statuscode: prioritycode: CS SET<CE> CNE [0..1] CWE <= ActStatus [] <= ActPriority time: TS [0..1] code: <= CE ManufacturerModelName CWE [0..1] <= EntityCode classcode*: <= PLC product SpecimenRole typecode*: <= SPC effectivetime: repeatnumber: GTS IVL<INT> [0..1] manufacturermodelname: [0..1] text: ED [1..1] softwarename: SC CWE SC [0..1] CWE [0..1] classcode*: <= SPEC prioritycode: independentind: SET<CE> BL [0..1] CWE [] <= ActPriority <= ManufacturerModelName typecode*: <= PRD Supply <= SoftwareName repeatnumber: name: EN [0..1] quantity: PQ [0..1] IVL<INT> [0..1] softwarename: SC CWE [0..1] addr: AD [0..1] classcode*: <= SPLY independentind: expectedusetime: BL [0..1] IVL<TS> [0..1] <= SoftwareName 1..1 place EntityChoice PlayingEntity quantity: PQ [0..1] moodcode*: <= x_documentsubstancemood expectedusetime: IVL<TS> [0..1] classcode*: <= ENT Procedure PlayingEntity 1..1 bodychoice Device 0..1 specimenplayingentity classcode*: <= PROC classcode*: code: CE <= CWE ENT[0..1] <= EntityCode moodcode*: <= x_documentproceduremood Birthplace Procedure StructuredBody determinercode*: quantity: SET<PQ> <= INSTANCE [] classcode*: <= DEV 0..1 specimenplayingentity classcode*: <= PROC classcode*: <= BIRTHPL specimenrole name: SET<PN> [] code: CE CWE [0..1] <= EntityCode classcode*: <= DOCBODY moodcode*: code: CD CWE <= x_documentproceduremood [0..1] 0..1 birthplace quantity: desc: SET<PQ> ED [0..1] [] 0..1 provider specimen 1..* patientrole name: SET<PN> [] code: CE CWE [0..1] <= EntityCode code: text: CD ED CWE [0..1] [0..1] recordtarget SpecimenRole desc: ED [0..1] 0..1 playingentitychoice 0..1 patient PatientRole typecode*: <= SPC effectivetime: GTS [0..1] negationind: statuscode: BL CS [0..1] CNE [0..1] <= ActStatus Patient typecode*: <= RCT manufacturermodelname: SC CWE [0..1] classcode*: <= PAT participantrole classcode*: <= SPEC prioritycode: SET<CE> CWE [] <= ActPriority 0..1 playingentitychoice ParticipantRole id: SET<II> [1..*] participant <= ManufacturerModelName classcode*: <= ROL typecode*: participantrole <= ParticipationType methodcode: SET<CE> CWE [] id: II [0..1](Deprecated) softwarename: SC CWE [0..1] ParticipantRole independentind: BL [0..1] participant approachsitecode: SET<CD> CWE [] name: SET<PN> [] classcode*: code: CE <= CWE ROL [0..1] <= RoleCode <= SoftwareName administrativegendercode: CE CWE [0..1] <= AdministrativeGender typecode*: <= ParticipationType targetsitecode: SET<CD> CWE [] quantity: PQ [0..1] awarenesscode: CE CWE [0..1] <= TargetAwareness methodcode: SET<CE> CWE [] birthtime: TS [0..1] code: telecom: CE CWE SET<TEL> [0..1] <= [] RoleCode approachsitecode: SET<CD> CWE [] maritalstatuscode: CE CWE [0..1] <= MaritalStatus LanguageCommunication expectedusetime: IVL<TS> [0..1] targetsitecode: religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation (LanguageCommunication) CDA R-MIM Encounter SET<CD> CWE [] awarenesscode: CE CWE [0..1] <= TargetAwareness PlayingEntity classcode*: <= ENC racecode: CE CWE [0..1] <= Race 0..1 scopingentity ethnicgroupcode: CE CWE [0..1] <= Ethnicity This RMIM is used to generate Encounter moodcode*: <= x_documentencountermood 1..