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: Continuity of Care Document (CCD)

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ContinuityofCareDocumentCCD Version: 2.1
Active as of 2023-09-29 Computable Name: ContinuityofCareDocumentCCD
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.2:2015-08-01

This document type was originally based on the Continuity of Care Document (CCD) Release 1.1 which itself was derived from HITSP C32 and CCD Release 1.0.

The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another to support the continuity of care.

The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, and administrative data for a specific patient. The key characteristic of a CCD is that the ServiceEvent is constrained to “PCPR”. This means it does not function to report new ServiceEvents associated with performing care. It reports on care that has already been provided. The CCD provides a historical tally of the care over a range of time and is not a record of new services delivered.

More specific use cases, such as a Discharge Summary, Transfer Summary, Referral Note, Consultation Note, or Progress Note, are available as alternative documents in this guide.

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:primary 1..1II
.... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.2
.... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csRequired Pattern: 34133-9
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... assignedAuthor C1..1AssignedAuthor1198-8456: Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456).
1198-8457: If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457).
... documentationOf 1..1DocumentationOfThe documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.
.... serviceEvent 1..1ServiceEventThe main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to 'PCPR' (care provision) and indicating the duration over which care was provided 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). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present.
..... classCode 1..1csFixed Value: PCPR
..... effectiveTime 1..1IVL_TS
...... low 1..1IVXB_TS
...... high 1..1IVXB_TS
..... performer 0..*Performer1The serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... typeCode 1..1csFixed Value: PRF
...... assignedEntity 1..1AssignedEntitySG 20230709: Illegal constraint - base has min = 1 (deleted min=0)
....... id C1..*II1198-32466: If this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466).
....... assignedPerson 0..1Person
... component 1..1Component
.... structuredBody 1..1StructuredBody
..... Slices for component 6..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:allergies 1..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:problems 1..1InfrastructureRoot
....... section 1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:results 1..1InfrastructureRoot
....... section 1..1ResultsSectionBase for all types and resources
...... component:advDirectives 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources
...... component:encounters 0..1InfrastructureRoot
....... section 1..1EncountersSectionBase for all types and resources
...... component:famHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section 1..1ImmunizationsSectionBase for all types and resources
...... component:medEquipment 0..1InfrastructureRoot
....... section 1..1MedicalEquipmentSectionBase for all types and resources
...... component:payers 0..1InfrastructureRoot
....... section 1..1PayersSectionBase for all types and resources
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:socialHist 1..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 1..1InfrastructureRoot
....... section 1..1VitalSignsSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section 1..1NutritionSectionBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
1198-8456errorClinicalDocument.author.assignedAuthorSuch assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456).
:
1198-8457errorClinicalDocument.author.assignedAuthorIf assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457).
:
1198-32466warningClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.idIf this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466).
:
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:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.2
..... @extension 1..1stRequired Pattern: 2015-08-01
... code C1..1CEBinding: FHIRDocumentTypeCodes (extensible)
.... @code 1..1csRequired Pattern: 34133-9
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... 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)
... 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..1AssignedAuthor1198-8456: Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456).
1198-8457: If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457).
..... 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 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
... documentationOf 1..1DocumentationOfThe documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.
.... serviceEvent 1..1ServiceEventThe main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to 'PCPR' (care provision) and indicating the duration over which care was provided 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). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present.
..... @classCode 1..1csBinding: ActClass (required)
Fixed Value: PCPR
..... effectiveTime 1..1IVL_TS
...... low 1..1IVXB_TS
...... high 1..1IVXB_TS
..... performer 0..*Performer1The serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
...... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
Fixed Value: PRF
...... assignedEntity 1..1AssignedEntitySG 20230709: Illegal constraint - base has min = 1 (deleted min=0)
....... id C1..*II1198-32466: If this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466).
....... assignedPerson 0..1Person
... component 1..1Component
.... structuredBody 1..1StructuredBody
..... Slices for component 6..*InfrastructureRootSlice: Unordered, Open by profile:section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:allergies 1..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:problems 1..1InfrastructureRoot
....... section 1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:results 1..1InfrastructureRoot
....... section 1..1ResultsSectionBase for all types and resources
...... component:advDirectives 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources
...... component:encounters 0..1InfrastructureRoot
....... section 1..1EncountersSectionBase for all types and resources
...... component:famHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section 1..1ImmunizationsSectionBase for all types and resources
...... component:medEquipment 0..1InfrastructureRoot
....... section 1..1MedicalEquipmentSectionBase for all types and resources
...... component:payers 0..1InfrastructureRoot
....... section 1..1PayersSectionBase for all types and resources
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:socialHist 1..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 1..1InfrastructureRoot
....... section 1..1VitalSignsSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section 1..1NutritionSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
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.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredFixed Value: PCPR
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredFixed Value: PRF

Constraints

IdGradePath(s)DetailsRequirements
1198-8456errorClinicalDocument.author.assignedAuthorSuch assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456).
:
1198-8457errorClinicalDocument.author.assignedAuthorIf assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457).
:
1198-32466warningClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.idIf this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466).
:
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).
:
4537-9946warningClinicalDocument.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).
:
4537-16790errorClinicalDocument.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.authenticator:authenticator1.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.authenticator:authenticator1.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.authenticator:authenticator1.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:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.2
..... @extension 1..1stRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEBinding: FHIRDocumentTypeCodes (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 34133-9
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @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..1AssignedAuthor1198-8456: Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456).
1198-8457: If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457).
..... @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)
...... @code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
...... @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
..... 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)
..... assignedPerson 0..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)
..... assignedAuthoringDevice 0..1AuthoringDevice
...... @classCode 0..1csBinding: EntityClassDevice (required)
Fixed Value: DEV
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... code 0..1CEBinding: EntityCode (extensible)
...... manufacturerModelName 1..1SCBinding: Manufacturer Model Name Example (example)
...... softwareName 1..1SCBinding: Software Name Example (example)
...... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEnterer
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: ENT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time 1..1TS
.... assignedEntity 1..1AssignedEntity
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... 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
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... 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)
..... assignedPerson 1..1Person
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1