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

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

Logical Model: ProcedureNote - Detailed Descriptions

Active as of 2023-09-29

Definitions for the ProcedureNote logical model.

Guidance on how to interpret the contents of this table can be found here

0. ClinicalDocument
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. ClinicalDocument.templateId
Control2..?
4. ClinicalDocument.templateId:secondary
Slice Namesecondary
Comments

SHALL contain exactly one [1..1] templateId (CONF:1198-8496) such that it

Control1..1
6. ClinicalDocument.templateId:secondary.root
Comments

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.6" (CONF:1198-10050).

Control1..?
Pattern Value2.16.840.1.113883.10.20.22.1.6
8. ClinicalDocument.templateId:secondary.extension
Comments

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32520).

Control1..?
Pattern Value2015-08-01
10. ClinicalDocument.code
ShortThe Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", 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.
Comments

SHALL contain exactly one [1..1] code (CONF:1198-17182).

12. ClinicalDocument.code.code
Comments

This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureNoteDocumentTypeCodes http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.6.1 DYNAMIC (CONF:1198-17183).

Control1..?
BindingThe codes SHALL be taken from ProcedureNoteDocumentTypeCodes
14. ClinicalDocument.participant
ShortThe participant element in the Procedure Note header follows the General Header Constraints for participants.
SlicingThis element introduces a set of slices on ClinicalDocument.participant. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ associatedEntity.classCode
  • value @ typeCode
  • value @ functionCode
16. ClinicalDocument.participant:participant1
Slice Nameparticipant1
Comments

MAY contain zero or more [0..*] participant (CONF:1198-8504) such that it

Control0..*
18. ClinicalDocument.participant:participant1.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="IND" Individual (CodeSystem: HL7ParticipationFunction urn:oid:2.16.840.1.113883.5.88 STATIC) (CONF:1198-8505).

Control1..?
Fixed ValueIND
20. ClinicalDocument.participant:participant1.functionCode
Comments

SHALL contain exactly one [1..1] functionCode="PCP" Primary Care Physician (CodeSystem: HL7ParticipationFunction urn:oid:2.16.840.1.113883.5.88 STATIC) (CONF:1198-8506).

Control1..?
22. ClinicalDocument.participant:participant1.functionCode.code
Control1..?
Pattern ValuePCP
24. ClinicalDocument.participant:participant1.associatedEntity
26. ClinicalDocument.participant:participant1.associatedEntity.classCode
Comments

SHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8507).

Fixed ValuePROV
28. ClinicalDocument.participant:participant1.associatedEntity.associatedPerson
Comments

This associatedEntity/@classCode SHALL contain exactly one [1..1] associatedPerson (CONF:1198-8508).

Control1..?
30. ClinicalDocument.documentationOf
ShortA serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
Control1..?
SlicingThis element introduces a set of slices on ClinicalDocument.documentationOf. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ serviceEvent
32. ClinicalDocument.documentationOf.serviceEvent
34. ClinicalDocument.documentationOf.serviceEvent.performer
ShortThis performer identifies any assistants.
Control1..?
SlicingThis element introduces a set of slices on ClinicalDocument.documentationOf.serviceEvent.performer. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ assignedEntity
  • value @ typeCode
36. ClinicalDocument.documentationOf.serviceEvent.performer:performer1
Slice Nameperformer1
ShortThis performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
Comments

This serviceEvent SHALL contain exactly one [1..1] performer (CONF:1198-8520) such that it

Control1..1
38. ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="PPRF" Primary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8521).

Fixed ValuePPRF
40. ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity
Comments

SHALL contain exactly one [1..1] assignedEntity (CONF:1198-14911).

42. ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code
Comments

This assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-14912).

BindingThe codes SHALL be taken from Healthcare Provider Taxonomy
44. ClinicalDocument.documentationOf.serviceEvent.performer:performer2
Slice Nameperformer2
Comments

This serviceEvent MAY contain zero or more [0..*] performer (CONF:1198-32732) such that it

Control0..*
46. ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="SPRF" Secondary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-32734).

Fixed ValueSPRF
48. ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity
Comments

SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32733).

50. ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code
Comments

This assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32735).

BindingThe codes SHALL be taken from Healthcare Provider Taxonomy
52. ClinicalDocument.documentationOf:documentationOf1
Slice NamedocumentationOf1
Comments

SHALL contain at least one [1..*] documentationOf (CONF:1198-8510) such that it

Control1..*
54. ClinicalDocument.documentationOf:documentationOf1.serviceEvent
Comments

SHALL contain exactly one [1..1] serviceEvent (CONF:1198-10061).

