HL7 CDA 入門 本日のテーマ 日本 HL7 協会 CDA WG 平井正明 CDA とは XML と CDA HL7 V3 と CDA 電子紹介状 = 診療情報提供書を作ってみよう = 2010 年 7 月 6 日

Transcription

1 HL7 CDA 入門 = 診療情報提供書を作ってみよう = 日本 HL7 協会 CDA WG 平井正明 2010 年 7 月 6 日 本日のテーマ CDA とは XML と CDA HL7 V3 と CDA 電子紹介状 2

2 CDA (Clinical Document Architecture) 診療文書アーキテクチャ CDA は 診療文書 を交換するため 構造とセマンティックを規定 永続性 ( 保存性 ): Persistent 診療文書は 定めた期間 存続し続ける 維持管理 : Stewardship 診療文書は その管理を受託した組織により維持管理される 真正性 : Potential for authentication 診療文書は 法的に認証された情報の集まりである 文脈 :Context 診療文書は その内容に対する初期値を設定する 完全性 :Wholeness 診療文書の認証は文書全体に適用し 部分 g 的な認証はしない 見読性 :Human readability 診療文書は 可読である CDAは テキスト イメージ サウンド その他のマルチメディア内容を含むことができる 3 CDA の各国での応用 4

3 紹介状 5 CDA R2 (Clinical Document Architecture Release 2) 6

4 CDA の歴史 1997 年 1 月 : HL7 SGML SIG として第一回目の会議が開催 1997 年 7 月 : Kona Mansion で運用開始 1998 年 1 月 : Kona(KEG) 編集グループ結成 1998 年 9 月 : (RIM ベースで ) Record Architecture (PRA) と改名 2000 年 1 月 : 第一回委員会投票パス 2000 年 5 月 : 第二回委員会投票パス 2000 年 9 月 : HL7 メンバー投票パス ( 全員賛同 ) 2000 年 11 月 : ANSI/HL7 CDA R 承認 2003 年 7 月 : CDA Release 2 第一回委員会投票パス 2005 年 1 月 : CDA R2 HL7 メンバー投票パス 2009 年 11 月 : ISO/HL :2009 Data Exchange Standards -- HL7 Clinical Document Architecture, Release 2 発行 7 CDA の構成 CDA <ClinicalDocument> ヘッダ 本体 患者情報作成者認証情報 ( 何の ) 文書等 検査情報観察情報処方情報処置 手技等 8

5 ヘッダ部に書かれる情報 患者情報 "recordtarget 作成者 " 代行入力者 "dataenterer 情報提供者 "informant 保管管理者 "custodian 情報受取者 "informationrecipient 法的認証者 "legalauthenticator 認証者 "authenticator 参加者 " オーダ情報 "infulfillmentof サービス行為 "documentationof 関連ドキュメント "relateddocument インフォームドコンセント情報 "ization 受診情報 "Of 9 本体 構造化本文 非 XML 文章 nonxmlbody 10

6 診療情報 診療行為 "encounter 検査 観察 "observation 検査メディア "observationmedia 画像等の注目点 "regionofinterest アクトの構成 "organizer 処置 手術 "procedure 投薬情報 "substanceadministration 物品管理 "supply 一般的な医療サービス "act ( 外部参照情報 ) 11 外部参照情報 外部行為情報 "externalact 外部検査 観察情報 "external 外部処置 手技情報 "externalprocedure 外部文書 "externaldocument 12

7 XML (extensible Markup Language) CDA は XML で書かれる 13 紹介状 XML <?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 " /> 14

8 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 15 XML の復習 < > で括られたタグで記述される < 名前 > 平井正明 </ 名前 > < 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 } 一般的記述 < 要素名属性 属性...> 内容 データ等 </ 要素名 > CDA では要素名 属性名は HL7 V3 で決められた名称が使用される 16

9 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?> 終わる < 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す 通常 1.0 で問題はない encoding= UTF-8 文字コードを示す日本語では Shift ー JIS ISO-2022-JP 等は使えるが 国際的な互換性を考慮し 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 17 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 > < 姓名 ID= > コメントの開始 平井正明 </ 姓名 > 属性値 < 性別 > 男 </ 性別 > < 年齢 /> < 住所 > 要素名 属性名 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 18

10 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 が使用されますが 実在の URI である必要はない 19 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 20

11 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) により検証する例 :CDA のスキーマは先頭に CDA.xsd として記述する <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す <?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 21 XML で記述 <?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 " /> 22

12 CDA の構成 CDA <ClinicalDocument> ヘッダ 本体 患者情報作成者認証者 検査情報観察情報処方 手技 23 CDA の構成 CDA <ClinicalDocument> ヘッダ 本体 患者情報作成者認証者 検査情報観察情報処方 手技 24

13 V3 RIM (Reference Information Model) V3 RIM (Reference Information Model) 26

14 スーパクラスの表現 Role -classcode 27 クラス例 Entity Role Participation Act 日本太郎 医師 Practitioner 実施者 Performer 診察 東京花子 患者 本人 Subject 28

15 クラス図に展開する 日本太郎 東京花子 医師 Practitioner 患者 実施者 Performer 本人 Subject 診察 (POLB_RM900001) sample R-MIM for HL7 seminar presentation by Hirai Entity Role Participation Act 日本太郎 医師 0..1 Practitioner classcode*: <= PRT addr: BAG<AD> [] 0..1 playertelecom: BAG<TEL> [] certificatetext: ED [0..1] Practitioner practitioner typecode*: <= PRF 実施者 Performer effectivetime: GTS [0..1] 診察 東京花子 name: BAG<PN> [] administrativegendercode: CE CWE [0..1] <= AdministrativeGender 患者 patient 本人 Subject patient subject typecode*: <= SBJ 29 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 XML インスタンス 診療情報提供書 30