* section modecode: CE CWE [0..1] <= LanguageAbilityMode classcode*: <= ENT Entity the CDA specification. Procedure classcode*: <= ENC proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency 0..1 scopingentity classcode*: <= ENT code: CD CWE [0..1] <= ActEncounterCode languagecommunication moodcode*: <= x_documentencountermood preferenceind: BL [0..1] 0..1 specimenplayingentity classcode*: <= PROC Section Entity id: text: SET<II> ED [0..1] [] code: CE CWE [0..1] <= EntityCode classcode*: <= DOCSECT classcode*: id: SET<II> <= [] ENT code: statuscode: CD CWE CS [0..1] CNE <= [0..1] ActEncounterCode <= ActStatus GuardianChoice moodcode*: <= x_documentproceduremood determinercode*: code: CE CWE <= [0..1] INSTANCE <= EntityCode text: effectivetime: ED [0..1] IVL<TS> [0..1] quantity: SET<PQ> [] id: II [0..1] desc: ED [0..1] statuscode: prioritycode: CS CE CNE CWE [0..1] [0..1] <= <= ActStatus ActPriority guardian Guardian name: SET<PN> [] code: CE CWE [0..1] <= DocumentSectionType section code: CE CWE [0..1] <= EntityCode classcode*: <= GUARD code: CD CWE [0..1] desc: ED [0..1] desc: ED [0..1] negationind: informant BL [0..1] text*: ED [0..1] Organizer classcode*: <= x_actclassdocumententryorganizer Organizer 0..1 playingentitychoice RelatedSubject 0..1 relatedsubject classcode*: <= x_actclassdocumententryorganizer 0..1 statuscode*: CS CNE [1..1] <= ActStatus participantrole subject id: informantchoice classcode*: <= x_documentsubject effectivetime: SET<II> [] IVL<TS> [0..1] ParticipantRole typecode*: <= SBJ 1..1 guardianchoice participant code: CE CWE [0..1] <= alrelationshiproletype 0..1 represented clinicalstatement statuscode*: CS CNE [1..1] <= ActStatus classcode*: <= ROL awarenesscode: CE CWE [0..1] languagecode: <= TargetAwareness CS CNE [0..1] <= entry 0..1 assigned typecode*: <= ParticipationType methodcode: SET<CE> CWE [] typecode*: <= x_actrelationshipentry Act RelatedEntity approachsitecode: SET<CD> CWE [] informantchoice classcode*: <= x_actclassdocumententryact subject classcode*: <= RoleClassMutualRelationship informant targetsitecode: SET<CD> CWE [] moodcode*: <= x_documentactmood code: CE CWE [0..1] <= Subject Act typecode*: <= INF awarenesscode: CE CWE [0..1] <= TargetAwareness alrelationshiproletype classcode*: code*: CD CWE <= x_actclassdocumententryact [1..1] <= ActCode moodcode*: negationind: <= BL x_documentactmood [0..1] 0..1 related Constraint: Section.text name: SET<PN> [] Encounter id: text: SET<II> ED [0..1] [] Section.text.mediaType administrativegendercode: CE CWE [0..1] <= AdministrativeGender code*: statuscode: CD CWE CS [1..1] CNE <= [0..1] ActCode <= ActStatus birthtime: TS [0..1] classcode*: <= ENC fixed as "text/x-hl7-text+xml". negationind: effectivetime: BL IVL<TS> [0..1] [0..1] 0..1 scoping 0..1 scopingentity text: prioritycode: ED [0..1] CE CWE [0..1] <= ActPriority associatedentity moodcode*: <= x_documentencountermood See section "Section Narrative statuscode: languagecode: CS CNE CS CNE [0..1] [0..1] <= ActStatus <= Block" for details. AssociatedEntity participant Entity classcode*: <= RoleClassAssociative typecode*: <= ParticipationType classcode*: <= ENT code: CD CWE [0..1] <= ActEncounterCode 0..1 associated code: CE CWE [0..1] <= EntityCode desc: ED [0..1] observationrange observationrange referencerange referencerange typecode*: <= REFV typecode*: <= REFV Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. criterion precondition criterion precondition typecode*: <= PRCN typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference clinicalstatement clinicalstatement sequencenumber: INT [0..1] typecode*: seperatableind: <= COMP BL [0..1] sequencenumber: INT [0..1] Constraint: Organizer ObservationRange classcode*: classcode*: <= <= OBS OBS moodcode*: