External Validation Service Front-end

Information

File Name: CDA_Cloture ADD.xml
OID :: 1.3.6.1.4.1.12559.11.36.3.1.76247
Schematron :: CNSA_SDO_2023 (Version N/A)
Schematron Validation Result :: FAILED
Validation Date :: 4/21/23 1:44:14 PM (CEST GMT+0200)
Model Based Validator :: N/A (Tool Version N/A)
Model Based Validation Result :: N/A
Permanent link :: https://interop.esante.gouv.fr/EVSClient/detailedResult.seam?type=CDA&oid=1.3.6.1.4.1.12559.11.36.3.1.76247
Data Visibility :: Public

Validation Results

Schematron validation

$type Validation Report

Well-formednessPASSED

The document you have validated is supposed to be a well-formed document. The validator has checked if it is well-formed, results of this validation are gathered in this section.

The document is well-formed

Schema Validation detailed ResultFAILED

Your document has been validated with the appropriate schema, here is the detail of the validation outcome.

The document is not valid regarding the schema because of the following reasons:

Summary of reports: 2

Description: Line:Col[23:30]:cvc-complex-type.2.4.a: Invalid content was found starting with element 'addr'. One of '{"urn:hl7-org:v3":id}' is expected.

Description: Line:Col[126:62]:cvc-complex-type.2.4.a: Invalid content was found starting with element 'effectiveTime'. One of '{"urn:hl7-org:v3":value, "urn:hl7-org:v3":interpretationCode, "urn:hl7-org:v3":methodCode, "urn:hl7-org:v3":targetSiteCode, "urn:hl7-org:v3":subject, "urn:hl7-org:v3":specimen, "urn:hl7-org:v3":performer, "urn:hl7-org:v3":author, "urn:hl7-org:v3":informant, "urn:hl7-org:v3":participant, "urn:hl7-org:v3":entryRelationship, "urn:hl7-org:v3":reference, "urn:hl7-org:v3":precondition, "urn:hl7-org:v3":referenceRange}' is expected.

Schematron validator resultsFAILED

Summary of checks: 4

2

3580

Errors

Test: not((//cnsaSDO:decision/cnsaSDO:dateEffetDeLaDecisionDeCloture and not(//cnsaSDO:decision/cnsaSDO:typeDeDecision[@code='5'])) or (not(//cnsaSDO:decision/cnsaSDO:dateEffetDeLaDecisionDeCloture) and //cnsaSDO:decision/cnsaSDO:typeDeDecision[@code='5']))E - 1
Location: /ClinicalDocument/component/structuredBody/component[3]/section
Description: (ESMS-Decision): dateEffetDeLaDecisionDeCloture obligatoire si Decision/typeDecision = '5' (clôture) Ne doit pas être présent si Decision/TypeDecision = '1' (attribution)

Test: not((//cnsaSDO:decision/cnsaSDO:droitPrestation/cnsaSDO:amendementCreton and not(//cnsaSDO:decision/cnsaSDO:typeDeDecision[@code='1'])) or (not(//cnsaSDO:decision/cnsaSDO:droitPrestation/cnsaSDO:amendementCreton) and //cnsaSDO:decision/cnsaSDO:typeDeDecision[@code='1']))E - 2
Location: /ClinicalDocument/component/structuredBody/component[3]/section
Description: (ESMS-Decision): AmendementCreton obligatoire si Decision/typeDecision = '1' (attribution) Ne doit pas être présent si Decision/TypeDecision ='5' (clôture)

Test: count(hl7:value[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-1.2.250.1.213.3.4.79-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor]) >= 1E - 3
Location: /ClinicalDocument/component/structuredBody/component[2]/section/component[2]/section/entry[3]/observation
Description: (ESMS-MaladieRare): element hl7:value[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-1.2.250.1.213.3.4.79-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor] is required [min 1x].

Test: count(hl7:value[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-1.2.250.1.213.3.4.78-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor]) >= 1E - 4
Location: /ClinicalDocument/component/structuredBody/component[2]/section/component[2]/section/entry[4]/observation
Description: (ESMS-HandicapRare): element hl7:value[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-1.2.250.1.213.3.4.78-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor] is required [min 1x].

