Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as an observation.

Implementation in XML Instance

• The XML attribute classCode is fixed to "OBS".

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as an observation event.

Implementation in XML Instance

• The XML attribute moodCode is fixed to "EVN".

Model Attribute Description

The HL7 attribute code uses a code from the CDAObservationType vocabulary to describe this class as a legal status observation.

Implementation in XML Instance

The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows:

• The XML attribute code shall contain the fixed value of "LSO"
• The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.220"
• The XML attribute displayName shall carry the description associated with the code.

Model Attribute Description

The HL7 attribute effectiveTime is used for the time of the legal status observation.

Where known the dates that the observation was effective on the patient should be recorded.

Implementation in XML Instance

The Interval of Points in Time data type flavour is used to carry this information in the XML element effectiveTime using the value attributes of the of the XML elements low and high.

The date range shall be carried as follows:

The XML attribute value of the XML elements low and high, shall be populated with a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where:

• yyyy is the year
• mm is the month
• dd is the day
• hh is the hour
• mm is the minute
• ss is seconds
  
• [+|-ZZzz] is the time zone offset in hours and minutes

Sections from the right of this representation may be left off when the sending system does not record to this level of accuracy. When hours are present, the time zone offset must also be present.

The Time Interval Complete data type shall be used:

• The XML attribute value of the XML element low shall be populated with a 'start date' time stamp to indicate the onset of the allergy or adverse reaction.
  

• The XML attribute value of the XML element high may be populated with an 'end date' time stamp to indicate when allergy or adverse reaction was no longer present.
  

The XML attribute value of the XML elements low and high should be populated to the level of detail that is available on the sending system.

Model Attribute Description

The HL7 attribute id uses an identifier to identify the instance of the legal status observation .

Implementation in XML Instance

The Identifier Global data type flavour is used to carry this information in the XML element id as follows:

• The XML attribute root shall contain a DCE UUID.

Model Attribute Description

The HL7 attribute code uses a code to describe the status of the legal status observation.

Implementation in XML Instance

The Coded Simple (CS) data type shall be used to carry this information in the XML element code as follows:

• The XML attribute code shall contain a fixed value of "completed".

Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:

• The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
• The XML attribute extension is fixed to "COCD_TP146093GB01#LegalStatus".

Model Attribute Description

The HL7 attribute value uses a code from SNOMED CT to describe the legal status.

Implementation in XML Instance

The Coded Value (CV) data type shall be used to carry this information in the XML element value as follows:

• The XML attribute xsi:type shall contain the value "CV"
• The XML attribute code should contain a value from the vocabulary.
• The XML attribute codeSystem should contain the fixed OID "2.16.840.1.113883.2.1.3.2.4.15"
  
• The XML attribute displayName should carry the description associated code.It is recommended that the preferred term is used.
  
• The XML element originalText may be used to carry the original text transcribed by the author.
  
• The XML element originalText may also be used to carry an XML element reference. This can be used to link the coded item to the relevant text in the CDA section
  

Where there is no suitable coding to enable the information to be coded then:

The Coded Value (CV) data type shall be used to carry this information in the XML element value as follows:

• The XML attribute xsi:type shall contain the value "CV"
• The XML attribute code should be omitted.
• The XML attribute codeSystem should be omitted.
  
• The XML attribute displayName should be omitted.
  
• The XML element originalText shall be used to carry the original text transcribed by the author.
  
• The XML element originalText may also be used to carry an XML element reference. This can be used to link the original text to the relevant text in the CDA section.

This template class constrains the CDA author class.

The person who authored the recording of the legal status observation, this must be included if the author is different to the document (inherited) author.

If there is no known author for the information held on the source system then:

• The information may be included and the document author will be deemed to be the author (by inheritance). The author should be asked to decide whether this is acceptable or not.
• If the document author does not want to be considered as the author of the information then information must not be included in the document.

Model Attribute Description

The HL7 attribute typeCode describes this class as an author participation.

Implementation in XML Instance

• The XML attribute typeCode is fixed to "AUT".

Model Attribute Description

The HL7 attribute contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent act are conducted across to the child act (also associated with the child act). This set of codes also determine how these participations conduct.

The conduction can only take place if the contextConductionInd in the actRelationships is set to "true".

The value of this attribute is fixed in the HL7 model to "OP":

• "O" (Overriding) - the author replaces any author that has been conducted from any previous acts.
• "P" (Propagating) - the author is conducted to all child acts where the contextConductionInd is set to "true".

Implementation in XML Instance

• The XML attribute contextControlCode shall contain the value "OP".

Model Attribute Description

The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at run time with a value from the allowed list contained in the model.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element contentId as follows:

• The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
• The XML attribute extension shall contain one of the allowed template artefact identifiers.

Model Attribute Description

The HL7 attribute functionCode uses a code from the vocabulary AuthorFunctionType to describe the function of the author

Implementation in XML Instance

The Coded Plain data type flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element functionCode as follows:

• The XML attribute code is fixed to "OA"
• The XML attribute codeSystem is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.17.178"
• The XML attribute displayName is fixed to the author's function name "Originating Author".

Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:

• The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
• The XML attribute extension is fixed to "COCD_TP146093GB01#author"

The time at which the author authored the observation.

A link to the choice of authors.

This template class constrains the CDA informant class.

Refers to who informed about the legal status.

Model Attribute Description

The HL7 attribute typeCode describes this class as a informant participation.

Implementation in XML Instance

• The XML attribute typeCode is fixed to "INF".

Model Attribute Description

The HL7 attribute contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent act are conducted across to the child act (also associated with the child act). This set of codes also determine how these participations conduct.

The conduction can only take place if the contextConductionInd in the actRelationships is set to "true".

The value of this attribute is fixed in the HL7 model to "OP":

• "O" (Overriding) - the author replaces any author that has been conducted from any previous acts.
• "P" (Propagating) - the author is conducted to all child acts where the contextConductionInd is set to "true".

Implementation in XML Instance

• The XML attribute contextControlCode shall contain the value "OP"

Model Attribute Description

The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at run time with a value from the allowed list contained in the model.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element contentId as follows:

• The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
• The XML attribute extension shall contain one of the allowed template artefact identifiers.

Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:

• The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
• The XML attribute extension is fixed to "COCD_TP146093GB01#informant".

A link to the choice of informant templates.

A link to the choice of templates for an informant.

A link to the author templates.