moodcode*: <= <= EVN.CRT EVN.CRT interpretationcode: CE CNE [0..1] <= ObservationInterpretation interpretationcode: CE CNE [0..1] <= ObservationInterpretation Criterion Criterion moodcode*: classcode*: <= EVN.CRT OBS code: moodcode*: CD CWE <= [0..1] EVN.CRT <= ActCode text: code: ED CD [0..1] CWE [0..1] <= ActCode value: text: ED ANY [0..1] [0..1] externalactchoice externalactchoice ExternalAct classcode*: <= ACT ExternalObservation ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType Organizer classcode*: <= x_actclassdocumententryorganizer statuscode*: CS CNE [1..1] <= ActStatus clinicalstatement sequencenumber: INT [0..1] Act classcode*: <= x_actclassdocumententryact moodcode*: <= x_documentactmood code*: CD CWE [1..1] <= ActCode 40

40 本文 ( レベル 3) で身体所見を記述 (POCD_RM000040JP00) clinicalstatement Observation PartOf classcode*: <= PART id*: SET<II> [] 0..1 whole statuscode: CS CNE [0..1] <= RoleStatus classcode*: <= ORG 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 represented 0..1 assigned 0..1 received assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] ParentDocument parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument code: CD CWE [0..1] <= DocumentType entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] ObservationRange.CRT observationrange referencerange typecode*: <= REFV interpretationcode: CE CNE [0..1] <= ObservationInterpretation Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] 0..1 informationrecipient 0..1 represented AssignedAuthor AuthorChoice 0..1 assignedauthorchoice name: SET<PN> [] AssignedCustodian intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 0..1 assignedcustodian custodian typecode*: <= CST 0..1 represented 0..1 assigned assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode ObservationMedia value*: ED [1..1] Custodian 1..1 representedcustodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] bodychoice Patient id: II [0..1] (Deprecated) name: SET<PN> [] desc: ED [0..1] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity GuardianChoice 0..1 patient 0..1 represented 0..1 assigned 0..1 provider guardian PatientRole classcode*: <= PAT id: SET<II> [1..*] Guardian classcode*: <= GUARD dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] 1..* patientrole recordtarget typecode*: <= RCT PREF RMIM This RMIM is used for patient referral document bodychoice 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..1 bodychoice StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT 1..* section contextconductionind*: moodcode*: BL [1..1] "true" <= EVN id: II [0..1] Section code: CE CWE [0..1] <= DocumentSectionType classcode*: <= DOCSECT id: II [0..1] text*: ED [0..1] code: CE CWE [0..1] <= DocumentSectionType section text*: ED [0..1] <= reference typecode*: <= x_actrelationshipexternalreference externalactchoice externalactchoice ExternalObservation ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType 1..1 guardianchoice entry typecode*: <= x_actrelationshipentry entry typecode*: <= x_actrelationshipentry clinicalstatement clinicalstatement 0..1 scoping 0..1 associated associatedentity AssociatedEntity participant classcode*: <= RoleClassAssociative typecode*: <= ParticipationType ヘッダ部变述部エントリー部 外部参照部 41

41 レベル 3 での記述 1..1 structuredbody StructuredBody classcode*: <= DOCBODY clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] bodychoice entry typecode*: <= x_actrelationshipentry 1..1 bodychoice StructuredBody classcode*: <= DOCBODY observation Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] value: ANY CWE [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] entry typecode*: <= x_actrelationshipentry clinicalstatement 42