Warnings

Test: not(.)W - 1
Location: /ClinicalDocument/component/structuredBody/component[2]/section/component[2]/section/entry[3]/observation/value
Description: (ESMS-EvaluationDeIndividu)/d22538e7-true-d22627e0: this element 'value' is not defined, or not defined with this content. This may concern the templateId, code or id. Expected in this context: hl7:templateId[@root = '1.2.250.1.213.1.1.3.184'] | hl7:templateId[@root = '2.16.840.1.113883.10.12.303'] | hl7:id | hl7:code | hl7:text | hl7:statusCode[@code = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-2.16.840.1.113883.1.11.15933-DYNAMIC.xml')//valueSet[1]/conceptList/*/@code or @nullFlavor] | hl7:effectiveTime | hl7:priorityCode[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-2.16.840.1.113883.1.11.16866-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor] | hl7:languageCode | hl7:value[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-1.2.250.1.213.3.4.79-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor] (rule-reference: d22538e7-true-d22627e0)

Test: not(.)W - 2
Location: /ClinicalDocument/component/structuredBody/component[2]/section/component[2]/section/entry[4]/observation/value
Description: (ESMS-EvaluationDeIndividu)/d22708e7-true-d22797e0: this element 'value' is not defined, or not defined with this content. This may concern the templateId, code or id. Expected in this context: hl7:templateId[@root = '1.2.250.1.213.1.1.3.185'] | hl7:templateId[@root = '2.16.840.1.113883.10.12.303'] | hl7:id | hl7:code | hl7:text | hl7:statusCode[@code = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-2.16.840.1.113883.1.11.15933-DYNAMIC.xml')//valueSet[1]/conceptList/*/@code or @nullFlavor] | hl7:effectiveTime | hl7:priorityCode[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-2.16.840.1.113883.1.11.16866-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor] | hl7:languageCode | hl7:value[concat(@code, @codeSystem) = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-1.2.250.1.213.3.4.78-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor] (rule-reference: d22708e7-true-d22797e0)

Reports

Test: descendant-or-self::hl7:ClinicalDocument[hl7:templateId[@root = '1.2.250.1.213.1.1.1.4.2'] and hl7:templateId[@root = '2.16.840.1.113883.10.12.1']]R - 1
Location: /ClinicalDocument
Description: descendant-or-self::hl7:ClinicalDocument[hl7:templateId[@root = '1.2.250.1.213.1.1.1.4.2'] and hl7:templateId[@root = '2.16.840.1.113883.10.12.1']]: Instance is expected to have the following element: %%2

Test: string(@classCode) = ('DOCCLIN') or not(@classCode)R - 2
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): The value for classCode SHALL be 'DOCCLIN'. Found: ""

Test: string(@moodCode) = ('EVN') or not(@moodCode)R - 3
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): The value for moodCode SHALL be 'EVN'. Found: ""

Test: //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:addr or //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:telecomR - 4
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): L'adresse postale doit être présente ou le numéro de téléphone ou le courriel.

Test: not(//hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/cnsaSDO:nomOrganismeAM) or //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/cnsaSDO:numSecuriteSocialeOuvrantDroitR - 5
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): Si nomOrganismeAM est renseigné alors numSecuriteSocialeOuvrantDroit est obligatoire.

Test: count(//hl7:ClinicalDocument/hl7:author/hl7:assignedAuthor/hl7:id)=1R - 6
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): L'identifiant de l'élément assignedAuthor est unique.

Test: count(//hl7:ClinicalDocument/hl7:custodian/hl7:assignedCustodian/hl7:representedCustodianOrganization/hl7:id)=1R - 7
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): L'identifiant de l'élément assignedCustodian est unique.

Test: //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:patientR - 8
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): La description du patient est obligatoire

Test: (not(//hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:id/@root='1.2.250.1.213.1.4.8') and not(//hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:id/@root='1.2.250.1.213.1.4.9') and not(//hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:id/@root='1.2.250.1.213.1.4.10') and not(//hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:id/@root='1.2.250.1.213.1.4.11')) and //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:id/@extension or (//hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:patient/hl7:name/hl7:family/@qualifier and //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:patient/hl7:name/hl7:given and //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:patient/hl7:birthTime and //hl7:ClinicalDocument/hl7:recordTarget/hl7:patientRole/hl7:patient/hl7:administrativeGenderCode)R - 9
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): Erreur de conformité CI-SIS : Dans le cadre de l'INS, les traits de l'INS (Nom de naissance, premier prénom, date de naissance et sexe) sont obligatoires

Test: count(hl7:realmCode) <= 1R - 10
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:realmCode appears too often [max 1x].

Test: count(hl7:typeId[@root = '2.16.840.1.113883.1.3'][@extension = 'POCD_HD000040']) >= 1R - 11
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:typeId[@root = '2.16.840.1.113883.1.3'][@extension = 'POCD_HD000040'] is required [min 1x].

Test: count(hl7:typeId[@root = '2.16.840.1.113883.1.3'][@extension = 'POCD_HD000040']) <= 1R - 12
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:typeId[@root = '2.16.840.1.113883.1.3'][@extension = 'POCD_HD000040'] appears too often [max 1x].