Invariants1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). ()
56. ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime
Comments

This serviceEvent SHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:1198-10062).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS(US Realm Date and Time (DT.US.FIELDED))
Invariants1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). ()
1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). ()
1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). ()
58. ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low
Comments

This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-26449).

60. ClinicalDocument.authorization
ShortAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
Comments

MAY contain zero or one [0..1] authorization (CONF:1198-32412).

Control0..1
62. ClinicalDocument.authorization.typeCode
Comments

The authorization, if present, SHALL contain exactly one [1..1] @typeCode="AUTH" authorized by (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-32413).

Control1..?
64. ClinicalDocument.authorization.consent
Comments

The authorization, if present, SHALL contain exactly one [1..1] consent (CONF:1198-32414).

66. ClinicalDocument.authorization.consent.classCode
Comments

This consent SHALL contain exactly one [1..1] @classCode="CONS" consent (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-32415).

Control1..?
68. ClinicalDocument.authorization.consent.moodCode
Comments

This consent SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-32416).

Control1..?
70. ClinicalDocument.authorization.consent.statusCode
Comments

This consent SHALL contain exactly one [1..1] statusCode (CONF:1198-32417).

72. ClinicalDocument.componentOf
Comments

SHOULD contain zero or one [0..1] componentOf (CONF:1198-30871).

74. ClinicalDocument.componentOf.encompassingEncounter
Comments

The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-30872).

76. ClinicalDocument.componentOf.encompassingEncounter.id
ShortSG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
Comments

This encompassingEncounter SHOULD contain zero or more [0..*] id (CONF:1198-32395).

78. ClinicalDocument.componentOf.encompassingEncounter.code
Comments

This encompassingEncounter SHALL contain exactly one [1..1] code (CONF:1198-30873).

Control1..?
80. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant
SlicingThis element introduces a set of slices on ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ typeCode
82. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1
Slice NameencounterParticipant1
Comments

This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (CONF:1198-30874) such that it

Control0..1
84. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="REF" Referrer (CONF:1198-30875).

Control1..?
Fixed ValueREF
86. ClinicalDocument.componentOf.encompassingEncounter.location
ShortSG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
Comments

This encompassingEncounter SHALL contain at least one [1..*] location (CONF:1198-30876).

Control1..?
88. ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility
Comments

Such locations SHALL contain exactly one [1..1] healthCareFacility (CONF:1198-30877).

90. ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.id
Comments

This healthCareFacility SHALL contain at least one [1..*] id (CONF:1198-30878).

Control1..?
92. ClinicalDocument.component
Comments

SHALL contain exactly one [1..1] component (CONF:1198-9588).

94. ClinicalDocument.component.structuredBody
Comments

This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30352).

Control1..?
Invariants1198-30412: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30412). ()
1198-30414: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30414). ()
1198-30415: 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:1198-30415). ()
96. ClinicalDocument.component.structuredBody.component
Control5..?
SlicingThis element introduces a set of slices on ClinicalDocument.component.structuredBody.component. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ ClinicalDocument.section
98. ClinicalDocument.component.structuredBody.component:component1
Slice Namecomponent1
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30353).

Control1..1
100. ClinicalDocument.component.structuredBody.component:component1.section
Comments

This component SHALL contain exactly one [1..1] Complications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.37:2015-08-01) (CONF:1198-30387).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Complications Section)
102. ClinicalDocument.component.structuredBody.component:component2
Slice Namecomponent2
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30355) such that it

Control1..1
104. ClinicalDocument.component.structuredBody.component:component2.section
Comments

SHALL contain exactly one [1..1] Procedure Description Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.27) (CONF:1198-30356).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Description Section)
106. ClinicalDocument.component.structuredBody.component:component3
Slice Namecomponent3
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30357) such that it

Control1..1
108. ClinicalDocument.component.structuredBody.component:component3.section
Comments

SHALL contain exactly one [1..1] Procedure Indications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.29:2014-06-09) (CONF:1198-30358).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Indications Section)
110. ClinicalDocument.component.structuredBody.component:component4
Slice Namecomponent4
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30359) such that it

Control1..1
112. ClinicalDocument.component.structuredBody.component:component4.section
Comments

