HL7 CDA R2 AIS Implementation Guide

HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R0303.4.3 Attachments Attributable to an OrganizationFor many administrative transactions identifying the organization to which the attachment isattributed is at least as important as identifying the person. For example this occurs in anattachment to a claim when the entity requesting the payment for service is an organization.When the administrative transaction associated with an attachment is performed on behalf of anorganization the attachment shall contain anauthor/assignedAuthor/representedOrganization elementin the header that identifies the organization.Where there is anauthor/assignedAuthor/representedOrganization elementthat identifies an organization, and the person responsible for the information in the attachmentis of no substantive consequence, the attachment need not contain anauthor/assignedAuthor/assignedPerson element.This is applicable when an organization is the sending entity. Example:Name of OrganizationEvery attachment must have either anauthor/assignedAuthor/representedOrganization elementor anauthor/assignedAuthor/assignedPerson element.Attachments may have both.3.4.4 Additional Header Compliance Statements for the "Computer-Decision" variantThe header elements of attachment documents in the "Computer-Decision" variant must meet allthe compliance statements of section 3.4.1. In addition, they must meet the following compliancestatements.1) Required and Optional Header Elements. Certain header elements that are required in theheader may be redundant with questions specified in individual Additional InformationSpecifications. In such cases the provider shall provide the information in the header, andshould provide it in the body.2) Authors. Authors of clinical documents shall be recorded in the /ClinicalDocument/authorelement of the header.3) Document Signer. When a document has been legally signed, the legal signer of theclinical document shall be represented in /ClinicalDocument/legalAuthenticator.4) Other Signers. Other parties may sign a document to attest to the accuracy of it. Theseshall be represented in /ClinicalDocument/authenticator elements.5) Responsible Physician. The physician responsible for the encounter shall be recorded inthe /ClinicalDocument/componentOf/encompassingEncounter/responsibleParty element.Copyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 43March 2007