Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
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
| 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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalDocument | 1..1 | USRealmHeader | XML 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..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
  extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | ||
| code | 1..1 | cs | Required Pattern: 34133-9 | |
 codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| author | 1..* | Author | ||
| assignedAuthor | C | 1..1 | AssignedAuthor | 1198-8456: 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..1 | DocumentationOf | The 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..1 | ServiceEvent | The 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..1 | cs | Fixed Value: PCPR | |
| effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | ||
| high | 1..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | The 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..1 | cs | Fixed Value: PRF | |
| assignedEntity | 1..1 | AssignedEntity | SG 20230709: Illegal constraint - base has min = 1 (deleted min=0) | |
| id | C | 1..* | II | 1198-32466: 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..1 | Person | ||
| component | 1..1 | Component | ||
| structuredBody | 1..1 | StructuredBody | ||
 Slices for component | 6..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
 component:allergies | 1..1 | InfrastructureRoot | ||
  section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:problems | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:advDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:encounters | 0..1 | InfrastructureRoot | ||
| section | 1..1 | EncountersSection | Base for all types and resources | |
| component:famHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:medEquipment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:payers | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:socialHist | 1..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 1..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
 component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8456 | error | ClinicalDocument.author.assignedAuthor | 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 | error | ClinicalDocument.author.assignedAuthor | 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). : | |
| 1198-32466 | warning | ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id | 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). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML 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..1 | CS | ||
 @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | Binding: FHIRDocumentTypeCodes (extensible) |
| @code | 1..1 | cs | Required Pattern: 34133-9 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| recordTarget | 1..* | RecordTarget | ||
| patientRole | 1..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| author | 1..* | Author | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 1198-8456: 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..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
 assignedEntity | 1..1 | AssignedEntity | ||
| id | C | 1..* | II | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| informant:informant2 | 0..* | Informant | informant | |
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
 signatureCode | 1..1 | CS | ||
 @code | 1..1 | cs | Required Pattern: S | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| documentationOf | 1..1 | DocumentationOf | The 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..1 | ServiceEvent | The 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..1 | cs | Binding: ActClass (required) Fixed Value: PCPR | |
| effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | ||
| high | 1..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | The 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..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PRF | |
| assignedEntity | 1..1 | AssignedEntity | SG 20230709: Illegal constraint - base has min = 1 (deleted min=0) | |
| id | C | 1..* | II | 1198-32466: 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..1 | Person | ||
| component | 1..1 | Component | ||
| structuredBody | 1..1 | StructuredBody | ||
| Slices for component | 6..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
 section | 1..1 | Section | ||
| component:allergies | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:problems | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:advDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:encounters | 0..1 | InfrastructureRoot | ||
| section | 1..1 | EncountersSection | Base for all types and resources | |
| component:famHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:medEquipment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:payers | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:socialHist | 1..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 1..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | Fixed Value: PCPR |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: PRF |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8456 | error | ClinicalDocument.author.assignedAuthor | 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 | error | ClinicalDocument.author.assignedAuthor | 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). : | |
| 1198-32466 | warning | ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id | 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). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If 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). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.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). : | |
| 81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML 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..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| realmCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: US | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | Binding: FHIRDocumentTypeCodes (extensible) |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: 34133-9 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| setId | C | 0..1 | II | |
| versionNumber | C | 0..1 | INT | |
| copyTime | 0..1 | TS | ||
| recordTarget | 1..* | RecordTarget | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| patientRole | 1..1 | PatientRole | ||
| @classCode | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
 useablePeriod | 0..* | |||
 useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..1 | II | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) |
| sdtcDeceasedTime | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] |
| sdtcMultipleBirthInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | C | 0..* | CE | XML 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..1 | CE | Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | 0..* | Guardian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| @classCode | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| templateId | 0..* | II | ||
| place | 1..1 | Place | ||
| @classCode | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 0..1 | EN | ||
| addr | C | 1..1 | AD | |
| nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required) |
| @isNotOrdered | 0..1 | bl | ||
| @use | 0..* | cs | ||
| delimiter | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DEL | |
| country | 0..1 | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CNT | |
| state | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STA | |
| county | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CPA | |
| city | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CTY | |
| postalCode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: SAL | |
| houseNumber | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNN | |
| direction | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DIR | |
| streetName | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STR | |
| streetNameBase | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STB | |
| streetNameType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STTYP | |
| additionalLocator | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ADL | |
| unitID | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNID | |
| unitType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNIT | |
| careOf | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CAR | |
| censusTract | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNS | |
| postBox | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: POB | |
| precinct | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: PRE | |
| other | 0..1 | st | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| languageCommunication | 0..* | LanguageCommunication | ||
| templateId | 0..* | II | ||
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..* | ON | ||
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 1198-8456: 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..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| @classCode | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: EntityCode (extensible) | |
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 1..1 | TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | C | 1..* | II | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| informant:informant2 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| receivedOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| name | 1..1 | ON | ||
| telecom | 0..* | TEL | ||
| addr | 0..* | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| participant | C | 0..* | Participant1 | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | 0..1 | IVL_TS | ||
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| documentationOf | 1..1 | DocumentationOf | The 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. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| serviceEvent | 1..1 | ServiceEvent | The 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..1 | cs | Binding: ActClass (required) Fixed Value: PCPR | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | ||
| effectiveTime | 1..1 | IVL_TS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 1..1 | IVXB_TS | ||
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 1..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | The 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. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PRF | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | 1..1 | AssignedEntity | SG 20230709: Illegal constraint - base has min = 1 (deleted min=0) | |
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | C | 1..* | II | 1198-32466: 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). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| relatedDocument | 0..* | RelatedDocument | ||