Test: count(hl7:templateId[@root = '1.2.250.1.213.1.1.1.4.2']) >= 1R - 13
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:templateId[@root = '1.2.250.1.213.1.1.1.4.2'] is mandatory [min 1x].

Test: count(hl7:templateId[@root = '1.2.250.1.213.1.1.1.4.2']) <= 1R - 14
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:templateId[@root = '1.2.250.1.213.1.1.1.4.2'] appears too often [max 1x].

Test: count(hl7:templateId[@root = '2.16.840.1.113883.10.12.1']) >= 1R - 15
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:templateId[@root = '2.16.840.1.113883.10.12.1'] is required [min 1x].

Test: count(hl7:templateId[@root = '2.16.840.1.113883.10.12.1']) <= 1R - 16
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:templateId[@root = '2.16.840.1.113883.10.12.1'] appears too often [max 1x].

Test: count(hl7:id) >= 1R - 17
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:id is required [min 1x].

Test: count(hl7:id) <= 1R - 18
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:id appears too often [max 1x].

Test: count(hl7:code[(@code = '18825-0' and @codeSystem = '2.16.840.1.113883.4.642.3.240') or @nullFlavor]) >= 1R - 19
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:code[(@code = '18825-0' and @codeSystem = '2.16.840.1.113883.4.642.3.240') or @nullFlavor] is required [min 1x].

Test: count(hl7:code[(@code = '18825-0' and @codeSystem = '2.16.840.1.113883.4.642.3.240') or @nullFlavor]) <= 1R - 20
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:code[(@code = '18825-0' and @codeSystem = '2.16.840.1.113883.4.642.3.240') or @nullFlavor] appears too often [max 1x].

Test: count(hl7:title) <= 1R - 21
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:title appears too often [max 1x].

Test: count(hl7:effectiveTime) >= 1R - 22
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:effectiveTime is required [min 1x].

Test: count(hl7:effectiveTime) <= 1R - 23
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:effectiveTime appears too often [max 1x].

Test: count(hl7:confidentialityCode[(@code = 'N' and @codeSystem = '2.16.840.1.113883.5.25') or @nullFlavor]) >= 1R - 24
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:confidentialityCode[(@code = 'N' and @codeSystem = '2.16.840.1.113883.5.25') or @nullFlavor] is required [min 1x].

Test: count(hl7:confidentialityCode[(@code = 'N' and @codeSystem = '2.16.840.1.113883.5.25') or @nullFlavor]) <= 1R - 25
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:confidentialityCode[(@code = 'N' and @codeSystem = '2.16.840.1.113883.5.25') or @nullFlavor] appears too often [max 1x].

Test: count(hl7:languageCode) <= 1R - 26
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:languageCode appears too often [max 1x].

Test: count(hl7:setId) <= 1R - 27
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:setId appears too often [max 1x].

Test: count(hl7:versionNumber) <= 1R - 28
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:versionNumber appears too often [max 1x].

Test: count(hl7:recordTarget) >= 1R - 29
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:recordTarget is required [min 1x].

Test: count(hl7:recordTarget) <= 1R - 30
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:recordTarget appears too often [max 1x].

Test: count(hl7:author[hl7:assignedAuthor]) >= 1R - 31
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:author[hl7:assignedAuthor] is required [min 1x].

Test: count(hl7:author[hl7:assignedAuthor]) <= 1R - 32
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:author[hl7:assignedAuthor] appears too often [max 1x].

Test: count(hl7:dataEnterer[hl7:assignedEntity]) <= 1R - 33
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:dataEnterer[hl7:assignedEntity] appears too often [max 1x].

Test: count(hl7:custodian[hl7:assignedCustodian]) >= 1R - 34
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:custodian[hl7:assignedCustodian] is required [min 1x].

Test: count(hl7:custodian[hl7:assignedCustodian]) <= 1R - 35
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:custodian[hl7:assignedCustodian] appears too often [max 1x].

Test: count(hl7:informationRecipient[@typeCode = 'PRCP'][hl7:intendedRecipient[@classCode = 'ASSIGNED']]) <= 2R - 36
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:informationRecipient[@typeCode = 'PRCP'][hl7:intendedRecipient[@classCode = 'ASSIGNED']] appears too often [max 2x].

Test: count(hl7:legalAuthenticator[hl7:signatureCode[@code = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-2.16.840.1.113883.1.11.10282-DYNAMIC.xml')//valueSet[1]/conceptList/*/@code or @nullFlavor]]) <= 1R - 37
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:legalAuthenticator[hl7:signatureCode[@code = doc('/opt/SchematronValidator_prod/bin/schematron/cda_asip/ANS-MS/_pre_compilation/include/voc-2.16.840.1.113883.1.11.10282-DYNAMIC.xml')//valueSet[1]/conceptList/*/@code or @nullFlavor]] appears too often [max 1x].