16 V3 RIM (Reference Information Model) 31 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> 32

17 患者情報は recordtarget 0..1 patient (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race 0..1 provider Role 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> 33 HL 7 V3 34

18 R-MIM V3 データタイプ XML <birthtime value=" " /> 35 R-MIM V3 用語 (Vocabulary) XML <administrativegendercode code="m" codesystem=" " /> 36

19 HMD (Hierarchical Message Description) 37 診療情報提供書 38

20 0..1 received 0..1 informationrecipient 0..1 related 0..1 scoping 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] 0..1 represented Place 0..1 assigned classcode*: <= PLC 1..1 place Birthplace classcode*: <= BIRTHPL 0..1 birthplace 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice PartOf classcode*: <= PART 0..1 whole id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 0..1 represented 1..* assignedauthor AssignedAuthor AuthorChoice 0..1 assignedauthorchoice 1..1 assignedcustodian AssignedCustodian custodian name: SET<PN> [] typecode*: <= CST AuthoringDevice classcode*: <= DEV Custodian 1..1 representedcustodian manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName name: ON [0..1] 1..1 guardianchoice AuthorChoice name: SET<PN> [] 0..1 represented 0..1 assigned asmaintainedentity 1..1 maintaining 0..1 received 0..1 informationrecipient 0..1 represented 0..1 scoping 0..1 associated MaintainedEntity classcode*: <= MNT languagecommunication guardian Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 0..1 represented 0..1 assigned 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice 0..1 whole 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 1..1 guardianchoice 0..1 represented 0..1 assigned PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus 1..* patientrole 1..1 representedcustodian guardian Guardian classcode*: <= GUARD AssociatedEntity classcode*: <= RoleClassAssociative telecom: TEL [0..1] time: TS [0..1] modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor 0..1 assignedcustodian custodian typecode*: <= CST 1..* patientrole Custodian name: ON [0..1] telecom: TEL [0..1] time: TS [0..1] associatedentity 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) ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] entryrelationship Constraint: relateddocument.typecode typecode*: <= x_actrelationshipentryrelationship A conformant CDA document can have a single inversionind: BL [0..1] relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and Range "RPLC"; or two relateddocuments with typecodes clinicalstatement "XFRM" and "APND"..CRT observationrange moodcode*: <= x_actmooddocument referencerange Constraint: ParentDocument.text typecode*: <= REFV interpretationcode: CE CNE [0..1] <= Interpretation ParentDocument ParentDocument.text can be used to indicate code*: CD CWE [1..1] <= Type parentdocument classcode*: <= DOCCLIN the MIME type of the related document. It is relateddocument not to be used to embed the related document, derivationexpr: ST [0..1] and thus ParentDocument.text.BIN is precluded typecode*: <= x_actrelationshipdocument from use. Note:.value has cardinality clinicalstatement [], which doesn't show up in the Visio representation. assignedentity ServiceEvent 0..1 represented interpretationcode: SET<CE> CNE [] serviceevent methodcode: SET<CE> CWE [] Criterion documentationof targetsitecode: SET<CD> CWE [] 0..1 assigned informant typecode*: <= DOC code: CE CWE [0..1].CRT RegionOfInterest criterion order classcode*: <= ROIOVL precondition 0..1 infulfillmentof typecode*: <= PRCN typecode*: <= FLFS Order subject code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] moodcode*: <= RQO 0..1 represented code: CE CWE [0..1] <= ActCode assignedentity Media 0..1 assigned consent Consent modecode: CE CWE [0..1] <= ParticipationMode ization classcode*: <= CONS value*: ED [1..1] typecode*: <= AUTH 0..1 manufacturer code: CE CWE [0..1] <= ActCode SubstanceAdministration statuscode*: CS CNE [1..1] <= completed DrugOrOtherMaterial classcode*: <= SBADM LabeledDrug moodcode*: <= x_documentsubstancemood classcode*: <= MMAT EncompassingEncounter responsibleparty ManufacturedProduct code: CD CWE [0..1] <= SubstanceAdministrationActCode 0..1 represented determinercode*: <= KIND classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= classcode*: <= MANU Of DrugEntity 1..1 manufacturedproduct assignedentity consumable 0..1 encompassingencounter code: CE CWE [0..1] <= ActEncounterCode effectivetime: GTS [0..1] effectivetime*: IVL<TS> [1..1] typecode*: <= CSM dischargedispositioncode: CE CWE [0..1] Material <= EncounterDischargeDisposition 0..1 assigned classcode*: <= MMAT routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite location determinercode*: <= KIND code: CE CWE [0..1] dosequantity: IVL<PQ> [0..1] typecode*: <= LOC ratequantity: IVL<PQ> [0..1] 0..1 healthcarefacility <= MaterialEntityClassType maxdosequantity: RTO<PQ,PQ> [0..1] lotnumbertext: ST [0..1] administrationunitcode: CE CWE [0..1] <= HealthCareFacility AdministrableDrugForm classcode*: <= SDLOC 1..1 manufactureddrugorothermaterial 0..1 manufacturedproduct * code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType product typecode*: <= PRD Supply classcode*: <= SPLY EntityChoice moodcode*: <= x_documentsubstancemood 0..1 serviceprovider 0..1 location Device Place classcode*: <= DEV specimenrole specimen NonXMLBody SpecimenRole typecode*: <= SPC effectivetime: GTS [0..1] manufacturermodelname: SC CWE [0..1] classcode*: <= SPEC prioritycode: SET<CE> CWE [] <= ActPriority <= ManufacturerModelName text: ED [1..1] softwarename: SC CWE [0..1] independentind: BL [0..1] <= SoftwareName quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] PlayingEntity classcode*: <= ENT Procedure 0..1 specimenplayingentity classcode*: <= PROC moodcode*: <= x_documentproceduremood quantity: SET<PQ> [] name: SET<PN> [] code: CD CWE [0..1] 0..1 playingentitychoice externalactchoice Role reference ParticipantRole typecode*: <= x_actrelationshipexternalreference classcode*: <= ROL methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] awarenesscode: CE CWE [0..1] <= TargetAwareness CDA R-MIM Encounter (POCD_RM000040) classcode*: <= ENC 0..1 scopingentity This RMIM is used to generate moodcode*: <= x_documentencountermood 1..* section Entity the CDA specification. classcode*: <= ENT code: CD CWE [0..1] <= ActEncounterCode section clinicalstatement informant text*: ED [0..1] Organizer classcode*: <= x_actclassdocumententryorganizer 0..1 relatedsubject RelatedSubject 0..1 statuscode*: CS CNE [1..1] <= ActStatus subject classcode*: <= x_documentsubject typecode*: <= SBJ code: CE CWE [0..1] <= alrelationshiproletype clinicalstatement awarenesscode: CE CWE [0..1] <= TargetAwareness entry typecode*: <= x_actrelationshipentry Constraint: Organizer Act The Organizer clone can be the source of the relationship or classcode*: <= x_actclassdocumententryact 0..1 subject the reference relationship, but not moodcode*: <= x_documentactmood the entryrelationship relationship. Subject code*: CD CWE [1..1] <= ActCode Constraint:.text name: SET<PN> [].text.mediatype fixed as "text/x-hl7-text+xml". See section " Narrative Block" for details. ParentDocument parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument PREF RMIM (POCD_RM000040JP00) This RMIM is used for patient referral document text*: ED [0..1] <= x_basicconfidentialitykind 1..* section section entry typecode*: <= x_actrelationshipentry 0..1 represented 0..1 assigned entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] clinicalstatement moodcode*: <= x_actmooddocument code*: CD CWE [1..1] <= Type derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] assignedentity modecode: CE CWE [0..1] <= ParticipationMode clinicalstatement Media value*: ED [1..1] observationrange referencerange typecode*: <= REFV Note:.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference Range.CRT interpretationcode: CE CNE [0..1] <= Interpretation externalactchoice externalactchoice ExternalAct External ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC externalactchoice External ExternalDocument classcode*: <= DOC CDA 詳細設計書 (CDA R2 R-MIM) authenticator typecode*: <= AUTHEN legalauthenticator typecode*: <= LA typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) typecode*: <= x_serviceeventperformer encounterparticipant typecode*: <= x_encounterparticipant typecode*: <= PRF ヘッダ部叙述部エントリー部 外部参照部 39 診療情報提供書と R-MIM の関係 authenticator typecode*: <= AUTHEN legalauthenticator typecode*: <= LA typecode*: <= PRF typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) recordtarget typecode*: <= RCT ヘッダ部叙述部エントリー部 外部参照部 40