| authorization | 0..* | Authorization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| consent | 1..1 | Consent | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible) | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| componentOf | 0..1 | ComponentOf | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible) | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| encounterParticipant | 0..* | EncounterParticipant | ||
| location | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| nonXMLBody | 0..1 | NonXMLBody | ||
| structuredBody | 1..1 | StructuredBody | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| confidentialityCode | 0..1 | CE | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| Slices for component | 6..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
 @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | Section | ||
| component:allergies | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:problems | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:advDirectives | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:encounters | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | EncountersSection | Base for all types and resources | |
| component:famHistory | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:medEquipment | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:payers | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PayersSection | Base for all types and resources | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:socialHist | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN |
| ClinicalDocument.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.realmCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:primary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT |
| ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT |
| ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | Marital Status |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | Race Value Set |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | Detailed Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| ClinicalDocument.author.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.typeCode | required | Fixed Value: AUT |
| ClinicalDocument.author.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Fixed Value: UNK |
| ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor |
| ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.informant:informant1.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor |
| ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.custodian.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor |
| ClinicalDocument.informationRecipient.typeCode | required | ParticipationType |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | NullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA |
| ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN |
| ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.participant.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO |
| ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode |
| ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority |
| ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | Fixed Value: PCPR |
| ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: PRF |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.nullFlavor | required | NullFlavor |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.authorization.consent.code | extensible | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.componentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC |
| ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | USEncounterDischargeDisposition |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
| ClinicalDocument.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY |
| ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:allergies.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medications.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:problems.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:procedures.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:results.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:advDirectives.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:encounters.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:famHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:functionalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:immunizations.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medEquipment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:payers.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:planOfTreatment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:socialHist.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:mentalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:nutrition.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8456 | error | ClinicalDocument.author.assignedAuthor | 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 | error | ClinicalDocument.author.assignedAuthor | 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). : | |
| 1198-32466 | warning | ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id | 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). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:4537-5402). : | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : | |
| 4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : | |
| 4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : | |
| 4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If 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). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : | |
| 4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
This structure is derived from USRealmHeader
Summary
Mandatory: 14 elements
Fixed Value: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML 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..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
| extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | ||
| code | 1..1 | cs | Required Pattern: 34133-9 | |
| codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| author | 1..* | Author | ||
| assignedAuthor | C | 1..1 | AssignedAuthor | 1198-8456: 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..1 | DocumentationOf | The 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..1 | ServiceEvent | The 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..1 | cs | Fixed Value: PCPR | |
| effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | ||
| high | 1..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | The 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..1 | cs | Fixed Value: PRF | |
| assignedEntity | 1..1 | AssignedEntity | SG 20230709: Illegal constraint - base has min = 1 (deleted min=0) | |
| id | C | 1..* | II | 1198-32466: 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..1 | Person | ||
| component | 1..1 | Component | ||
| structuredBody | 1..1 | StructuredBody | ||
| Slices for component | 6..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:allergies | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:problems | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:advDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:encounters | 0..1 | InfrastructureRoot | ||
| section | 1..1 | EncountersSection | Base for all types and resources | |
| component:famHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:medEquipment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:payers | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:socialHist | 1..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 1..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8456 | error | ClinicalDocument.author.assignedAuthor | 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 | error | ClinicalDocument.author.assignedAuthor | 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). : | |
| 1198-32466 | warning | ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id | 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). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML 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..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | Binding: FHIRDocumentTypeCodes (extensible) |
| @code | 1..1 | cs | Required Pattern: 34133-9 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| recordTarget | 1..* | RecordTarget | ||
| patientRole | 1..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| author | 1..* | Author | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 1198-8456: 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..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | C | 1..* | II | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| informant:informant2 | 0..* | Informant | informant | |
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: S | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| documentationOf | 1..1 | DocumentationOf | The 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..1 | ServiceEvent | The 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..1 | cs | Binding: ActClass (required) Fixed Value: PCPR | |
| effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | ||
| high | 1..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | The 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..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PRF | |
| assignedEntity | 1..1 | AssignedEntity | SG 20230709: Illegal constraint - base has min = 1 (deleted min=0) | |
| id | C | 1..* | II | 1198-32466: 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..1 | Person | ||
| component | 1..1 | Component | ||
| structuredBody | 1..1 | StructuredBody | ||
| Slices for component | 6..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
| section | 1..1 | Section | ||
| component:allergies | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:problems | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:advDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:encounters | 0..1 | InfrastructureRoot | ||
| section | 1..1 | EncountersSection | Base for all types and resources | |
| component:famHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:medEquipment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:payers | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:socialHist | 1..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 1..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | Fixed Value: PCPR |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: PRF |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8456 | error | ClinicalDocument.author.assignedAuthor | 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 | error | ClinicalDocument.author.assignedAuthor | 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). : | |
| 1198-32466 | warning | ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id | 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). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If 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). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.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). : | |
