Specification - Extended

HL7 CDA® R2 Implementation Guide: C-CDA Templates for Clinical Notes Companion Guide, Release 2 STU - US Realm

Document Description

extended per TSC vote https://confluence.hl7.org/x/Ujb9Aw

Existing Wording

Appendix C: Provenance Author Participation says that the template is consistent with the C-CDA Author Participation template. However, it says: When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. c. This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:4440-33). i. The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:4440-34). While the C-CDA Author Participation template says: b. This assignedAuthor SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-31671). i. If the content is patient authored the code SHOULD be selected from Personal And Legal Relationship Role Type (2.16.840.1.113883.11.20.12.1) (CONF:1098-32315). As written, the Companion Guide says nothing about the case where content is authored by a clinician like the Author Participation template does, and so it might mislead people into using the Personal and Legal Relationship Role Type value set even when the content was written by a clinician. To remain consistent, could we add that in to clarify? (The Provenance - Author Participation template also disallows a @nullFlavor, unlike the equivalent statement in the Author Participation template, although because of the different ways in which they're written I don't know whether this was done on purpose or not.)

Proposed Wording

Make the Companion Guide explicitly consistent with the C-CDA IG: c. This assignedAuthor SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:4440-33). i. If the content is patient authored the code SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:4440-34).