Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Care Plan

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/CarePlan Version: 2.1
Active as of 2023-09-29 Computable Name: CarePlan
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2015-08-01

CARE PLAN FRAMEWORK

A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patient’s and Care Team Member’s prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patient’ss care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.

A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patients life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care.

The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic.

Key differentiators between a Care Plan CDA and CCD (another snapshot in time document): There are 2 required sections:

  • Health Concerns
  • Activities

There are 2 optional sections:

  • Goals
  • Outcomes Provides the ability to identify patient and provider priorities with each act Provides a header participant to indicate occurrences of Care Plan review

A care plan document can include entry references from the information in these sections to the information (entries) in other sections.

Please see Volume 1 of this guide to view a Care Plan Relationship diagram and story board.

Usage:

  • This Logical Model is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... templateId 2..*II
... templateId:secondary 1..1II
.... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
.... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csBinding: Care Plan Document Type (required)
... versionNumber 0..1INT
... Slices for informationRecipient 0..*InformationRecipientSlice: Unordered, Open by value:intendedRecipient
.... informationRecipient:informationRecipient1 0..*InformationRecipient
..... intendedRecipient 1..1IntendedRecipient
...... id 1..*II
...... addr 0..*AD
...... telecom 0..*TEL
...... informationRecipient 0..1Person
....... name 1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... receivedOrganization 0..1Organization
....... id 0..*II
....... standardIndustryClassCode 0..1CEBinding: Healthcare Provider Taxonomy (required)
.... authenticator:authenticator2 0..1Authenticator
..... time 1..1TS
..... signatureCode 1..1CS
..... sdtcSignatureText 0..1EDThe prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the signatureText element
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... code 1..1CE
....... code 1..1csRequired Pattern: ONESELF
....... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.111
... Slices for participant 0..*Participant1Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant1
..... typeCode 1..1csFixed Value: VRF
..... functionCode 1..1CE
...... code 1..1csRequired Pattern: 425268008
...... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... time 1..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1csFixed Value: ASSIGNED
...... id 1..*II
...... code 0..1CE
....... code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
.... participant:participant2 0..*Participant1
..... typeCode 1..1csFixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*PN
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent
.... documentationOf:All Slices Content/Rules for all slices
..... serviceEvent
...... Slices for performer 1..*Performer1Slice: Unordered, Open by value:assignedEntity
....... performer:performer1 1..*Performer1
........ assignedEntity 1..1AssignedEntity
......... id 1..*II
......... code 0..1CE
......... assignedPerson 1..1Person
.......... name 1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent 1..1ServiceEvent
...... classCode 1..1csFixed Value: PCPR
...... effectiveTime 1..1IVL_TS
....... low 1..1IVXB_TS
....... high 0..1IVXB_TS
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by value:parentDocument, value:typeCode
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... id 1..*II
...... setId 1..1II
...... versionNumber 1..1INT
... componentOf 0..1ComponentOf
.... encompassingEncounter 1..1EncompassingEncounter
..... effectiveTime 1..1IVL_TS
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by value:ClinicalDocument.section
...... component:component1 1..1InfrastructureRoot
....... section 1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... section 1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.code.coderequiredCare Plan Document Type
ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.receivedOrganization.standardIndustryClassCoderequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonal And Legal Relationship Role Type
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredx_ActRelationshipDocument

