HL7 CDA R2 AIS Implementation Guide

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HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R0306) Referring or Ordering Physician. The physician responsible for referring the patient orordering the study shall be represented in /ClinicalDocument/participant element, and the@typeCode of that participant shall be "REF".3.5 Body Compliance Statements3.5.1 General Body Compliance StatementsThis section applies to attachments where the contents are expressed in XML. This section doesnot apply to attachments that have a body and the content is transmitted asimage or text. The compliance statements for those attachments are included in section 3.5.2.1) Natural Language Title for Attachment Components. Where an attachment documentcontains an attachment component as described in an Additional InformationSpecification, a natural language representation of the name of that attachmentcomponent shall be present in a section/title element.Within these compliance statements the that contains this title is said to be the"section that contains the attachment component."2) Cardinality of Attachment Components. Sections that contain attachment componentsshall appear in an attachments document consistent with the cardinality specification ofthe relevant Additional Information Specification.The above notwithstanding, a sender cannot send information that it does not have. If asender does not have the information required in a component of an AdditionalInformation Specification, and if the cardinality specified for the component is greaterthan zero, the sender shall send a or element with the captionand an explanation of why the information is not available. Common explanations are"not observed or not asked", "patient declined or was unable to provide the information"or "no result could be obtained for this request or specimen (for example, if a bloodspecimen is hydrolyzed).3) Positioning of Attachment Component Answer Parts. Attachment component answerparts shall appear as natural language text in CDA structure elements descended fromthe section element that contains the attachment component.There is no compliance statement requiring that the answer part be directly descendedfrom the section element that contains the attachment component. The preparer haslatitude to group the answer parts into subsections should it choose any of the CDAstructure elements, except if more specific instructions are given in an AdditionalInformation Specification.There is no compliance statement saying whether the content element is descended froma or element. The preparer has latitude to choose among thealternatives available through the CDA.4) Cardinality of Attachment Component Answer Parts. Attachment component answerparts shall appear in an attachment document consistent with the cardinalityspecification of the relevant Additional Information Specification.5) Natural Language Caption for Attachment Component Answer Parts. Where anattachment component contains more than one answer part, the text for each answershould be in a separate CDA structure element. Each such structure element shouldcontain a element that identifies the answer part in natural language.Page 44March 2007Copyright © 1998-2007Health Level Seven, Inc. All rights reserved.Release 3.0 Draft Standard
HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R030If, however, the contents of a section of an attachment are organized using the element, the captions should appear in elements that head columns of the table."Should" is used here to allow for the possibility that a pre-existing CDA document thatcontains all the required information exists, but was not structured specifically to be anattachment. As long as a person can discern the answers that should suffice.6) Referent. If an answer part includes the element, the element shall reference a file contained in the attachment package.7) Referent Type. The is used when an image isembedded within a CDA Body. Unless this compliance statement is overridden by anAdditional Information Specification, if an answer part includes the element, referenced file shall be one of the file types listed in Table 3.5-1 and thefile name shall include the suffix identified in the table. The table also shows the value ofobservationMedia/ @mediaType that corresponds to the image type.8) Images should have a pixel density suitable for rendering on a screen (i.e., they should besuitably sized when displayed at 96pixels per inch).Table 3.5-1 Acceptable File Types for Observation MediaFile NameFile TypeSuffix MT ValueJoint Photographic Experts Group image .JPG, .JPEG image/jpegPortable Network Graphics image .PNG image/pngGraphics Interchange Format .GIF image/gifTag Image File Format .TIF image/tiff3.5.2 Non-XML Body Compliance StatementsThe non-XML body is used when an external file contains all of the information to be transmittedas the attachment.1) Permissible File Types. The nonXMLBody/text/@mediaType attribute should contain oneof the file types listed in Table 3.5-2.Table 3.5-2 Acceptable File Types for File Type File Name Suffix MT ValuePlain text .TXT text/plainHTML .HTM, .HTML text/htmlJoint Photographic Experts Group image .JPG, .JPEG image/jpegPortable Document Format .PDF application/pdfPortable Network Graphics image .PNG image/pngGraphics Interchange Format .GIF image/gifRich Text Format .RTF text/rtfTag Image File Format 8 .TIF image/tiff8 TIFF is a trademark of the Adobe Developers Association; 345 Park Avenue; San Jose, CA 95110-2704 See:http://partners.adobe.com/asn/developer/pdfs/tn/TIFF6.pdfCopyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 45March 2007
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HL7 CDA R2 AIS Implementation Guide

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