| 81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML 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..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| realmCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: US | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | Binding: FHIRDocumentTypeCodes (extensible) |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: 34133-9 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| setId | C | 0..1 | II | |
| versionNumber | C | 0..1 | INT | |
| copyTime | 0..1 | TS | ||
| recordTarget | 1..* | RecordTarget | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| patientRole | 1..1 | PatientRole | ||
| @classCode | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..1 | II | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) |
| sdtcDeceasedTime | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] |
| sdtcMultipleBirthInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | C | 0..* | CE | XML 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..1 | CE | Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | 0..* | Guardian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| @classCode | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| templateId | 0..* | II | ||
| place | 1..1 | Place | ||
| @classCode | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 0..1 | EN | ||
| addr | C | 1..1 | AD | |
| nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required) |
| @isNotOrdered | 0..1 | bl | ||
| @use | 0..* | cs | ||
| delimiter | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DEL | |
| country | 0..1 | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CNT | |
| state | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STA | |
| county | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CPA | |
| city | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CTY | |
| postalCode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: SAL | |
| houseNumber | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNN | |
| direction | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DIR | |
| streetName | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STR | |
| streetNameBase | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STB | |
| streetNameType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STTYP | |
| additionalLocator | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ADL | |
| unitID | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNID | |
| unitType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNIT | |
| careOf | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CAR | |
| censusTract | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNS | |
| postBox | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: POB | |
| precinct | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: PRE | |
| other | 0..1 | st | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| languageCommunication | 0..* | LanguageCommunication | ||
| templateId | 0..* | II | ||
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | ||
| providerOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..* | ON | ||
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | 1198-8456: 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..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| @classCode | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: EntityCode (extensible) | |
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 1..1 | TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | C | 1..* | II | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| informant:informant2 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| receivedOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| name | 1..1 | ON | ||
| telecom | 0..* | TEL | ||
| addr | 0..* | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| participant | C | 0..* | Participant1 | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | 0..1 | IVL_TS | ||
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| documentationOf | 1..1 | DocumentationOf | The 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. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| serviceEvent | 1..1 | ServiceEvent | The 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..1 | cs | Binding: ActClass (required) Fixed Value: PCPR | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | ||
| effectiveTime | 1..1 | IVL_TS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 1..1 | IVXB_TS | ||
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 1..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | The 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. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PRF | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | 1..1 | AssignedEntity | SG 20230709: Illegal constraint - base has min = 1 (deleted min=0) | |
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | C | 1..* | II | 1198-32466: 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). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| relatedDocument | 0..* | RelatedDocument | ||
| authorization | 0..* | Authorization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| consent | 1..1 | Consent | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible) | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| componentOf | 0..1 | ComponentOf | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible) | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| encounterParticipant | 0..* | EncounterParticipant | ||
| location | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| nonXMLBody | 0..1 | NonXMLBody | ||
| structuredBody | 1..1 | StructuredBody | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| confidentialityCode | 0..1 | CE | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| Slices for component | 6..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | Section | ||
| component:allergies | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:problems | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:advDirectives | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:encounters | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | EncountersSection | Base for all types and resources | |
| component:famHistory | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:medEquipment | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:payers | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PayersSection | Base for all types and resources | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:socialHist | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN |
| ClinicalDocument.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.realmCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:primary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT |
| ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT |
| ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | Marital Status |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | Race Value Set |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | Detailed Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| ClinicalDocument.author.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.typeCode | required | Fixed Value: AUT |
| ClinicalDocument.author.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Fixed Value: UNK |
| ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor |
| ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.informant:informant1.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor |
| ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.custodian.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor |
| ClinicalDocument.informationRecipient.typeCode | required | ParticipationType |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | NullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA |
| ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN |
| ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.participant.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO |
| ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode |
| ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority |
| ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | Fixed Value: PCPR |
| ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: PRF |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.nullFlavor | required | NullFlavor |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.authorization.consent.code | extensible | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.componentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC |
| ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | USEncounterDischargeDisposition |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
| ClinicalDocument.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY |
| ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:allergies.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medications.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:problems.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:procedures.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:results.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:advDirectives.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:encounters.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:famHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:functionalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:immunizations.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medEquipment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:payers.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:planOfTreatment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:socialHist.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:mentalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:nutrition.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8456 | error | ClinicalDocument.author.assignedAuthor | 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 | error | ClinicalDocument.author.assignedAuthor | 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). : | |
| 1198-32466 | warning | ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id | 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). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:4537-5402). : | |
| 4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : | |
| 4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : | |
| 4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : | |
| 4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If 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). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-10006 | error | ClinicalDocument.participant | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant | When 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). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : | |
| 4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
This structure is derived from USRealmHeader
Summary
Mandatory: 14 elements
Fixed Value: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1 based on FHIR 5.0.0. Generated 2023-09-29
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