21 AuthorChoice name: SET<PN> [] 0..1 received 0..1 informationrecipient 0..1 represented 0..1 scoping 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian 0..1 represented 0..1 assigned 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice 0..1 whole 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 1..1 guardianchoice 0..1 represented 0..1 assigned 0..1 received 0..1 informationrecipient 0..1 related 0..1 scoping 0..1 associated PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus guardian Guardian classcode*: <= GUARD AssociatedEntity classcode*: <= RoleClassAssociative PartOf classcode*: <= PART 0..1 whole id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] 0..1 represented Place 0..1 assigned classcode*: <= PLC 1..1 place Birthplace classcode*: <= BIRTHPL 0..1 birthplace 0..1 provider 0..1 patient 0..1 patient Role id: SET<II> [1..*] (Deprecated) (Deprecated) name: SET<PN> [] name: SET<PN> [] racecode: CE CWE [0..1] <= Race racecode: CE CWE [0..1] <= Race languagecommunication GuardianChoice guardian Guardian classcode*: <= GUARD RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor 0..1 assignedcustodian custodian typecode*: <= CST 1..* patientrole Custodian name: ON [0..1] telecom: TEL [0..1] time: TS [0..1] associatedentity assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 0..1 represented 1..* assignedauthor AssignedAuthor AuthorChoice 0..1 assignedauthorchoice 1..1 assignedcustodian AssignedCustodian custodian name: SET<PN> [] typecode*: <= CST AuthoringDevice classcode*: <= DEV Custodian 1..1 representedcustodian manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName name: ON [0..1] 1..1 guardianchoice 0..1 represented 0..1 assigned asmaintainedentity 1..1 maintaining MaintainedEntity classcode*: <= MNT informantchoice 0..1 represented 0..1 assigned telecom: TEL [0..1] time: TS [0..1] 1..* patientrole recordtarget typecode*: <= RCT modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] 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 parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument PREF RMIM (POCD_RM000040JP00) This RMIM is used for patient referral document text*: ED [0..1] <= x_basicconfidentialitykind 1..* section section entry typecode*: <= x_actrelationshipentry 0..1 represented 0..1 assigned entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] clinicalstatement moodcode*: <= x_actmooddocument code*: CD CWE [1..1] <= Type derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] assignedentity modecode: CE CWE [0..1] <= ParticipationMode clinicalstatement Media value*: ED [1..1] observationrange referencerange typecode*: <= REFV Note:.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference Range.CRT interpretationcode: CE CNE [0..1] <= Interpretation entryrelationship Constraint: relateddocument.typecode typecode*: <= x_actrelationshipentryrelationship A conformant CDA document can have a single inversionind: BL [0..1] relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and Range "RPLC"; or two relateddocuments with typecodes clinicalstatement "XFRM" and "APND"..CRT observationrange moodcode*: <= x_actmooddocument referencerange Constraint: ParentDocument.text typecode*: <= REFV interpretationcode: CE CNE [0..1] <= Interpretation ParentDocument ParentDocument.text can be used to indicate code*: CD CWE [1..1] <= Type parentdocument classcode*: <= DOCCLIN the MIME type of the related document. It is relateddocument not to be used to embed the related document, derivationexpr: ST [0..1] and thus ParentDocument.text.BIN is precluded typecode*: <= x_actrelationshipdocument from use. Note:.value has cardinality clinicalstatement [], which doesn't show up in the Visio representation. assignedentity ServiceEvent 0..1 represented interpretationcode: SET<CE> CNE [] serviceevent methodcode: SET<CE> CWE [] Criterion documentationof targetsitecode: SET<CD> CWE [] 0..1 assigned informant typecode*: <= DOC code: CE CWE [0..1].CRT RegionOfInterest criterion order classcode*: <= ROIOVL precondition 0..1 infulfillmentof typecode*: <= PRCN typecode*: <= FLFS Order subject code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] moodcode*: <= RQO 0..1 represented code: CE CWE [0..1] <= ActCode assignedentity Media 0..1 assigned consent Consent modecode: CE CWE [0..1] <= ParticipationMode ization classcode*: <= CONS value*: ED [1..1] typecode*: <= AUTH 0..1 manufacturer code: CE CWE [0..1] <= ActCode SubstanceAdministration statuscode*: CS CNE [1..1] <= completed DrugOrOtherMaterial classcode*: <= SBADM LabeledDrug moodcode*: <= x_documentsubstancemood classcode*: <= MMAT EncompassingEncounter responsibleparty ManufacturedProduct code: CD CWE [0..1] <= SubstanceAdministrationActCode 0..1 represented determinercode*: <= KIND classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= classcode*: <= MANU Of DrugEntity 1..1 manufacturedproduct assignedentity consumable 0..1 encompassingencounter code: CE CWE [0..1] <= ActEncounterCode effectivetime: GTS [0..1] effectivetime*: IVL<TS> [1..1] typecode*: <= CSM dischargedispositioncode: CE CWE [0..1] Material <= EncounterDischargeDisposition 0..1 assigned classcode*: <= MMAT routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite location determinercode*: <= KIND code: CE CWE [0..1] dosequantity: IVL<PQ> [0..1] typecode*: <= LOC ratequantity: IVL<PQ> [0..1] 0..1 healthcarefacility <= MaterialEntityClassType maxdosequantity: RTO<PQ,PQ> [0..1] lotnumbertext: ST [0..1] administrationunitcode: CE CWE [0..1] <= HealthCareFacility AdministrableDrugForm classcode*: <= SDLOC 1..1 manufactureddrugorothermaterial 0..1 manufacturedproduct * code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType product typecode*: <= PRD Supply classcode*: <= SPLY EntityChoice moodcode*: <= x_documentsubstancemood 0..1 serviceprovider 0..1 location Device Place classcode*: <= DEV specimenrole specimen NonXMLBody SpecimenRole typecode*: <= SPC effectivetime: GTS [0..1] manufacturermodelname: SC CWE [0..1] classcode*: <= SPEC prioritycode: SET<CE> CWE [] <= ActPriority <= ManufacturerModelName text: ED [1..1] softwarename: SC CWE [0..1] independentind: BL [0..1] <= SoftwareName quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] PlayingEntity classcode*: <= ENT Procedure 0..1 specimenplayingentity classcode*: <= PROC moodcode*: <= x_documentproceduremood quantity: SET<PQ> [] name: SET<PN> [] code: CD CWE [0..1] 0..1 playingentitychoice externalactchoice Role reference ParticipantRole typecode*: <= x_actrelationshipexternalreference classcode*: <= ROL methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] awarenesscode: CE CWE [0..1] <= TargetAwareness CDA R-MIM Encounter (POCD_RM000040) classcode*: <= ENC 0..1 scopingentity This RMIM is used to generate moodcode*: <= x_documentencountermood 1..* section Entity the CDA specification. classcode*: <= ENT code: CD CWE [0..1] <= ActEncounterCode section clinicalstatement informant text*: ED [0..1] Organizer classcode*: <= x_actclassdocumententryorganizer 0..1 relatedsubject RelatedSubject 0..1 statuscode*: CS CNE [1..1] <= ActStatus subject classcode*: <= x_documentsubject typecode*: <= SBJ code: CE CWE [0..1] <= alrelationshiproletype clinicalstatement awarenesscode: CE CWE [0..1] <= TargetAwareness entry typecode*: <= x_actrelationshipentry Constraint: Organizer Act The Organizer clone can be the source of the relationship or classcode*: <= x_actclassdocumententryact 0..1 subject the reference relationship, but not moodcode*: <= x_documentactmood the entryrelationship relationship. Subject code*: CD CWE [1..1] <= ActCode Constraint:.text name: SET<PN> [].text.mediatype fixed as "text/x-hl7-text+xml". See section " Narrative Block" for details. externalactchoice externalactchoice External ExternalDocument classcode*: <= DOC externalactchoice ExternalAct External ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC 診療情報提供書の本文の記述 authenticator typecode*: <= AUTHEN legalauthenticator typecode*: <= LA typecode*: <= PRF typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) recordtarget typecode*: <= RCT ヘッダ部叙述部エントリー部 外部参照部 41 患者情報は recordtarget で記述 0..1 patient (Deprecated) name: SET<PN> [] authenticator typecode*: AUTHEN racecode: CE CWE [0..1] <= Race legalauthenticator typecode*: <= LA 患者情報 typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) LanguageCommunication (LanguageCommunication) 0..1 provider Role id: SET<II> [1..*] typecode*: <= x_serviceeventperformer encounterparticipant typecode*: <= x_encounterparticipant 1..* patientrole recordtarget typecode*: <= RCT typecode*: <= PRF 患者情報 ヘッダ部叙述部エントリー部 外部参照部 42

