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/DischargeSummary | Version: 2.1 | |||
| Active as of 2023-09-29 | Computable Name: DischargeSummary | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.8:2015-08-01 | ||||
The Discharge Summary is a document which synopsizes a patient’s admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary (http://www.jointcommission.org/):
The best practice for a Discharge Summary is to include the discharge disposition in the display of the header.
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:secondary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.8 | |
  extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | |
 code | 1..1 | cs | Binding: DischargeSummaryDocumentTypeCode (required) | |
| participant | C | 0..* | Participant1 | The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8469: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). |
| componentOf | 1..1 | ComponentOf | The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | |
 encompassingEncounter | 1..1 | EncompassingEncounter | ||
 effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | |
| high | 1..1 | IVXB_TS | The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | |
| dischargeDispositionCode | 1..1 | CE | The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements.
The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered. Binding: VSAC 2.16.840.1.113883.3.88.12.80.33 (preferred) | |
| responsibleParty | 0..1 | InfrastructureRoot | The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32898: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32899: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. 1198-30569: This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). |
 Slices for component | 7..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section | |
 component:component1 | 1..1 | InfrastructureRoot | ||
  section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component2 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalCourseSection | Base for all types and resources | |
| component:component3 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeDiagnosisSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component7 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionDiagnosisSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionMedicationsSectionEntriesOptional | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalConsultationsSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeInstructionsSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargePhysicalSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeStudiesSummarySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component21 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component26 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
 component:component27 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code.code | required | DischargeSummaryDocumentTypeCode |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.33 |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8469 | error | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). : | |
| 1198-30569 | error | ClinicalDocument.component.structuredBody | This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). : | |
| 1198-32898 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). : | |
| 1198-32899 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). : |
| 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:secondary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.8 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible) |
| @code | 1..1 | cs | Binding: DischargeSummaryDocumentTypeCode (required) | |
| 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 | |
| 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 |
| participant | C | 0..* | Participant1 | The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8469: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). |
| associatedEntity | 1..1 | AssociatedEntity | ||
| componentOf | 1..1 | ComponentOf | The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| id | 1..* | II | ||
| effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | |
| high | 1..1 | IVXB_TS | The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | |
| dischargeDispositionCode | 1..1 | CE | The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements.
The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered. Binding: VSAC 2.16.840.1.113883.3.88.12.80.33 (preferred) | |
| responsibleParty | 0..1 | InfrastructureRoot | The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32898: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32899: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. 1198-30569: This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). |
| Slices for component | 7..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section | |
| component:All Slices | Content/Rules for all slices | |||
 section | 1..1 | Section | ||
| component:component1 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component2 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalCourseSection | Base for all types and resources | |
| component:component3 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeDiagnosisSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component7 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionDiagnosisSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionMedicationsSectionEntriesOptional | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalConsultationsSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeInstructionsSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargePhysicalSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeStudiesSummarySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component21 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component26 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
| component:component27 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.code.code | required | DischargeSummaryDocumentTypeCode |
| 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.componentOf.encompassingEncounter.dischargeDispositionCode | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.33 |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8469 | error | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). : | |
| 1198-30569 | error | ClinicalDocument.component.structuredBody | This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). : | |
| 1198-32898 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). : | |
| 1198-32899 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). : | |
| 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). : | |
| 4537-10006 | 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). : | |
| 4537-32418 | 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:secondary | 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: 2.16.840.1.113883.10.20.22.1.8 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible) |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Binding: DischargeSummaryDocumentTypeCode (required) | |
| @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 | ||
| 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 | |
| @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 | The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8469: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). |
| @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 | 0..* | DocumentationOf | ||
| @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 | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @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 | 0..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| 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 | ||
| @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 | 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 | 1..1 | ComponentOf | The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | |
| @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 | ||
| @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 | The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | |
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 1..1 | IVXB_TS | The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | |
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 1..1 | CE | The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements.