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... realmCode 1..1CS
.... @code 1..1csRequired Pattern: US
... typeId 1..1II
.... @root 1..1stFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stExtension
Fixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2023-05-01
.... templateId:secondary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
..... @extension 1..1stRequired Pattern: 2015-08-01
... code C1..1CEBinding: FHIRDocumentTypeCodes (extensible)
.... @code 1..1csBinding: Care Plan Document Type (required)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId C0..1II
... versionNumber C0..1INT
... recordTarget 1..*RecordTarget
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
... author 1..*Author
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:id1 0..1IIid
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
... Slices for informant 0..*InformantSlice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*Informantinformant
..... assignedEntity 1..1AssignedEntity
...... id C1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:informant2 0..*Informantinformant
..... relatedEntity 1..1RelatedEntity
... custodian 1..1Custodian
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganization
...... id 1..*II
...... name 1..1ON
...... telecom 1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... Slices for informationRecipient 0..*InformationRecipientSlice: Unordered, Open by value:intendedRecipient
.... informationRecipient:All Slices Content/Rules for all slices
..... intendedRecipient 1..1IntendedRecipient
...... @classCode 1..1cs
.... informationRecipient:informationRecipient1 0..*InformationRecipient
..... intendedRecipient 1..1IntendedRecipient
...... @classCode 1..1cs
...... id 1..*II
...... addr 0..*AD
...... telecom 0..*TEL
...... informationRecipient 0..1Person
....... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... receivedOrganization 0..1Organization
....... id 0..*II
....... name 1..1ON
....... standardIndustryClassCode 0..1CEBinding: Healthcare Provider Taxonomy (required)
... Slices for authenticator 0..*AuthenticatorSlice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
.... authenticator:authenticator1 0..*Authenticatorauthenticator
..... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... @code 1..1csRequired Pattern: S
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... authenticator:authenticator2 0..1Authenticator
..... time 1..1TS
..... signatureCode 1..1CS
..... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the signatureText element
XML: signatureText (urn:hl7-org:sdtc)
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... code 1..1CEBinding: v3 Code System RoleCode (extensible)
....... @code 1..1csRequired Pattern: ONESELF
....... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.5.111
... Slices for participant C0..*Participant1Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... associatedEntity 1..1AssociatedEntity
.... participant:participant1 C0..*Participant1
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: VRF
..... functionCode 1..1CE
...... @code 1..1csRequired Pattern: 425268008
...... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.96
..... time 1..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... @code 0..1csBinding: Personal And Legal Relationship Role Type (preferred)
.... participant:participant2 C0..*Participant1
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*PN
... Slices for documentationOf 1..*DocumentationOfThe serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range).
Slice: Unordered, Open by value:serviceEvent
.... documentationOf:All Slices Content/Rules for all slices
..... serviceEvent 1..1ServiceEvent
...... @classCode 1..1csBinding: ActClass (required)
...... effectiveTime 1..1IVL_TS
....... low 1..1IVXB_TS
...... Slices for performer 1..*Performer1Slice: Unordered, Open by value:assignedEntity
....... performer:All Slices Content/Rules for all slices
........ @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
........ assignedEntity 1..1AssignedEntity
......... id 1..*II
....... performer:performer1 1..*Performer1
........ @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
........ assignedEntity 1..1AssignedEntity
......... id 1..*II
......... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
......... assignedPerson 1..1Person
.......... name C1..1USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent 1..1ServiceEvent
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: PCPR
...... effectiveTime 1..1IVL_TS
....... low 1..1IVXB_TS
....... high 0..1IVXB_TS
... Slices for relatedDocument 0..*RelatedDocumentSlice: Unordered, Open by value:parentDocument, value:typeCode
.... relatedDocument:relatedDocument1 0..*RelatedDocument
..... @typeCode 1..1csBinding: x_ActRelationshipDocument (required)
..... parentDocument 1..1ParentDocument
...... id 1..*II
...... setId 1..1II
...... versionNumber 1..1INT
... componentOf 0..1ComponentOf
.... encompassingEncounter 1..1EncompassingEncounter
..... id 1..*II
..... effectiveTime 1..1IVL_TS
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
..... Slices for component 3..*InfrastructureRootSlice: Unordered, Open by value:ClinicalDocument.section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... section 1..1HealthConcernsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1GoalsSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1ActivitiesSectionBase for all types and resources
...... component:component4 0..1InfrastructureRoot
....... section 1..1HealthStatusEvaluationsandOutcomesSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
ClinicalDocument.code.coderequiredCare Plan Document Type
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.receivedOrganization.standardIndustryClassCoderequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator2.assignedEntity.codeextensibleRoleCode
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: VRF
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.participant:participant1.associatedEntity.codeextensibleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.code.codepreferredPersonal And Legal Relationship Role Type
ClinicalDocument.participant:participant2.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredx_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCoderequiredx_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCoderequiredFixed Value: PCPR
ClinicalDocument.relatedDocument:relatedDocument1.typeCoderequiredx_ActRelationshipDocument