22 0..1 received 0..1 informationrecipient 0..1 related 0..1 scoping 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] 0..1 represented Place 0..1 assigned classcode*: <= PLC 1..1 place Birthplace classcode*: <= BIRTHPL 0..1 birthplace 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice PartOf classcode*: <= PART 0..1 whole id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 0..1 represented 0..1 assigned RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative assignedentity authenticator typecode*: <= AUTHEN intendedrecipient informationrecipient typecode*: <= x_informationrecipient 0..1 represented 1..* assignedauthor AssignedAuthor AuthorChoice 0..1 assignedauthorchoice 1..1 assignedcustodian AssignedCustodian custodian name: SET<PN> [] typecode*: <= CST AuthoringDevice classcode*: <= DEV Custodian 1..1 representedcustodian manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName name: ON [0..1] 1..1 guardianchoice asmaintainedentity 1..1 maintaining MaintainedEntity classcode*: <= MNT languagecommunication guardian Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned 1..* patientrole telecom: TEL [0..1] time: TS [0..1] modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity 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) entryrelationship Constraint: relateddocument.typecode typecode*: <= x_actrelationshipentryrelationship A conformant CDA document can have a single inversionind: BL [0..1] relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and Range "RPLC"; or two relateddocuments with typecodes clinicalstatement "XFRM" and "APND"..CRT observationrange moodcode*: <= x_actmooddocument referencerange Constraint: ParentDocument.text typecode*: <= REFV interpretationcode: CE CNE [0..1] <= Interpretation ParentDocument ParentDocument.text can be used to indicate code*: CD CWE [1..1] <= Type parentdocument classcode*: <= DOCCLIN the MIME type of the related document. It is relateddocument not to be used to embed the related document, derivationexpr: ST [0..1] and thus ParentDocument.text.BIN is precluded typecode*: <= x_actrelationshipdocument from use. Note:.value has cardinality clinicalstatement [], which doesn't show up in the Visio representation. assignedentity ServiceEvent 0..1 represented interpretationcode: SET<CE> CNE [] serviceevent methodcode: SET<CE> CWE [] Criterion documentationof targetsitecode: SET<CD> CWE [] 0..1 assigned informant typecode*: <= DOC code: CE CWE [0..1].CRT RegionOfInterest criterion order classcode*: <= ROIOVL precondition 0..1 infulfillmentof typecode*: <= PRCN typecode*: <= FLFS Order subject code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] moodcode*: <= RQO 0..1 represented code: CE CWE [0..1] <= ActCode assignedentity Media 0..1 assigned consent Consent modecode: CE CWE [0..1] <= ParticipationMode ization classcode*: <= CONS value*: ED [1..1] typecode*: <= AUTH 0..1 manufacturer code: CE CWE [0..1] <= ActCode SubstanceAdministration statuscode*: CS CNE [1..1] <= completed DrugOrOtherMaterial classcode*: <= SBADM LabeledDrug moodcode*: <= x_documentsubstancemood classcode*: <= MMAT EncompassingEncounter responsibleparty ManufacturedProduct code: CD CWE [0..1] <= SubstanceAdministrationActCode 0..1 represented determinercode*: <= KIND classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= classcode*: <= MANU Of DrugEntity 1..1 manufacturedproduct assignedentity consumable 0..1 encompassingencounter code: CE CWE [0..1] <= ActEncounterCode effectivetime: GTS [0..1] effectivetime*: IVL<TS> [1..1] typecode*: <= CSM dischargedispositioncode: CE CWE [0..1] Material <= EncounterDischargeDisposition 0..1 assigned classcode*: <= MMAT routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite location determinercode*: <= KIND code: CE CWE [0..1] dosequantity: IVL<PQ> [0..1] typecode*: <= LOC ratequantity: IVL<PQ> [0..1] 0..1 healthcarefacility <= MaterialEntityClassType maxdosequantity: RTO<PQ,PQ> [0..1] lotnumbertext: ST [0..1] administrationunitcode: CE CWE [0..1] <= HealthCareFacility AdministrableDrugForm classcode*: <= SDLOC 1..1 manufactureddrugorothermaterial 0..1 manufacturedproduct * code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType product typecode*: <= PRD Supply classcode*: <= SPLY EntityChoice moodcode*: <= x_documentsubstancemood 0..1 serviceprovider 0..1 location Device Place classcode*: <= DEV specimenrole specimen NonXMLBody SpecimenRole typecode*: <= SPC effectivetime: GTS [0..1] manufacturermodelname: SC CWE [0..1] classcode*: <= SPEC prioritycode: SET<CE> CWE [] <= ActPriority <= ManufacturerModelName text: ED [1..1] softwarename: SC CWE [0..1] independentind: BL [0..1] <= SoftwareName quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] PlayingEntity classcode*: <= ENT Procedure 0..1 specimenplayingentity classcode*: <= PROC moodcode*: <= x_documentproceduremood quantity: SET<PQ> [] name: SET<PN> [] code: CD CWE [0..1] 0..1 playingentitychoice externalactchoice Role reference ParticipantRole typecode*: <= x_actrelationshipexternalreference classcode*: <= ROL methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] awarenesscode: CE CWE [0..1] <= TargetAwareness Encounter CDA R-MIM (POCD_RM000040) classcode*: <= ENC 0..1 scopingentity This RMIM is used to generate moodcode*: <= x_documentencountermood 1..* section Entity the CDA specification. classcode*: <= ENT code: CD CWE [0..1] <= ActEncounterCode section clinicalstatement informant text*: ED [0..1] Organizer classcode*: <= x_actclassdocumententryorganizer 0..1 relatedsubject RelatedSubject 0..1 statuscode*: CS CNE [1..1] <= ActStatus subject classcode*: <= x_documentsubject typecode*: <= SBJ code: CE CWE [0..1] <= alrelationshiproletype clinicalstatement awarenesscode: CE CWE [0..1] <= TargetAwareness entry typecode*: <= x_actrelationshipentry Constraint: Organizer Act The Organizer clone can be the source of the relationship or classcode*: <= x_actclassdocumententryact 0..1 subject the reference relationship, but not moodcode*: <= x_documentactmood the entryrelationship relationship. Subject code*: CD CWE [1..1] <= ActCode Constraint:.text name: SET<PN> [].text.mediatype fixed as "text/x-hl7-text+xml". See section " Narrative Block" for details. externalactchoice ExternalAct External ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC 患者情報 0..1 patient (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race 0..1 provider Role 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> 43 AuthorChoice name: SET<PN> [] legalauthenticator typecode*: <= LA 作成者 typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) 診療情報提供書記載者 ( 紹介元 ) 0..1 represented 0..1 assignedauthorchoice typecode*: <= x_serviceeventperformer encounterparticipant typecode*: <= x_encounterparticipant AssignedAuthor 1..* assignedauthor typecode*: <= AUT typecode*: <= PRF ヘッダ部叙述部エントリー部 外部参照部 44