The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered. Binding: VSAC 2.16.840.1.113883.3.88.12.80.33 (preferred) | |
| responsibleParty | 0..1 | InfrastructureRoot | The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | |
| @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 | C | 1..1 | AssignedEntity | 1198-32898: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32899: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). |
| 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 | C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. 1198-30569: This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). |
| @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 | 7..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.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:component1 | 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:component2 | 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 | HospitalCourseSection | Base for all types and resources | |
| component:component3 | 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 | DischargeDiagnosisSection | Base for all types and resources | |
| component:component4 | 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 | DischargeMedicationsSection | Base for all types and resources | |
| component:component5 | 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 | PlanofTreatmentSection | Base for all types and resources | |
| component:component6 | 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 | ChiefComplaintSection | Base for all types and resources | |
| component:component7 | 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 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component8 | 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 | |
| component:component9 | 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:component10 | 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:component11 | 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 | PastMedicalHistory | Base for all types and resources | |
| component:component12 | 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 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component13 | 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 | AdmissionDiagnosisSection | Base for all types and resources | |
| component:component14 | 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 | AdmissionMedicationsSectionEntriesOptional | Base for all types and resources | |
| component:component15 | 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 | HospitalConsultationsSection | Base for all types and resources | |
| component:component16 | 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 | HospitalDischargeInstructionsSection | Base for all types and resources | |
| component:component17 | 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 | HospitalDischargePhysicalSection | Base for all types and resources | |
| component:component18 | 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 | HospitalDischargeStudiesSummarySection | Base for all types and resources | |
| component:component19 | 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:component20 | 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 | ProblemSection | Base for all types and resources | |
| component:component21 | 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 | ProceduresSection | Base for all types and resources | |
| component:component22 | 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 | ReasonforVisitSection | Base for all types and resources | |
| component:component23 | 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 | ReviewofSystemsSection | Base for all types and resources | |
| component:component24 | 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 | SocialHistorySection | Base for all types and resources | |
| component:component25 | 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 | VitalSignsSection | Base for all types and resources | |
| component:component26 | 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 | DischargeMedicationsSection | Base for all types and resources | |
| component:component27 | 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 | |
| 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:secondary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.code.code | required | DischargeSummaryDocumentTypeCode |
| 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 | ActClass |
| 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 | x_ServiceEventPerformer |
| 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.effectiveTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.33 |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.typeCode | required | ParticipationType |
| 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:component1.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component26.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component27.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8469 | error | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). : | |
| 1198-30569 | error | ClinicalDocument.component.structuredBody | This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). : | |
| 1198-32898 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). : | |
| 1198-32899 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). : | |
| 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: 16 elements (1 nested mandatory element)
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:secondary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.8 | |
| extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | |
| code | 1..1 | cs | Binding: DischargeSummaryDocumentTypeCode (required) | |
| participant | C | 0..* | Participant1 | The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8469: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). |
| componentOf | 1..1 | ComponentOf | The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | |
| high | 1..1 | IVXB_TS | The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | |
| dischargeDispositionCode | 1..1 | CE | The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements.
The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered. Binding: VSAC 2.16.840.1.113883.3.88.12.80.33 (preferred) | |
| responsibleParty | 0..1 | InfrastructureRoot | The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32898: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32899: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. 1198-30569: This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). |
| Slices for component | 7..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section | |
| component:component1 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component2 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalCourseSection | Base for all types and resources | |
| component:component3 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeDiagnosisSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component7 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionDiagnosisSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionMedicationsSectionEntriesOptional | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalConsultationsSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeInstructionsSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargePhysicalSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeStudiesSummarySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component21 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component26 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
| component:component27 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code.code | required | DischargeSummaryDocumentTypeCode |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.33 |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8469 | error | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). : | |
| 1198-30569 | error | ClinicalDocument.component.structuredBody | This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). : | |
| 1198-32898 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). : | |
| 1198-32899 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). : |
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:secondary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.8 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible) |
| @code | 1..1 | cs | Binding: DischargeSummaryDocumentTypeCode (required) | |
| 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 | |
| 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 |
| participant | C | 0..* | Participant1 | The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8469: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). |
| associatedEntity | 1..1 | AssociatedEntity | ||
| componentOf | 1..1 | ComponentOf | The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| id | 1..* | II | ||
| effectiveTime | 1..1 | IVL_TS | ||
| low | 1..1 | IVXB_TS | The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | |
| high | 1..1 | IVXB_TS | The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | |
| dischargeDispositionCode | 1..1 | CE | The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements.