Test: count(hl7:componentOf[hl7:encompassingEncounter]) <= 1R - 38
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:componentOf[hl7:encompassingEncounter] appears too often [max 1x].

Test: count(hl7:component[hl7:structuredBody]) >= 1R - 39
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:component[hl7:structuredBody] is required [min 1x].

Test: count(hl7:component[hl7:structuredBody]) <= 1R - 40
Location: /ClinicalDocument
Description: (MS_SDO-ClinicalDocument): element hl7:component[hl7:structuredBody] appears too often [max 1x].

Test: every $elm in descendant-or-self::* satisfies $elm[ not(@nullFlavor) or (@nullFlavor and not(@* except (@xsi:type|@xsi:nil|@classCode|@typeCode|@determinerCode|@moodCode|@nullFlavor|@partType|@codeSystem[. = '2.16.840.1.113883.5.139']|@codeSystemName[. = 'TimingEvent']|@integrityCheckAlgorithm[. = 'SHA-1']|@inverted[. = 'false']|@mediaType[. = 'text/plain']|@operator[. = 'I']|@representation[. = 'TXT']|@inclusive[. = 'true']|@unit[. = '1']) | * | text()[string-length(normalize-space()) gt 0])) or (@nullFlavor = ('OTH', 'NA', 'UNC') and not(@* except (@xsi:type|@xsi:nil|@*:valueSet|@*:valueSetVersion|@codeSystem|@codeSystemName|@codeSystemVersion|@extension|@nullFlavor|@partType|@integrityCheckAlgorithm[. = 'SHA-1']|@mediaType[. = 'text/plain']|@operator[. = 'I']|@representation[. = 'TXT']|@inclusive[. = 'true']|@unit[. = '1'])) and (@extension | @codeSystem | *[local-name()='originalText'] | *[local-name()='translation'])) ]R - 41
Location: /ClinicalDocument/realmCode
Description: dtr1-1-ANY: if there is a nullFlavor, there shall be no text or other attribute or element, unless it's nullFlavor='OTH' or 'NA' (@codeSystem, or may have a value), or nullFlavor 'UNC' (@extension or may have a value). Found:

Test: (@nullFlavor and not(@code or @typeCode)) or (not(@nullFlavor) and (@code or @typeCode))R - 42
Location: /ClinicalDocument/realmCode
Description: dtr1-1-CS: @code/@typeCode and @nullFlavor are mutually exclusive

Test: not(@codeSystem) or @codeSystem = '2.16.840.1.113883.5.139'R - 43
Location: /ClinicalDocument/realmCode
Description: dtr1-2-CS: cannot have codeSystem

Test: not(@codeSystemName) or @codeSystemName = 'TimingEvent'R - 44
Location: /ClinicalDocument/realmCode
Description: dtr1-3-CS: cannot have codeSystemName

Test: not(@codeSystemVersion)R - 45
Location: /ClinicalDocument/realmCode
Description: dtr1-4-CS: cannot have codeSystemVersion

Test: not(@displayName)R - 46
Location: /ClinicalDocument/realmCode
Description: dtr1-5-CS: cannot have displayName

Test: not(hl7:originalText)R - 47
Location: /ClinicalDocument/realmCode
Description: dtr1-6-CS: cannot have originalText

Test: not(hl7:qualifier)R - 48
Location: /ClinicalDocument/realmCode
Description: dtr1-7-CS: cannot have qualifier

Test: not(hl7:translation)R - 49
Location: /ClinicalDocument/realmCode
Description: dtr1-8-CS: cannot have translation

Test: empty(@xsi:type) or resolve-QName(@xsi:type, .) = QName('urn:hl7-org:v3', 'CS')R - 50
Location: /ClinicalDocument/realmCode
Description: (MS_SDO-ClinicalDocument): If an @xsi:type instruction is present it SHALL be valued "{urn:hl7-org:v3}:CS". Found "{}:"