23 0..1 received 0..1 informationrecipient 0..1 related 0..1 scoping 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] 0..1 represented Place 0..1 assigned classcode*: <= PLC 1..1 place Birthplace classcode*: <= BIRTHPL 0..1 birthplace 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice PartOf classcode*: <= PART 0..1 whole id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass RelatedEntity classcode*: <= RoleClassMutualRelationship code: CE CWE [0..1] <= alrelationshiproletype AssociatedEntity classcode*: <= RoleClassAssociative assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 0..1 represented 1..* assignedauthor AssignedAuthor AuthorChoice 0..1 assignedauthorchoice 1..1 assignedcustodian AssignedCustodian custodian name: SET<PN> [] typecode*: <= CST AuthoringDevice classcode*: <= DEV Custodian 1..1 representedcustodian manufacturermodelname: SC CWE [0..1] <= ManufacturerModelName softwarename: SC CWE [0..1] <= SoftwareName name: ON [0..1] 1..1 guardianchoice 0..1 represented 0..1 assigned asmaintainedentity 1..1 maintaining MaintainedEntity classcode*: <= MNT languagecommunication guardian Guardian classcode*: <= GUARD informantchoice 0..1 represented 0..1 assigned 1..* patientrole telecom: TEL [0..1] time: TS [0..1] modecode: CE CWE [0..1] <= LanguageAbilityMode proficiencylevelcode: CE CWE [0..1] <= LanguageAbilityProficiency preferenceind: BL [0..1] informantchoice informant typecode*: <= INF associatedentity 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) entryrelationship Constraint: relateddocument.typecode typecode*: <= x_actrelationshipentryrelationship A conformant CDA document can have a single inversionind: BL [0..1] relateddocument with typecode "APND"; a single relateddocument with typecode "RPLC"; a single relateddocument with typecode "XFRM"; two relateddocuments with typecodes "XFRM" and Range "RPLC"; or two relateddocuments with typecodes clinicalstatement "XFRM" and "APND"..CRT observationrange moodcode*: <= x_actmooddocument referencerange Constraint: ParentDocument.text typecode*: <= REFV interpretationcode: CE CNE [0..1] <= Interpretation ParentDocument ParentDocument.text can be used to indicate code*: CD CWE [1..1] <= Type parentdocument classcode*: <= DOCCLIN the MIME type of the related document. It is relateddocument not to be used to embed the related document, derivationexpr: ST [0..1] and thus ParentDocument.text.BIN is precluded typecode*: <= x_actrelationshipdocument from use. Note:.value has cardinality clinicalstatement [], which doesn't show up in the Visio representation. assignedentity ServiceEvent 0..1 represented interpretationcode: SET<CE> CNE [] serviceevent methodcode: SET<CE> CWE [] Criterion documentationof targetsitecode: SET<CD> CWE [] 0..1 assigned informant typecode*: <= DOC code: CE CWE [0..1].CRT RegionOfInterest criterion order classcode*: <= ROIOVL precondition 0..1 infulfillmentof typecode*: <= PRCN typecode*: <= FLFS Order subject code*: CS CNE [1..1] <= ROIOverlayShape value*: LIST<INT> [1..*] moodcode*: <= RQO 0..1 represented code: CE CWE [0..1] <= ActCode assignedentity Media 0..1 assigned consent Consent modecode: CE CWE [0..1] <= ParticipationMode ization classcode*: <= CONS value*: ED [1..1] typecode*: <= AUTH 0..1 manufacturer code: CE CWE [0..1] <= ActCode SubstanceAdministration statuscode*: CS CNE [1..1] <= completed DrugOrOtherMaterial classcode*: <= SBADM LabeledDrug moodcode*: <= x_documentsubstancemood classcode*: <= MMAT EncompassingEncounter responsibleparty ManufacturedProduct code: CD CWE [0..1] <= SubstanceAdministrationActCode 0..1 represented determinercode*: <= KIND classcode*: <= ENC typecode*: <= RESP code: CE CWE [0..1] <= classcode*: <= MANU Of DrugEntity 1..1 manufacturedproduct assignedentity consumable 0..1 encompassingencounter code: CE CWE [0..1] <= ActEncounterCode effectivetime: GTS [0..1] effectivetime*: IVL<TS> [1..1] typecode*: <= CSM dischargedispositioncode: CE CWE [0..1] Material <= EncounterDischargeDisposition 0..1 assigned classcode*: <= MMAT routecode: CE CWE [0..1] <= RouteOfAdministration approachsitecode: SET<CD> CWE [] <= ActSite location determinercode*: <= KIND code: CE CWE [0..1] dosequantity: IVL<PQ> [0..1] typecode*: <= LOC ratequantity: IVL<PQ> [0..1] 0..1 healthcarefacility <= MaterialEntityClassType maxdosequantity: RTO<PQ,PQ> [0..1] lotnumbertext: ST [0..1] administrationunitcode: CE CWE [0..1] <= HealthCareFacility AdministrableDrugForm classcode*: <= SDLOC 1..1 manufactureddrugorothermaterial 0..1 manufacturedproduct * code: CE CWE [0..1] <= ServiceDeliveryLocationRoleType product typecode*: <= PRD Supply classcode*: <= SPLY EntityChoice moodcode*: <= x_documentsubstancemood 0..1 serviceprovider 0..1 location Device Place classcode*: <= DEV specimenrole specimen NonXMLBody SpecimenRole typecode*: <= SPC effectivetime: GTS [0..1] manufacturermodelname: SC CWE [0..1] classcode*: <= SPEC prioritycode: SET<CE> CWE [] <= ActPriority <= ManufacturerModelName text: ED [1..1] softwarename: SC CWE [0..1] independentind: BL [0..1] <= SoftwareName quantity: PQ [0..1] expectedusetime: IVL<TS> [0..1] PlayingEntity classcode*: <= ENT Procedure 0..1 specimenplayingentity classcode*: <= PROC moodcode*: <= x_documentproceduremood quantity: SET<PQ> [] name: SET<PN> [] code: CD CWE [0..1] 0..1 playingentitychoice externalactchoice Role reference ParticipantRole typecode*: <= x_actrelationshipexternalreference classcode*: <= ROL methodcode: SET<CE> CWE [] approachsitecode: SET<CD> CWE [] targetsitecode: SET<CD> CWE [] awarenesscode: CE CWE [0..1] <= TargetAwareness Encounter CDA R-MIM (POCD_RM000040) classcode*: <= ENC 0..1 scopingentity This RMIM is used to generate moodcode*: <= x_documentencountermood 1..* section Entity the CDA specification. classcode*: <= ENT code: CD CWE [0..1] <= ActEncounterCode section clinicalstatement informant text*: ED [0..1] Organizer classcode*: <= x_actclassdocumententryorganizer 0..1 relatedsubject RelatedSubject 0..1 statuscode*: CS CNE [1..1] <= ActStatus subject classcode*: <= x_documentsubject typecode*: <= SBJ code: CE CWE [0..1] <= alrelationshiproletype clinicalstatement awarenesscode: CE CWE [0..1] <= TargetAwareness entry typecode*: <= x_actrelationshipentry Constraint: Organizer Act The Organizer clone can be the source of the relationship or classcode*: <= x_actclassdocumententryact 0..1 subject the reference relationship, but not moodcode*: <= x_documentactmood the entryrelationship relationship. Subject code*: CD CWE [1..1] <= ActCode Constraint:.text name: SET<PN> [].text.mediatype fixed as "text/x-hl7-text+xml". See section " Narrative Block" for details. externalactchoice ExternalAct External ExternalProcedure classcode*: <= PROC ExternalDocument classcode*: <= DOC 診療情報提供書記載者 ( 紹介元 ) AuthorChoice name: SET<PN> [] 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> </> 45 診療情報提供書記載者 ( 紹介先 ) 0..1 received 紹介先 authenticator typecode*: <= AUTHEN legalauthenticator typecode*: <= LA typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) recordtarget typecode*: <= RCT LanguageCommunication (LanguageCommunication) 0..1 informationrecipient IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] typecode*: <= x_serviceeventperformer encounterparticipant typecode*: <= x_encounterparticipant intendedrecipient informationrecipient typecode*: <= x_informationrecipient typecode*: <= PRF ヘッダ部叙述部エントリー部 外部参照部 46