42 CDA R2 レベル 3 の記述例 1..1 structuredbody Clinical Statement StructuredBody classcode*: <= DOCBODY Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] entry typecode*: <= x_actrelationshipentry Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] value: ANY CWE [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] 1..* section observation < contextconductionind="true"> <section> <code code="md " codesystem=" " codesystemname="jmix" displayname=" 身体所見 " /> <title> 身体所見 </title> <entry contextconductionind="true"> <observation classcode="obs" moodcode="evn"> <code code="3137-7" codesystem=" " codesystemname="loinc" displayname=" 身長 " /> <statuscode code="completed" /> <value xsi:type="pq" value="170" unit="cm" /> </observation> </entry> <entry contextconductionind="true"> <observation classcode="obs" moodcode="evn"> <code code="3141-9" codesystem=" " codesystemname="loinc" displayname=" 体重 " /> <statuscode code="completed" /> <value xsi:type="pq" value="58" unit="kg" /> </observation> </entry> </section> </> 43

43 スタイルシートによる表示制御 (CDA.xsl) <name use="ide"> <family> 日本 </family> <given> 次郎 </given> </name> <name use="syl"> <family> ニホン </family> <given> ジロウ </given> </name> <desc> 職業会社員 </desc> <administrativegendercode code="m" codesystem=" " /> <table class="patient" cellspacing="0"> <tr> <td class="patient-fname-hd" rowspan="2"> 患者氏名 </td> <td class="patient-fname" colspan="4"> <xsl:apply-templates select="hl7:recordtarget/hl7:patientrole/hl7:patient/hl7:name" /> </td> </tr> <tr> <td class="patient-name" colspan="2"> <xsl:value-of select="hl7:recordtarget/hl7:patientrole/hl7:patient/hl7:name" /> XML インスタンス <xsl:template match="/hl7:clinicaldocument/hl7:recordtarget/hl7:pat ientrole/hl7:patient/hl7:name"> <xsl:if <xsl:value-of select="hl7:family" /> <xsl:text /> <xsl:value-of select="hl7:given" /> </xsl:if> </xsl:template> XSL スタイルシート 44

44 外部参照文書 < contextconductionind="true"> <section> <code code="md " codesystem=" " displayname=" 検査結果 " /> <title> 検査結果 </title> <text> 心電図検査を添付致します </text> <entry contextconductionind="true"> <observation classcode="obs" moodcode="evn"> <code code="9a110" codesystem="890e A59-8BF9-A5CFA9AD66EB" codesystemname="lc10" displayname=" 標準 12 誘導心電図検査 " /> <reference typecode="sprt"> <externaldocument> <code code="1" codesystem=" " codesystemname="mfer" displayname="12 誘導心電図 " /> < text mediatype =" application/mwf " representation ="B64" integritycheck="bpu2x6j9j3ah5ulhzz1jx8wx0ks="> < reference value ="0153_130_ _ mwf"/> </text> </externaldocument> </reference> </observation> </entry> </section> </> 診療情報提供書 <xsl:choose> <xsl:when test="hl7:section/hl7:entry/hl7:observation/hl7:reference/hl7:externaldo cument"> <xsl:element name="a"> <xsl:attribute name="href"> <xsl:value-of select="hl7:section/hl7:entry/hl7:observation/hl7:reference/hl7:externald ocument/hl7:text" /> </xsl:attribute> <xsl:if test="hl7:section/hl7:entry/hl7:observation"> <xsl:for-each select="hl7:section"> <xsl:apply-templates select="child::hl7:entry/hl7:observation" /> </xsl:for-each> </xsl:if> スタイルシート </xsl:element> </xsl:when> 45