Only the first 50 reports are displayed

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Indent file

1	<?xml version="1.0" encoding="UTF-8"?>
2	<ClinicalDocument xmlns:mif="urn:hl7-org:v3/mif"
3	xmlns:cnsaSDO="urn:cnsaSDO"
4	xmlns:sch="http://www.ascc.net/xml/schematron"
5	xmlns="urn:hl7-org:v3"
6	xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
7	<realmCode code="FR"/>
8	<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
9	<templateId root="1.2.250.1.213.1.1.1.4.2"/>
10	<templateId root="2.16.840.1.113883.10.12.1"/>
11	<id root="1.2.250.1.213.1.1.1.4.2" extension="513679452"/>
12	<code code="18825-0" codeSystem="2.16.840.1.113883.4.642.3.240" displayName="Medical social services attachment"/>
13	<title>CDA_ClotureADD</title>
14	<effectiveTime value="20221117"/>
15	<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="Normal"/>
16	<languageCode code="fr-FR" />
17
18	<recordTarget>
19	<patientRole>
20	<!-- INS-NIR de production : 1.2.250.1.213.1.4.8 -->
21	<id extension="276059205062865" root="1.2.250.1.213.1.4.8"/>
22	<!-- Adresse -->
23	<addr use="PHYS">
24	<streetAddressLine>17 AV de Bruxelles</streetAddressLine>
25	<postalCode>35830</postalCode>
26	<city>Betton</city>
27	</addr>
28	<!-- Téléphone mobile -->
29	<telecom value="tel:0686970800" use="MC"/>
30	<!-- Adresse mail -->
31	<telecom value="mailto:lafayette.marie@gmail.com" />
32	<!-- Assurance maladie -->
33	<cnsaSDO:nomOrganismeAM>CPAM</cnsaSDO:nomOrganismeAM>
34	<cnsaSDO:numSecuriteSocialeOuvrantDroit>276059205062865</cnsaSDO:numSecuriteSocialeOuvrantDroit>
35	<!-- Date de transfert du dossier -->
36	<cnsaSDO:dateTransfertDossier value="20230201"/>
37	<!-- Identité du patient, le patient est renommé individu dans le CNSA -->
38	<patient>
39	<name>
40	<!-- Nom de naissance : Elément obligatoire s’il s’agit de l’identité de référence : Information de l’INS -->
41	<family qualifier="BR">Lafayette</family>
42	<!-- • Nom d’usage : Elément obligatoire s’il s’agit de l’identité de référence : Information de l’INS -->
43	<family qualifier="SP">Lafayette</family>
44	<!-- Prénom acte de naissance -->
45	<given>Marie</given>
46	<!-- Premier prénom de l'acte de naissance -->
47	<given qualifier="BR">Marie</given>
48	<!-- Prénom utilisé -->
49	<given qualifier="CL">Marie</given>
50	</name>
51	<administrativeGenderCode code="F" displayName="Féminin" codeSystem="1.2.250.1.213.2.53"/>
52	<birthTime value="19960531"/>
53
54	<!-- Mesure de protection -->
55	<guardian>
56	<code code="1" displayName="Tutelle" codeSystem="1.2.250.1.213.3.3.208"/>
57	<addr use="PHYS">
58	<postalCode>35000</postalCode>
59	<city>Rennes</city>
60	</addr>
61	<telecom value="tel:0186940900"/>
62
63	<guardianPerson> <!-- Personne physique désignée responsable de l’individu par le juge des tutelles-->
64	<name>
65	<prefix>Madame</prefix>
66	<family>Lafayette</family>
67	<given>Flore</given>
68	</name>
69	</guardianPerson>
70	</guardian>
71
72	<!-- Lieu et date de naissance -->
73	<birthplace>
74	<place>
75	<addr use="PHYS">
76	<county>35238</county>
77	<city>RENNES</city>
78	</addr>
79	</place>
80	</birthplace>
81
82	</patient>
83	</patientRole>
84	</recordTarget>
85
86	<!-- MDPH ayant créé la décision -->
87	<author contextControlCode="OP" typeCode="AUT">
88	<time value="20221201093000+0100"/>
89	<assignedAuthor classCode="ASSIGNED">
90	<id root="1.2.250.1.213.7.14" extension="14-CALVADOS"/>
91	</assignedAuthor>
92	</author>
93
94	<!-- MDPH actuellement responsable du dossier -->
95	<custodian>
96	<assignedCustodian classCode="ASSIGNED">
97	<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
98	<id root="1.2.250.1.213.7.14" extension="14-CALVADOS"/>
99	</representedCustodianOrganization>
100	</assignedCustodian>
101	</custodian>
102
103	<!-- MDPH d'accueil du dossier -->
104	<informationRecipient typeCode="PRCP">
105	<intendedRecipient classCode="ASSIGNED">
106	<receivedOrganization>
107	<id root="1.2.250.1.213.7.25" extension="23-CREUSE"/>
108	</receivedOrganization>
109	</intendedRecipient>
110	</informationRecipient>
111
112	<!-- Corps du document -->
113	<component>
114	<structuredBody>
115	<component>
116	<!-- Section représentant les informations sur le décès de l’individu -->
117	<section>