Constraints

IdGradePath(s)DetailsRequirements
1198-31044errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain a Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044).
:
4537-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:4537-5299).
:
4537-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:4537-5300).
:
4537-6380errorClinicalDocument.setIdIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
:
4537-6387errorClinicalDocument.versionNumberIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
:
4537-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
:
4537-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:4537-9991).
:
4537-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
:
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
:
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
:
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
:
4537-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:4537-32418).
:
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name, ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... @classCode 0..1csBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: US
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..1II
.... @root 1..1stFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stExtension
Fixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2023-05-01
.... templateId:secondary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.15
..... @extension 1..1stRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEBinding: FHIRDocumentTypeCodes (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csBinding: Care Plan Document Type (required)
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId C0..1II
... versionNumber C0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... patientRole 1..1PatientRole
..... @classCode 0..1csBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... sdtcDeceasedInd C0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime 0..1TSXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedTime
XML: deceasedTime (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @value C0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... sdtcMultipleBirthInd 0..1BLXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... sdtcRaceCode C0..*CEXML Namespace: urn:hl7-org:sdtc
The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML Namespace: urn:hl7-org:sdtc
ethnicGroupCode
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (required)
...... guardian 0..*Guardian
....... @classCode 0..1csBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... templateId 0..*II
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressADUSFIELDEDBase for all types and resources
....... telecom 0..*TEL
........ @nullFlavor 0..1csBinding: NullFlavor (required)
........ @value 0..1url
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcAsPatientRelationship 0..*CEXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... @classCode 0..1csBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... templateId 0..*II
....... place 1..1Place
........ @classCode 0..1csBinding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name 0..1EN
........ addr C1..1AD
......... nullFlavor C0..1csPrimitive Type code
Binding: NullFlavor (required)
......... @isNotOrdered 0..1bl
......... @use 0..*cs
......... delimiter 0..*ADXP
.......... @partType 0..1csFixed Value: DEL
......... country 0..1ADXP
.......... @partType 0..1csFixed Value: CNT
......... state 0..*ADXP
.......... @partType 0..1csFixed Value: STA
......... county 0..*ADXP
.......... @partType 0..1csFixed Value: CPA
......... city 0..*ADXP
.......... @partType 0..1csFixed Value: CTY
......... postalCode 0..*ADXP
.......... @partType 0..1csFixed Value: ZIP
......... streetAddressLine 0..*ADXP
.......... @partType 0..1csFixed Value: SAL
......... houseNumber 0..*ADXP
.......... @partType 0..1csFixed Value: BNR
......... houseNumberNumeric 0..*ADXP
.......... @partType 0..1csFixed Value: BNN
......... direction 0..*ADXP
.......... @partType 0..1csFixed Value: DIR
......... streetName 0..*ADXP
.......... @partType 0..1csFixed Value: STR
......... streetNameBase 0..*ADXP
.......... @partType 0..1csFixed Value: STB
......... streetNameType 0..*ADXP
.......... @partType 0..1csFixed Value: STTYP
......... additionalLocator 0..*ADXP
.......... @partType 0..1csFixed Value: ADL
......... unitID 0..*ADXP
.......... @partType 0..1csFixed Value: UNID
......... unitType 0..*ADXP
.......... @partType 0..1csFixed Value: UNIT
......... careOf 0..*ADXP
.......... @partType 0..1csFixed Value: CAR
......... censusTract 0..*ADXP
.......... @partType 0..1csFixed Value: CEN
......... deliveryAddressLine 0..*ADXP
.......... @partType 0..1csFixed Value: DAL
......... deliveryInstallationType 0..*ADXP
.......... @partType 0..1csFixed Value: DINST
......... deliveryInstallationArea 0..*ADXP
.......... @partType 0..1csFixed Value: DINSTA
......... deliveryInstallationQualifier 0..*ADXP
.......... @partType 0..1csFixed Value: DINSTQ
......... deliveryMode 0..*ADXP
.......... @partType 0..1csFixed Value: DMOD
......... deliveryModeIdentifier 0..*ADXP
.......... @partType 0..1csFixed Value: DMODID
......... buildingNumberSuffix 0..*ADXP
.......... @partType 0..1csFixed Value: BNS
......... postBox 0..*ADXP
.......... @partType 0..1csFixed Value: POB
......... precinct 0..*ADXP
.......... @partType 0..1csFixed Value: PRE
......... other 0..1st
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication 0..*LanguageCommunication
....... templateId 0..*II
....... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... realmCode 0..*CS
...... typeId 0..1II
...... templateId 0..*II
...... id 1..*II
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
...... name 1..*ON
...... telecom 1..*TEL
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*Author
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CE
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:id1 0..1IIid
....... @nullFlavor 0..1csBinding: NullFlavor (required)
Fixed Value: UNK
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... @nullFlavor 0..1csBinding: NullFlavor (required)
.....