45 CDA レベル 1 レベル 2 レベル 3 < typecode="comp" contextconductionind="true"> <structuredbody classcode="docbody" moodcode="evn"> < typecode="comp" contextconductionind="true"> <section classcode="docsect" moodcode="evn"> <code code= MD " codesystem=" " codesystemname= JMIX" codesystemversion="1.0" displayname=" 現投与 " /> <title> 現投与 </title> <text> <table> <tr><td>rp1</td><td> ジルテック錠 10mg</td><td>1 錠 1 日 1 回 </td><td> 朝食後 </td><td>14 日 </td></tr> <tr><td>rp2</td><td> ポララミン復効錠 6mg</td><td>1 錠 </td><td> かゆい時 </td><td> 14 回 </td><tr> <tr><td>rp3</td><td> トプシムローション 10g</td><td>4 本 1 日 2 回 </td><td> 頭 </td><tr> <tr><td>rp4 </td><td> 混用ヒルドイド軟膏 20g</td><td>0.5 本 </td></tr> <tr><td></td><td> リンデロン-V 軟膏 5g</td><td>2 本 </td><td>1 日 2 回 </td><td> 体幹 四肢 </td><tr> </table></text> <entry typecode="comp" contextconductionind="true"> <substanceadministration classcode="sbadm" moodcode="evn"> <consumable typecode="csm"> <manufacturedproduct classcode="manu"> <manufacturedlabeleddrug classcode="mmat" determinercode="kind"> codesystemversion="1.0" displayname=" ジルテック錠 10mg" /> <name> ジルテック錠 10mg</name> </manufacturedlabeleddrug> </manufacturedproduct> </consumable> レベル 2 レベル 1 <code code=" " codesystem=" " codesystemname="drugcode" レベル 3 46

46 CDA で診療文書の記述 (POCD_RM000040) The Organizer clone can be the source of the relationship or the reference relationship, but not the entryrelationship relationship. name: SET<PN> [] AuthorChoice Place classcode*: <= PLC name: EN [0..1] addr: AD [0..1] 0..1 received Patient id: II [0..1] (Deprecated) name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] maritalstatuscode: CE CWE [0..1] <= MaritalStatus religiousaffiliationcode: CE CWE [0..1] <= ReligiousAffiliation racecode: CE CWE [0..1] <= Race ethnicgroupcode: CE CWE [0..1] <= Ethnicity GuardianChoice 0..1 informationrecipient 0..1 represented AuthoringDevice classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 1..1 place Birthplace classcode*: <= BIRTHPL classcode*: <= ORG name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 birthplace 1..1 guardianchoice 0..1 whole 0..1 represented 0..1 assigned 1..1 maintaining 0..1 related 0..1 patient 0..1 scoping 0..1 aspartof asmaintainedentity 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian MaintainedEntity classcode*: <= MNT 0..1 represented 0..1 assigned 0..1 provider guardian PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus PatientRole classcode*: <= PAT id: SET<II> [1..*] languagecommunication Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative assignedentity authenticator typecode*: <= AUTHEN signaturecode*: CS CNE [1..1] <= ParticipationSignature 認証者 legalauthenticator typecode*: <= LA signaturecode*: CS CNE [1..1] <= ParticipationSignature 受取者 intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor typecode*: <= AUT 作成者 1..1 assignedcustodian custodian typecode*: <= CST 文書管理者 転記者 Custodian classcode*: <= ORG name: ON [0..1] telecom: TEL [0..1] addr: AD [0..1] dataenterer typecode*: <= ENT (Transcriptionist) time: TS [0..1] 患者情報 1..* patientrole recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] 情報提供者 informantchoice informant typecode*: <= INF associatedentity participant typecode*: <= ParticipationType 関係者 文書情報 ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] confidentialitycode*: CE CWE [1..1] copytime: TS [0..1] (Deprecated) parentdocument relateddocument typecode*: <= x_actrelationshipdocument documentationof typecode*: <= DOC infulfillmentof typecode*: <= FLFS ization typecode*: <= AUTH serviceevent Of 0..1 encompassingencounter Constraint: relateddocument.typecode A conformant CDA