118	<templateId root="1.2.250.1.213.1.1.2.228"></templateId>
119	<templateId root="2.16.840.1.113883.10.12.201"></templateId>
120	<entry>
121	<observation classCode="OBS" moodCode="EVN">
122	<templateId root="1.2.250.1.213.1.1.3.176"></templateId>
123	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
124	<code> <originalText>StatutDeces</originalText> </code>
125	<value xsi:type="CE" code="1" codeSystem="1.2.250.1.213.3.3.100" displayName="Certifié"></value>
126	<effectiveTime value="20230402"/>
127	</observation>
128	</entry>
129	</section>
130	</component>
131
132	<component>
133	<!-- Section représentant l’évaluation d’un individu -->
134	<section>
135	<templateId root="1.2.250.1.213.1.1.2.229"/>
136	<templateId root="2.16.840.1.113883.10.12.201"/>
137	<text>20230110</text> <!-- Date de dernière mise à jour de la qualification de la situation et des besoins -->
138
139	<!-- Eléments environnementaux -->
140	<component>
141	<section>
142	<templateId root="1.2.250.1.213.1.1.2.230"/>
143	<templateId root="2.16.840.1.113883.10.12.201"/>
144	<!-- Composition du foyer -->
145	<entry>
146	<observation classCode="OBS" moodCode="EVN">
147	<templateId root="1.2.250.1.213.1.1.3.177"></templateId>
148	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
149	<code nullFlavor="NA">
150	<originalText>CompositionFoyer</originalText>
151	</code>
152	<value xsi:type="CE" code="II.1.bis.1" codeSystem="1.2.250.1.213.3.3.106" displayName="vit seule"></value>
153	</observation>
154	</entry>
155	<!-- type d'hébergement -->
156	<entry>
157	<observation classCode="OBS" moodCode="EVN">
158	<templateId root="1.2.250.1.213.1.1.3.178"></templateId>
159	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
160	<code><originalText>TypeHebergement</originalText></code>
161	<value xsi:type="CE" code="III.1.1" codeSystem="1.2.250.1.213.3.3.207" displayName="Domicile personnel"></value>
162	</observation>
163	</entry>
164	<!-- Caractéristiques du logement -->
165	<entry>
166	<observation classCode="OBS" moodCode="EVN">
167	<templateId root="1.2.250.1.213.1.1.3.179"></templateId>
168	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
169	<code><originalText>CaracteristiqueLogement</originalText></code>
170	<value xsi:type="CE" code="III.5.4" codeSystem="1.2.250.1.213.3.3.99" displayName="logement accessible, adapté"></value>
171	</observation>
172	</entry>
173	<!-- Ressources propres de la personne -->
174	<entry>
175	<observation classCode="OBS" moodCode="EVN">
176	<templateId root="1.2.250.1.213.1.1.3.180"></templateId>
177	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
178	<code><originalText>RessourceProprePersonne</originalText></code>
179	<value xsi:type="CE" code="II.3.2.a" codeSystem="1.2.250.1.213.3.3.174" displayName="a des ressources personnelles issues d'un salaire ou d'autre revenu du travail" ></value>
180	</observation>
181	</entry>
182	<!-- Caractéristiques transport -->
183	<entry>
184	<observation classCode="OBS" moodCode="EVN">
185	<templateId root="1.2.250.1.213.1.1.3.181"></templateId>
186	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
187	<code> <originalText>CaracteristiqueTransport</originalText></code>
188	<value xsi:type="CE" code="IV.2" codeSystem="1.2.250.1.213.3.3.201" displayName="utilisation des transports en commun"></value>
189	</observation>
190	</entry>
191	</section>
192	</component>
193
194	<!-- Eléments médicaux -->
195	<component>
196	<section>
197	<templateId root="1.2.250.1.213.1.1.2.231"></templateId>
198	<templateId root="2.16.840.1.113883.10.12.201"></templateId>
199	<!-- Pathologie principale -->
200	<entry>
201	<observation classCode="OBS" moodCode="EVN">
202	<templateId root="1.2.250.1.213.1.1.3.182"></templateId>
203	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
204	<code> <originalText>PathologiePrincipale</originalText></code>
205	<value xsi:type="CE" code="A81" codeSystem="1.2.250.1.213.3.3.162" displayName="Infections atypiques à virus, du système nerveux central"></value>
206	</observation>
207	</entry>
208	<!-- Pathologie secondaire -->
209	<entry>
210	<observation classCode="OBS" moodCode="EVN">
211	<templateId root="1.2.250.1.213.1.1.3.183"></templateId>
212	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