SHALL contain exactly one [1..1] Postprocedure Diagnosis Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.36:2015-08-01) (CONF:1198-30360).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Postprocedure Diagnosis Section)
114. ClinicalDocument.component.structuredBody.component:component5
Slice Namecomponent5
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30361) such that it

Control0..1
116. ClinicalDocument.component.structuredBody.component:component5.section
Comments

SHALL contain exactly one [1..1] Assessment Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.8) (CONF:1198-30362).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Assessment Section)
118. ClinicalDocument.component.structuredBody.component:component6
Slice Namecomponent6
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30363) such that it

Control0..1
120. ClinicalDocument.component.structuredBody.component:component6.section
Comments

SHALL contain exactly one [1..1] Assessment and Plan Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.9:2014-06-09) (CONF:1198-30364).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Assessment and Plan Section)
122. ClinicalDocument.component.structuredBody.component:component7
Slice Namecomponent7
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30365) such that it

Control0..1
124. ClinicalDocument.component.structuredBody.component:component7.section
Comments

SHALL contain exactly one [1..1] Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30366).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Plan of Treatment Section)
126. ClinicalDocument.component.structuredBody.component:component8
Slice Namecomponent8
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30367) such that it

Control0..1
128. ClinicalDocument.component.structuredBody.component:component8.section
Comments

SHALL contain exactly one [1..1] Allergies and Intolerances Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.6.1:2015-08-01) (CONF:1198-30368).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Allergies and Intolerances Section)
130. ClinicalDocument.component.structuredBody.component:component9
Slice Namecomponent9
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30369) such that it

Control0..1
132. ClinicalDocument.component.structuredBody.component:component9.section
Comments

SHALL contain exactly one [1..1] Anesthesia Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.25:2014-06-09) (CONF:1198-30370).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Anesthesia Section)
134. ClinicalDocument.component.structuredBody.component:component10
Slice Namecomponent10
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30371) such that it

Control0..1
136. ClinicalDocument.component.structuredBody.component:component10.section
Comments

SHALL contain exactly one [1..1] Chief Complaint Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:1198-30372).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Chief Complaint Section)
138. ClinicalDocument.component.structuredBody.component:component11
Slice Namecomponent11
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30373) such that it

Control0..1
140. ClinicalDocument.component.structuredBody.component:component11.section
Comments

SHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.13) (CONF:1198-30374).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Chief Complaint and Reason for Visit Section)
142. ClinicalDocument.component.structuredBody.component:component12
Slice Namecomponent12
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30375) such that it

Control0..1
144. ClinicalDocument.component.structuredBody.component:component12.section
Comments

SHALL contain exactly one [1..1] Family History Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.15:2015-08-01) (CONF:1198-30376).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Family History Section)
146. ClinicalDocument.component.structuredBody.component:component13
Slice Namecomponent13
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30377) such that it

Control0..1
148. ClinicalDocument.component.structuredBody.component:component13.section
Comments

SHALL contain exactly one [1..1] Past Medical History (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.20:2015-08-01) (CONF:1198-30378).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Past Medical History)
150. ClinicalDocument.component.structuredBody.component:component14
Slice Namecomponent14
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30379) such that it

Control0..1
152. ClinicalDocument.component.structuredBody.component:component14.section
Comments

SHALL contain exactly one [1..1] History of Present Illness Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:1198-30380).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(History of Present Illness Section)
154. ClinicalDocument.component.structuredBody.component:component15
Slice Namecomponent15
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30381) such that it

Control0..1
156. ClinicalDocument.component.structuredBody.component:component15.section
Comments

SHALL contain exactly one [1..1] Medical (General) History Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.39) (CONF:1198-30382).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medical (General) History Section)
158. ClinicalDocument.component.structuredBody.component:component16
Slice Namecomponent16
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30383) such that it

Control0..1
160. ClinicalDocument.component.structuredBody.component:component16.section
Comments

SHALL contain exactly one [1..1] Medications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1.1:2014-06-09) (CONF:1198-30384).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medications Section)
162. ClinicalDocument.component.structuredBody.component:component17
Slice Namecomponent17
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30388) such that it

Control0..1
164. ClinicalDocument.component.structuredBody.component:component17.section
Comments

SHALL contain exactly one [1..1] Medications Administered Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.38:2014-06-09) (CONF:1198-30389).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medications Administered Section)
166. ClinicalDocument.component.structuredBody.component:component18
Slice Namecomponent18
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30390) such that it

Control0..1
168. ClinicalDocument.component.structuredBody.component:component18.section
Comments