document can have a single relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and "RPLC"; or two relateddocuments with typecodes "XFRM" and "APND". HealthCareFacility classcode*: <= SDLOC code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType 0..1 serviceprovider CDA R-MIM order consent This RMIM is used to generate the CDA specification. ParentDocument classcode*: <= DOCCLIN code: CD CWE [0..1] <= DocumentType 親文書 行為者 ServiceEvent classcode*: <= ACT code: CE CWE [0..1] オーダ情報 Order classcode*: <= ACT moodcode*: <= RQO code: CE CWE [0..1] <= ActCode Consent classcode*: <= CONS code: CE CWE [0..1] <= ActCode statuscode*: CS CNE [1..1] <= completed EncompassingEncounter responsibleparty classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= ActEncounterCode assignedentity effectivetime*: IVL<TS> [1..1] encounterparticipant dischargedispositioncode: CE CWE [0..1] typecode*: <= x_encounterparticipant <= EncounterDischargeDisposition 受診情報 location typecode*: <= LOC 0..1 healthcarefacility 0..1 location Place RelatedSubject 0..1 classcode*: <= x_documentsubject code: CE CWE [0..1] <= alrelationshiproletype 0..1 subject Constraint: ParentDocument.text ParentDocument.text can be used to indicate the MIME type of the related document. It is not to be used to embed the related document, and thus ParentDocument.text.BIN is precluded from use. assignedentity performer typecode*: <= x_serviceeventperformer 1..1 bodychoice 0..1 relatedsubject subject typecode*: <= SBJ awarenesscode: CE CWE [0..1] <= TargetAwareness Subject name: SET<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender birthtime: TS [0..1] 0..1 represented 0..1 assigned インフォームドコンセント 入力点 関連患者 0..1 represented 0..1 assigned informant bodychoice NonXMLBody classcode*: <= DOCBODY text: ED [1..1] 非 XML データ StructuredBody classcode*: <= DOCBODY 1..* section Section classcode*: <= DOCSECT id: II [0..1] code: CE CWE [0..1] <= DocumentSectionType text*: ED [0..1] 本文 section entry typecode*: <= x_actrelationshipentry DrugOrOtherMaterial LabeledDrug classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= DrugEntity name: EN [0..1] Material classcode*: <= MMAT determinercode*: <= KIND code: CE CWE [0..1] <= MaterialEntityClassType name: EN [0..1] lotnumbertext: ST [0..1] PlayingEntity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode quantity: SET<PQ> [] name: SET<PN> [] desc: ED [0..1] Constraint: Section.text Section.text.mediaType fixed as "text/x-hl7-text+xml". See section "Section Narrative Block" for details. EntityChoice Device classcode*: <= DEV code: CE CWE [0..1] <= EntityCode manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName 0..1 manufacturer 1..1 manufactureddrugorothermaterial 0..1 playingentitychoice 0..1 scopingentity Entity classcode*: <= ENT code: CE CWE [0..1] <= EntityCode desc: ED [0..1] 0..1 assigned ManufacturedProduct classcode*: <= MANU ParticipantRole classcode*: <= ROL 0..1 represented 0..1 specimenplayingentity entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] sequencenumber: INT [0..1] informant 0..1 subject 1..1 manufacturedproduct consumable typecode*: <= CSM 製品情報 clinicalstatement assignedentity performer typecode*: <= PRF modecode: CE CWE [0..1] <= ParticipationMode 0..1 manufacturedproduct * product typecode*: <= PRD specimenrole specimen SpecimenRole typecode*: <= SPC classcode*: <= SPEC 検体情報 関係者 participantrole participant typecode*: <= ParticipationType awarenesscode: CE