213	<code> <originalText>PathologieSecondaire</originalText></code>
214	<value xsi:type="CE" code="C17" codeSystem="1.2.250.1.213.3.3.162" displayName="Tumeur maligne de l'intestin grêle"></value>
215	</observation>
216	</entry>
217	<!-- Maladie rare -->
218	<entry>
219	<observation classCode="OBS" moodCode="EVN">
220	<templateId root="1.2.250.1.213.1.1.3.184"></templateId>
221	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
222	<code> <originalText>MaladieRare</originalText></code>
223	<value xsi:type="CE" code="VII.1.b" codeSystem="1.2.250.1.213.3.3.224" displayName="non, ce n'est pas une maladie rare"></value>
224	</observation>
225	</entry>
226	<!-- Handicap rare -->
227	<entry>
228	<observation classCode="OBS" moodCode="EVN">
229	<templateId root="1.2.250.1.213.1.1.3.185"></templateId>
230	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
231	<code> <originalText>HandicapRare</originalText></code>
232	<value xsi:type="CE" code="VII.9.bis.2" codeSystem="1.2.250.1.213.3.3.225"></value>
233	</observation>
234	</entry>
235	<!-- Déficience principale -->
236	<entry>
237	<observation classCode="OBS" moodCode="EVN">
238	<templateId root="1.2.250.1.213.1.1.3.186"></templateId>
239	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
240	<code> <originalText>DeficiencePrincipale</originalText></code>
241	<value xsi:type="CE" code="9999" codeSystem="1.2.250.1.213.3.3.108" displayName="Pas de déficience"></value>
242	</observation>
243	</entry>
244	<!-- Prise en charge -->
245	<entry>
246	<observation classCode="OBS" moodCode="EVN">
247	<templateId root="1.2.250.1.213.1.1.3.188"></templateId>
248	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
249	<code> <originalText>PriseEnCharge</originalText></code>
250	<value xsi:type="CE" code="VII.10.2.k.3" codeSystem="1.2.250.1.213.3.3.170" displayName="nécessité d'assurer une prévention pulmonaire"></value>
251	</observation>
252	</entry>
253	<!-- Difficulté rencontrée -->
254	<entry>
255	<observation classCode="OBS" moodCode="EVN">
256	<templateId root="1.2.250.1.213.1.1.3.189"></templateId>
257	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
258	<code> <originalText>DifficulteRencontree</originalText></code>
259	<value xsi:type="CE" code="IX.2.b.6.g" codeSystem="1.2.250.1.213.3.3.86" displayName="gère seul et avec difficulté l'activité utiliser les transports en commun"></value>
260	</observation>
261	</entry>
262	</section>
263	</component>
264
265	<!-- Eléments Scolaires ou Professionnels -->
266	<component>
267	<section>
268	<templateId root="1.2.250.1.213.1.1.2.232"></templateId>
269	<templateId root="2.16.840.1.113883.10.12.201"></templateId>
270	<!-- Situation par rapport à la scolarité -->
271	<entry>
272	<observation classCode="OBS" moodCode="EVN">
273	<templateId root="1.2.250.1.213.1.1.3.190"></templateId>
274	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
275	<code> <originalText>SituationScolarite</originalText></code>
276	<value xsi:type="CE" code="II.2.2.a.9" codeSystem="1.2.250.1.213.3.3.178" displayName="Formation en CFA "></value>
277	</observation>
278	</entry>
279	<!-- Temps de scolarisation -->
280	<entry>
281	<observation classCode="OBS" moodCode="EVN">
282	<templateId root="1.2.250.1.213.1.1.3.191"></templateId>
283	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
284	<code> <originalText>TempsScolarisation</originalText></code>
285	<value xsi:type="CE" code="V.5.10" codeSystem="1.2.250.1.213.3.3.198" displayName="9 demi-journées"></value>
286	</observation>
287	</entry>
288	<!-- Evaluation scolarité -->
289	<entry>
290	<observation classCode="OBS" moodCode="EVN">
291	<templateId root="1.2.250.1.213.1.1.3.192"></templateId>
292	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
293	<code> <originalText>EvaluationScolarite</originalText></code>
294	<value xsi:type="CE" code="V.2.1" codeSystem="1.2.250.1.213.3.3.122" displayName="scolarité sans aménagements avec acquisitions comparables en rythme et en contenu à la classe d'âge"></value>
295	</observation>
296	</entry>
297	<!-- Niveau de formation professionnelle -->
298	<entry>
299	<observation classCode="OBS" moodCode="EVN">
300	<templateId root="1.2.250.1.213.1.1.3.193"></templateId>