24 AuthorChoice name: SET<PN> [] 0..1 received 0..1 informationrecipient 0..1 represented 0..1 scoping 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian 0..1 represented 0..1 assigned 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice 0..1 whole 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 1..1 guardianchoice 0..1 represented 0..1 assigned PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus guardian Guardian classcode*: <= GUARD AssociatedEntity classcode*: <= RoleClassAssociative assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor 0..1 assignedcustodian custodian typecode*: <= CST Custodian name: ON [0..1] telecom: TEL [0..1] time: TS [0..1] 1..* patientrole recordtarget typecode*: <= RCT associatedentity 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 PREF RMIM (POCD_RM000040JP00) This RMIM is used for patient referral document text*: ED [0..1] <= x_basicconfidentialitykind 1..* section section entry typecode*: <= x_actrelationshipentry 0..1 represented 0..1 assigned entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] clinicalstatement moodcode*: <= x_actmooddocument code*: CD CWE [1..1] <= Type derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] assignedentity modecode: CE CWE [0..1] <= ParticipationMode clinicalstatement Media value*: ED [1..1] observationrange referencerange typecode*: <= REFV Note:.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference Range.CRT interpretationcode: CE CNE [0..1] <= Interpretation externalactchoice externalactchoice External ExternalDocument classcode*: <= DOC 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> 47 診療情報提供書と R-MIM の関係 ( ヘッダ部 ) authenticator typecode*: <= AUTHEN legalauthenticator typecode*: <= LA 文書情報 受取者 typecode*: <= PRF typecode*: <= AUT 作成者 dataenterer typecode*: <= ENT (Transcriptionist) 患者情報 ヘッダ部叙述部エントリー部 外部参照部 48