CWE [0..1] <= TargetAwareness clinicalstatement clinicalstatement Observation moodcode*: <= x_actmooddocumentobservation code*: CD CWE [1..1] <= ObservationType derivationexpr: ST [0..1] interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] 受診 検査 注目領域 RegionOfInterest classcode*: <= ROIOVL code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] 観察情報 ObservationMedia value*: ED [1..1] SubstanceAdministration classcode*: <= SBADM moodcode*: <= x_documentsubstancemood code: CD CWE [0..1] <= SubstanceAdministrationActCode effectivetime: GTS [0..1] 投薬情報 routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite dosequantity: IVL<PQ> [0..1] ratequantity: IVL<PQ> [0..1] maxdosequantity: RTO<PQ,PQ> [0..1] administrationunitcode: CE CWE [0..1] <= AdministrableDrugForm Supply classcode*: <= SPLY moodcode*: <= x_documentsubstancemood effectivetime: GTS [0..1] prioritycode: SET<CE> CWE [] <= ActPriority independentind: BL [0..1] quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] 物品情報 Procedure classcode*: <= PROC moodcode*: <= x_documentproceduremood code: CD CWE [0..1] methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] 処置 手術 Encounter classcode*: <= ENC moodcode*: <= x_documentencountermood code: CD CWE [0..1] <= ActEncounterCode 受診情報 検体 Organizer classcode*: <= x_actclassdocumententryorganizer statuscode*: CS CNE [1..1] <= ActStatus Act classcode*: <= x_actclassdocumententryact moodcode*: <= x_documentactmood code*: CD CWE [1..1] <= ActCode text: ED その他 [0..1] observationrange referencerange typecode*: <= REFV Note: Observation.value has cardinality [], which doesn't show up in the Visio representation. criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference clinicalstatement sequencenumber: INT [0..1] ObservationRange.CRT interpretationcode: CE CNE [0..1] <= ObservationInterpretation Criterion.CRT Constraint: Organizer externalactchoice externalactchoice ExternalAct classcode*: <= ACT 外部参照情報 ExternalObservation ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC code: CD CWE [0..1] <= DocumentType ヘッダ部变述部エントリー部 外部参照部 47

47 CDA XML ファイル構成 CDA XML 文書 CDA.xsd POCD_MT xsd coreschemas POCD_MT000040JP00.xsd datatypes.xsd refvoc.xsd datattypes-base.xsd InfrastructureRoot.xsd CDA xsl voc.xsd narrative.xsd 48

48 JAVA で XML を実装 import org.w3c.dom.document; import org.w3c.dom.element; public class PatientRefarral { public static void main(string[] args) { try { DocumentBuilderFactory dbfactory = DocumentBuilderFactory.newInstance(); dbfactory.setnamespaceaware(true); dbfactory.setvalidating(true); DocumentBuilder docbuilder = dbfactory.newdocumentbuilder(); Document document = docbuilder.newdocument(); /* * ClinicalDocuemnt をルート要素として生成する */ Element root = document.createelement("clinicaldocument"); root.setattribute("xmlns", "urn:hl7-org:v3"); root.setattribute("xmlns:xsi", " root.setattribute("xsi:schemalocation", "urn:hl7-org:v3 CDA.xsd"); document.appendchild(root); /* * TypeID エレメントを追加 */ Element typeid = document.createelement("typeid"); typeid.setattribute("extension", "POCD_HD000040JP00"); typeid.setattribute("root", " "); root.appendchild(typeid); /* * DOM オブジェクトを文字列として出力 */ TransformerFactory tfactory = TransformerFactory.newInstance(); Transformer transformer = tfactory.newtransformer(); File outfile = new File("PatientRefarralExample.xml"); transformer.transform(new DOMSource(document), new StreamResult(outfile)); 49

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