SHALL contain exactly one [1..1] Physical Exam Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.2.10:2015-08-01) (CONF:1198-30391).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Physical Exam Section)
170. ClinicalDocument.component.structuredBody.component:component19
Slice Namecomponent19
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30392) such that it

Control0..1
172. ClinicalDocument.component.structuredBody.component:component19.section
Comments

SHALL contain exactly one [1..1] Planned Procedure Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.30:2014-06-09) (CONF:1198-30393).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Planned Procedure Section)
174. ClinicalDocument.component.structuredBody.component:component20
Slice Namecomponent20
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30394) such that it

Control0..1
176. ClinicalDocument.component.structuredBody.component:component20.section
Comments

SHALL contain exactly one [1..1] Procedure Disposition Section (identifier: urn:oid:2.16.840.1.113883.10.20.18.2.12) (CONF:1198-30395).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Disposition Section)
178. ClinicalDocument.component.structuredBody.component:component21
Slice Namecomponent21
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30396) such that it

Control0..1
180. ClinicalDocument.component.structuredBody.component:component21.section
Comments

SHALL contain exactly one [1..1] Procedure Estimated Blood Loss Section (identifier: urn:oid:2.16.840.1.113883.10.20.18.2.9) (CONF:1198-30397).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Estimated Blood Loss Section)
182. ClinicalDocument.component.structuredBody.component:component22
Slice Namecomponent22
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30398) such that it

Control0..1
184. ClinicalDocument.component.structuredBody.component:component22.section
Comments

SHALL contain exactly one [1..1] Procedure Findings Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.28:2015-08-01) (CONF:1198-30399).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Findings Section)
186. ClinicalDocument.component.structuredBody.component:component23
Slice Namecomponent23
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30400) such that it

Control0..1
188. ClinicalDocument.component.structuredBody.component:component23.section
Comments

SHALL contain exactly one [1..1] Procedure Implants Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.40) (CONF:1198-30401).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Implants Section)
190. ClinicalDocument.component.structuredBody.component:component24
Slice Namecomponent24
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30402) such that it

Control0..1
192. ClinicalDocument.component.structuredBody.component:component24.section
Comments

SHALL contain exactly one [1..1] Procedure Specimens Taken Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.31) (CONF:1198-30403).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Specimens Taken Section)
194. ClinicalDocument.component.structuredBody.component:component25
Slice Namecomponent25
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30404) such that it

Control0..1
196. ClinicalDocument.component.structuredBody.component:component25.section
Comments

SHALL contain exactly one [1..1] Procedures Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.7.1:2014-06-09) (CONF:1198-30405).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedures Section)
198. ClinicalDocument.component.structuredBody.component:component26
Slice Namecomponent26
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30406) such that it

Control0..1
200. ClinicalDocument.component.structuredBody.component:component26.section
Comments

SHALL contain exactly one [1..1] Reason for Visit Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30407).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Reason for Visit Section)
202. ClinicalDocument.component.structuredBody.component:component27
Slice Namecomponent27
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30408) such that it

Control0..1
204. ClinicalDocument.component.structuredBody.component:component27.section
Comments

SHALL contain exactly one [1..1] Review of Systems Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:1198-30409).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Review of Systems Section)
206. ClinicalDocument.component.structuredBody.component:component28
Slice Namecomponent28
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30410) such that it

Control0..1
208. ClinicalDocument.component.structuredBody.component:component28.section
Comments

SHALL contain exactly one [1..1] Social History Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2015-08-01) (CONF:1198-30411).

Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Social History Section)

Guidance on how to interpret the contents of this table can be found here

0. ClinicalDocument
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Control10..1*
Is Modifierfalse
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
2. ClinicalDocument.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Comments

SHALL contain exactly one [1..1] realmCode="US" (CONF:4537-16791).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
4. ClinicalDocument.realmCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control1..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
Pattern ValueUS
6. ClinicalDocument.realmCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..0
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
8. ClinicalDocument.realmCode.codeSystemName
Definition

The common name of the coding system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
10. ClinicalDocument.realmCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
12. ClinicalDocument.realmCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
14. ClinicalDocument.realmCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
16. ClinicalDocument.realmCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
18. ClinicalDocument.realmCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
20. ClinicalDocument.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Comments

SHALL contain exactly one [1..1] typeId (CONF:4537-5361).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
22. ClinicalDocument.typeId.root
Comments

This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" (CONF:4537-5250).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed Value2.16.840.1.113883.1.3
24. ClinicalDocument.typeId.extension
Definition

An Extension

ShortExtension
Comments

This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:4537-5251).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePOCD_HD000040
26. ClinicalDocument.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control2..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
SlicingThis element introduces a set of slices on ClinicalDocument.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
28. ClinicalDocument.templateId:us-realm
Slice Nameus-realm
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

ShorttemplateId
Comments

SHALL contain exactly one [1..1] templateId (CONF:4537-5252) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
30. ClinicalDocument.templateId:us-realm.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Comments

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1" (CONF:4537-10036).