301	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
302	<code> <originalText>NiveauFormationProfessionnelle</originalText></code>
303	<value xsi:type="CE" code="VI.1.bis.10" codeSystem="1.2.250.1.213.3.3.152" displayName="Niv. 6 - Bac + 4 - Maîtrise"></value>
304	</observation>
305	</entry>
306	<!-- Situation par rapport au travail -->
307	<entry>
308	<observation classCode="OBS" moodCode="EVN">
309	<templateId root="1.2.250.1.213.1.1.3.194"></templateId>
310	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
311	<code> <originalText>SituationProfessionnelle</originalText></code>
312	<value xsi:type="CE" code="VI.3.bis.2.e" codeSystem="1.2.250.1.213.3.3.179" displayName="travaille en CDI"></value>
313	</observation>
314	</entry>
315	<!-- Aptitude actuelle au poste -->
316	<entry>
317	<observation classCode="OBS" moodCode="EVN">
318	<templateId root="1.2.250.1.213.1.1.3.195"></templateId>
319	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
320	<code> <originalText>AptitudePoste</originalText></code>
321	<value xsi:type="CE" code="VI.4.septies.1.a" codeSystem="1.2.250.1.213.3.3.89" displayName="apte sans restriction sans aménagement de poste"></value>
322	</observation>
323	</entry>
324	<!-- Perspectives professionnelles -->
325	<entry>
326	<observation classCode="OBS" moodCode="EVN">
327	<templateId root="1.2.250.1.213.1.1.3.196"></templateId>
328	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
329	<code> <originalText>PerspectiveProfessionnelle</originalText></code>
330	<value xsi:type="CE" code="VI.5.4" codeSystem="1.2.250.1.213.3.3.164" displayName="reconversion professionnelle"></value>
331	</observation>
332	</entry>
333	</section>
334	</component>
335
336	<!-- Evolution et Besoins -->
337	<component>
338	<section>
339	<templateId root="1.2.250.1.213.1.1.2.233"></templateId>
340	<templateId root="2.16.840.1.113883.10.12.201"></templateId>
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342	<entry>
343	<observation classCode="OBS" moodCode="EVN">
344	<templateId root="1.2.250.1.213.1.1.3.197"></templateId>
345	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
346	<code> <originalText>EvolutionEnvisagee</originalText></code>
347	<value xsi:type="CE" code="VII.7.2" codeSystem="1.2.250.1.213.3.3.124" displayName="stabilité envisagée"></value>
348	</observation>
349	</entry>
350	<!-- Evolution constatée -->
351	<entry>
352	<observation classCode="OBS" moodCode="EVN">
353	<templateId root="1.2.250.1.213.1.1.3.198"></templateId>
354	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
355	<code> <originalText>EvolutionConstatee</originalText></code>
356	<value xsi:type="CE" code="VII.8.1" codeSystem="1.2.250.1.213.3.3.123" displayName="amélioration depuis la précédente évaluation"></value>
357	</observation>
358	</entry>
359	<!--Besoins de compensation identifiés -->
360	<entry>
361	<observation classCode="OBS" moodCode="EVN">
362	<templateId root="1.2.250.1.213.1.1.3.199"></templateId>
363	<templateId root="2.16.840.1.113883.10.12.303"></templateId>
364	<code> <originalText>BesoinCompensation</originalText></code>
365	<value xsi:type="CE" code="9999" codeSystem="1.2.250.1.213.3.3.94" displayName="Pas de besoins"></value>
366	</observation>
367	</entry>
368	</section>
369	</component>
370	</section>
371	</component>
372
373	<component>
374	<!-- Section représentant les informations sur la décision de l’individu -->
375	<section>
376	<templateId root="1.2.250.1.213.1.1.2.235"></templateId>
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380	<cnsaSDO:dateDeDecision value="20220101"/>
381	<cnsaSDO:dateEffetDeLaDecisionDeCloture value="20230325"/>
382	<cnsaSDO:identifiantDesDecisionsReviseesRenouveleesCloturee extension="846532649597" root="1.2.250.1.213.7.14"/>
383	<cnsaSDO:identifiantDesDecisionsReviseesRenouveleesCloturee extension="156457862161" root="1.2.250.1.213.7.14"/>
384	<cnsaSDO:idNat extension="2876531652" root="1.2.250.1.213.7.14"/>
385	<cnsaSDO:motivation code="364" displayName="Attrib PCH3 à 0€ adulte surcoût pris en charge ESMS" codeSystem="1.2.250.1.213.3.3.148"/>
386	</cnsaSDO:decision>
387	</section>
388	</component>
389	</structuredBody>
390	</component>
391	</ClinicalDocument>

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