25 AuthorChoice name: SET<PN> [] 0..1 received 0..1 informationrecipient 0..1 represented 0..1 scoping 0..1 associated IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 1..1 representedcustodian 0..1 represented 0..1 assigned 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice 0..1 whole 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 1..1 guardianchoice AuthorChoice name: SET<PN> [] 0..1 represented 0..1 assigned 0..1 received 0..1 informationrecipient 0..1 represented 0..1 scoping 0..1 associated PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus guardian Guardian classcode*: <= GUARD AssociatedEntity classcode*: <= RoleClassAssociative IntendedRecipient classcode*: <= x_informationrecipientrole id*: SET<II> [] AssignedAuthor 0..1 assignedauthorchoice AssignedCustodian 0..1 represented 0..1 assigned 0..1 provider 0..1 patient Role id: SET<II> [1..*] (Deprecated) name: SET<PN> [] racecode: CE CWE [0..1] <= Race GuardianChoice 0..1 whole 0..1 aspartof name: SET<ON> [] standardindustryclasscode: CE CWE [0..1] <= IndustryClass 1..1 guardianchoice 0..1 represented 0..1 assigned PartOf classcode*: <= PART id*: SET<II> [] statuscode: CS CNE [0..1] <= RoleStatus assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor 0..1 assignedcustodian custodian typecode*: <= CST 1..* patientrole 1..1 representedcustodian guardian Guardian classcode*: <= GUARD AssociatedEntity classcode*: <= RoleClassAssociative Custodian name: ON [0..1] telecom: TEL [0..1] time: TS [0..1] associatedentity assignedentity intendedrecipient informationrecipient typecode*: <= x_informationrecipient 1..* assignedauthor 0..1 assignedcustodian custodian typecode*: <= CST 1..* patientrole Custodian name: ON [0..1] telecom: TEL [0..1] time: TS [0..1] associatedentity ClinicalDocument classcode*: <= DOCCLIN id*: II [1..1] code*: CE CWE [1..1] <= DocumentType effectivetime*: TS [1..1] 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 PREF RMIM (POCD_RM000040JP00) This RMIM is used for patient referral document ParentDocument parentdocument classcode*: <= DOCCLIN relateddocument typecode*: <= x_actrelationshipdocument typecode*: <= <= COMP COMP contextconductionind*: BL BL [1..1] [1..1] "true" "true" PREF RMIM (POCD_RM000040JP00) This RMIM is used for patient referral document text*: ED [0..1] <= x_basicconfidentialitykind text*: ED [0..1] <= x_basicconfidentialitykind 1..* section section entry typecode*: <= x_actrelationshipentry 1..* section section entry typecode*: <= x_actrelationshipentry 0..1 represented 0..1 assigned 0..1 represented 0..1 assigned entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] clinicalstatement moodcode*: <= x_actmooddocument code*: CD CWE [1..1] <= Type derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] assignedentity modecode: CE CWE [0..1] <= ParticipationMode clinicalstatement clinicalstatement Media value*: ED [1..1] entryrelationship typecode*: <= x_actrelationshipentryrelationship inversionind: BL [0..1] clinicalstatement moodcode*: <= x_actmooddocument code*: CD CWE [1..1] <= Type derivationexpr: ST [0..1] clinicalstatement interpretationcode: SET<CE> CNE [] methodcode: SET<CE> CWE [] targetsitecode: SET<CD> CWE [] assignedentity modecode: CE CWE [0..1] <= ParticipationMode Media value*: ED [1..1] observationrange referencerange typecode*: <= REFV Note:.value has cardinality [], which doesn't show up in the Visio representation. Criterion.CRT criterion precondition typecode*: <= PRCN reference typecode*: <= x_actrelationshipexternalreference observationrange referencerange typecode*: <= REFV Note:.value has cardinality [], which doesn't show up in the Visio representation. reference typecode*: <= x_actrelationshipexternalreference Range.CRT interpretationcode: CE CNE [0..1] <= Interpretation Criterion.CRT criterion precondition typecode*: <= PRCN externalactchoice Range.CRT interpretationcode: CE CNE [0..1] <= Interpretation externalactchoice externalactchoice External ExternalDocument classcode*: <= DOC externalactchoice External ExternalDocument classcode*: <= DOC 診療情報提供書の本文の記述 authenticator typecode*: <= AUTHEN legalauthenticator typecode*: <= LA typecode*: <= PRF typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) recordtarget typecode*: <= RCT ヘッダ部叙述部エントリー部 外部参照部 49 診療情報提供書本文例レベル 1 2 での記述 authenticator typecode*: <= AUTHEN legalauthenticator typecode*: <= LA typecode*: <= AUT dataenterer typecode*: <= ENT (Transcriptionist) typecode*: <= PRF 1..* section text*: ED [0..1] <= x_basicconfidentialitykind recordtarget typecode*: <= RCT ヘッダ部叙述部エントリー部 外部参照部 50