The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered. Binding: VSAC 2.16.840.1.113883.3.88.12.80.33 (preferred) | |
| responsibleParty | 0..1 | InfrastructureRoot | The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32898: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32899: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. 1198-30569: This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). |
| Slices for component | 7..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section | |
| component:All Slices | Content/Rules for all slices | |||
| section | 1..1 | Section | ||
| component:component1 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component2 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalCourseSection | Base for all types and resources | |
| component:component3 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeDiagnosisSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component7 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionDiagnosisSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdmissionMedicationsSectionEntriesOptional | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalConsultationsSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeInstructionsSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargePhysicalSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HospitalDischargeStudiesSummarySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component21 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component26 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | DischargeMedicationsSection | Base for all types and resources | |
| component:component27 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.code.code | required | DischargeSummaryDocumentTypeCode |
| 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.componentOf.encompassingEncounter.dischargeDispositionCode | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.33 |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8469 | error | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). : | |
| 1198-30569 | error | ClinicalDocument.component.structuredBody | This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). : | |
| 1198-32898 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). : | |
| 1198-32899 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). : | |
| 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). : | |
| 4537-10006 | 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). : | |
| 4537-32418 | 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:secondary | 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: 2.16.840.1.113883.10.20.22.1.8 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible) |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Binding: DischargeSummaryDocumentTypeCode (required) | |
| @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 | ||
| 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 | |
| @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 | The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8469: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). |
| @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 | 0..* | DocumentationOf | ||
| @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 | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @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 | 0..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| 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 | ||
| @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 | 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 | 1..1 | ComponentOf | The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header. | |
| @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 | ||
| @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 | The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low. | |
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 1..1 | IVXB_TS | The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high. | |
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 1..1 | CE | The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements.
The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered. Binding: VSAC 2.16.840.1.113883.3.88.12.80.33 (preferred) | |
| responsibleParty | 0..1 | InfrastructureRoot | The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care. | |
| @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 | C | 1..1 | AssignedEntity | 1198-32898: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32899: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). |
| 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 | C | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional. 1198-30569: This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). |
| @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 | 7..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.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:component1 | 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:component2 | 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 | HospitalCourseSection | Base for all types and resources | |
| component:component3 | 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 | DischargeDiagnosisSection | Base for all types and resources | |
| component:component4 | 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 | DischargeMedicationsSection | Base for all types and resources | |
| component:component5 | 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 | PlanofTreatmentSection | Base for all types and resources | |
| component:component6 | 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 | ChiefComplaintSection | Base for all types and resources | |
| component:component7 | 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 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component8 | 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 | |
| component:component9 | 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:component10 | 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:component11 | 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 | PastMedicalHistory | Base for all types and resources | |
| component:component12 | 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 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component13 | 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 | AdmissionDiagnosisSection | Base for all types and resources | |
| component:component14 | 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 | AdmissionMedicationsSectionEntriesOptional | Base for all types and resources | |
| component:component15 | 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 | HospitalConsultationsSection | Base for all types and resources | |
| component:component16 | 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 | HospitalDischargeInstructionsSection | Base for all types and resources | |
| component:component17 | 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 | HospitalDischargePhysicalSection | Base for all types and resources | |
| component:component18 | 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 | HospitalDischargeStudiesSummarySection | Base for all types and resources | |
| component:component19 | 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:component20 | 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 | ProblemSection | Base for all types and resources | |
| component:component21 | 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 | ProceduresSection | Base for all types and resources | |
| component:component22 | 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 | ReasonforVisitSection | Base for all types and resources | |
| component:component23 | 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 | ReviewofSystemsSection | Base for all types and resources | |
| component:component24 | 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 | SocialHistorySection | Base for all types and resources | |
| component:component25 | 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 | VitalSignsSection | Base for all types and resources | |
| component:component26 | 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 | DischargeMedicationsSection | Base for all types and resources | |
| component:component27 | 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 | |
| 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:secondary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | extensible | FHIRDocumentTypeCodes |
| ClinicalDocument.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.code.code | required | DischargeSummaryDocumentTypeCode |
| 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 | ActClass |
| 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 | x_ServiceEventPerformer |
| 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.effectiveTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | preferred | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.33 |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.typeCode | required | ParticipationType |
| 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:component1.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component26.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component27.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-8469 | error | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469). : | |
| 1198-30569 | error | ClinicalDocument.component.structuredBody | This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569). : | |
| 1198-32898 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898). : | |
| 1198-32899 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899). : | |
| 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: 16 elements (1 nested mandatory element)
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
Links: Table of Contents |
QA Report
| Version History 
|
|
Propose a change