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/EncounterActivity | Version: 2.1 | |||
| Draft as of 2023-09-29 | Computable Name: EncounterActivity | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01 | ||||
This clinical statement describes an interaction between a patient and clinician. Interactions may include in-person encounters, telephone conversations, and email exchanges.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Encounter
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Encounter | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition | ||
 classCode | 1..1 | cs | ||
| moodCode | 1..1 | cs | Fixed Value: EVN | |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49 | |
  extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: EncounterTypeCode (preferred) | |
| originalText | 0..1 | ED | ||
 reference | 0..1 | TEL | ||
 value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). |
| translation | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set. | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcDischargeDispositionCode | C | 0..1 | CE | 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 dischargeDispositionCode element 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | cs | Fixed Value: LOC | |
 participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by value:act | |
 entryRelationship:indication | 0..* | EntryRelationship | ||
 typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:diagnosis | 0..* | EntryRelationship | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Encounter.code | preferred | EncounterTypeCode |
| Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : | |
| 1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : | |
| 1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources | |
 @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: EncounterTypeCode (preferred) | |
| originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
| @value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). |
| translation | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set. | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:location | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by value:act | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:diagnosis | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) | |
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Encounter.classCode | required | Fixed Value: ENC |
| Encounter.code | preferred | EncounterTypeCode |
| Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Encounter.participant:location.typeCode | required | Fixed Value: LOC |
| Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : | |
| 1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : | |
| 1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources | |
| @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: EncounterTypeCode (preferred) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | ||
| @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 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @charset | 0..1 | cs | ||
| @compression | 0..1 | cs | Binding: CompressionAlgorithm (required) | |
| @integrityCheck | 0..1 | bin | ||
| @integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (required) | |
| @language | 0..1 | cs | ||
| @mediaType | 0..1 | cs | ||
| @representation | 0..1 | cs | ||
 data[x] | 0..1 | |||
| dataString | string(st) | |||
| dataBase64Binary | base64Binary(bin) | |||
| reference | 0..1 | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). |
| useablePeriod | 0..* | |||
 useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..* | cs | Binding: AddressUse (required) | |
| thumbnail | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set. | |
| text | 0..1 | ED | ||
| statusCode | 0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationPhysicalPerformer (required) Fixed Value: PRF | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| modeCode | 0..1 | CE | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 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 | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| author | 0..* | Author | ||
| informant | 0..* | Informant | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:location | 0..* | Participant2 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| awarenessCode | 0..1 | CE | ||
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by value:act | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:diagnosis | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Encounter.classCode | required | Fixed Value: ENC |
| Encounter.templateId:primary.nullFlavor | required | NullFlavor |
| Encounter.code | preferred | EncounterTypeCode |
| Encounter.code.nullFlavor | required | NullFlavor |
| Encounter.code.originalText.nullFlavor | required | NullFlavor |
| Encounter.code.originalText.compression | required | CompressionAlgorithm |
| Encounter.code.originalText.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Encounter.code.originalText.reference.nullFlavor | required | NullFlavor |
| Encounter.code.originalText.reference.use | required | AddressUse |
| Encounter.statusCode | required | ActStatus |
| Encounter.priorityCode | extensible | ActPriority |
| Encounter.performer.nullFlavor | required | NullFlavor |
| Encounter.performer.typeCode | required | Fixed Value: PRF |
| Encounter.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Encounter.participant:location.nullFlavor | required | NullFlavor |
| Encounter.participant:location.typeCode | required | Fixed Value: LOC |
| Encounter.participant:location.contextControlCode | required | Fixed Value: OP |
| Encounter.entryRelationship:indication.nullFlavor | required | NullFlavor |
| Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Encounter.entryRelationship:diagnosis.nullFlavor | required | NullFlavor |
| Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : | |
| 1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : | |
| 1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Encounter
Summary
Mandatory: 7 elements (3 nested mandatory elements)
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Encounter
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition | ||
| classCode | 1..1 | cs | ||
| moodCode | 1..1 | cs | Fixed Value: EVN | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49 | |
| extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: EncounterTypeCode (preferred) | |
| originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
| value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). |
| translation | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set. | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcDischargeDispositionCode | C | 0..1 | CE | 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 dischargeDispositionCode element 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | cs | Fixed Value: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by value:act | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:diagnosis | 0..* | EntryRelationship | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Encounter.code | preferred | EncounterTypeCode |
| Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : | |
| 1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : | |
| 1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources | |
| @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: EncounterTypeCode (preferred) | |
| originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
| @value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). |
| translation | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set. | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:location | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by value:act | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:diagnosis | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) | |
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Encounter.classCode | required | Fixed Value: ENC |
| Encounter.code | preferred | EncounterTypeCode |
| Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Encounter.participant:location.typeCode | required | Fixed Value: LOC |
| Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : | |
| 1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : | |
| 1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources | |
| @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: EncounterTypeCode (preferred) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | ||
| @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 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @charset | 0..1 | cs | ||
| @compression | 0..1 | cs | Binding: CompressionAlgorithm (required) | |
| @integrityCheck | 0..1 | bin | ||
| @integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (required) | |
| @language | 0..1 | cs | ||
| @mediaType | 0..1 | cs | ||
| @representation | 0..1 | cs | ||
| data[x] | 0..1 | |||
| dataString | string(st) | |||
| dataBase64Binary | base64Binary(bin) | |||
| reference | 0..1 | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). |
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..* | cs | Binding: AddressUse (required) | |
| thumbnail | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set. | |
| text | 0..1 | ED | ||
| statusCode | 0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationPhysicalPerformer (required) Fixed Value: PRF | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| modeCode | 0..1 | CE | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 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 | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| author | 0..* | Author | ||
| informant | 0..* | Informant | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:location | 0..* | Participant2 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| awarenessCode | 0..1 | CE | ||
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by value:act | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:diagnosis | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Encounter.classCode | required | Fixed Value: ENC |
| Encounter.templateId:primary.nullFlavor | required | NullFlavor |
| Encounter.code | preferred | EncounterTypeCode |
| Encounter.code.nullFlavor | required | NullFlavor |
| Encounter.code.originalText.nullFlavor | required | NullFlavor |
| Encounter.code.originalText.compression | required | CompressionAlgorithm |
| Encounter.code.originalText.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Encounter.code.originalText.reference.nullFlavor | required | NullFlavor |
| Encounter.code.originalText.reference.use | required | AddressUse |
| Encounter.statusCode | required | ActStatus |
| Encounter.priorityCode | extensible | ActPriority |
| Encounter.performer.nullFlavor | required | NullFlavor |
| Encounter.performer.typeCode | required | Fixed Value: PRF |
| Encounter.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Encounter.participant:location.nullFlavor | required | NullFlavor |
| Encounter.participant:location.typeCode | required | Fixed Value: LOC |
| Encounter.participant:location.contextControlCode | required | Fixed Value: OP |
| Encounter.entryRelationship:indication.nullFlavor | required | NullFlavor |
| Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Encounter.entryRelationship:diagnosis.nullFlavor | required | NullFlavor |
| Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : | |
| 1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : | |
| 1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Encounter
Summary
Mandatory: 7 elements (3 nested mandatory elements)
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1 based on FHIR 5.0.0. Generated 2023-09-29
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