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Pattern Value2.16.840.1.113883.10.20.22.1.1
32. ClinicalDocument.templateId:us-realm.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Comments

SHALL contain exactly one [1..1] @extension="2023-05-01" (CONF:4537-32503).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Pattern Value2023-05-01
34. ClinicalDocument.templateId:secondary
Slice Namesecondary
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Comments

SHALL contain exactly one [1..1] templateId (CONF:1198-8496) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
36. ClinicalDocument.templateId:secondary.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Comments

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.6" (CONF:1198-10050).

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Pattern Value2.16.840.1.113883.10.20.22.1.6
38. ClinicalDocument.templateId:secondary.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Comments

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32520).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Pattern Value2015-08-01
40. ClinicalDocument.id
Comments

SHALL contain exactly one [1..1] id (CONF:4537-5363).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
Invariants4537-9991: This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). ()
42. ClinicalDocument.code
ShortThe Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", 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.
Comments

SHALL contain exactly one [1..1] code (CONF:1198-17182).

Control1..1
BindingUnless not suitable, these codes SHALL be taken from FHIRDocumentTypeCodes
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
Invariants4537-9992: This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). ()
4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). ()
44. ClinicalDocument.code.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Comments

This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureNoteDocumentTypeCodes http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.6.1 DYNAMIC (CONF:1198-17183).

Control1..1
BindingThe codes SHALL be taken from ProcedureNoteDocumentTypeCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
46. ClinicalDocument.code.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
48. ClinicalDocument.title
ShortThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
Comments

SHALL contain exactly one [1..1] title (CONF:4537-5254).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
50. ClinicalDocument.effectiveTime
Definition

A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5256).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS(US Realm Date and Time (DTM.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-10127: **SHALL** be precise to the day (CONF:81-10127). ()
81-10128: **SHOULD** be precise to the minute (CONF:81-10128). ()
81-10129: **MAY** be precise to the second (CONF:81-10129). ()
81-10130: If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). ()
52. ClinicalDocument.confidentialityCode
Comments

SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926 DYNAMIC (CONF:4537-5259).

Control1..1
BindingThe codes SHOULD be taken from HL7 BasicConfidentialityKind
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
54. ClinicalDocument.languageCode
Comments

SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:4537-5372).

Control1..1
BindingThe codes SHALL be taken from VSAC 2.16.840.1.113883.1.11.11526
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
56. ClinicalDocument.recordTarget
Comments

SHALL contain at least one [1..*] recordTarget (CONF:4537-5266).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
58. ClinicalDocument.recordTarget.patientRole
Comments

Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:4537-5267).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PatientRole
60. ClinicalDocument.recordTarget.patientRole.id
Comments

This patientRole SHALL contain at least one [1..*] id (CONF:4537-5268).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
62. ClinicalDocument.recordTarget.patientRole.addr
Definition

Mailing and home or office addresses. A sequence of address parts, such as street or post office Box, city, postal code, country, etc.

ShortBase for all types and resources
Comments

This patientRole SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5271).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD(US Realm Address (AD.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296). ()
64. ClinicalDocument.recordTarget.patientRole.telecom
Comments

This patientRole SHALL contain at least one [1..*] telecom (CONF:4537-5280).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
66. ClinicalDocument.recordTarget.patientRole.telecom.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Comments

Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-5375).

Control0..1
BindingThe codes SHALL be taken from Telecom Use (US Realm Header)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUse Code
68. ClinicalDocument.recordTarget.patientRole.patient
Comments

This patientRole SHALL contain exactly one [1..1] patient (CONF:4537-5283).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Patient
70. ClinicalDocument.recordTarget.patientRole.patient.name
Definition

A name for a person. A sequence of name parts, such as given name or family name, prefix, suffix, etc. Examples for person name values are "Jim Bob Walton, Jr.", "Adam Everyman", etc. A person name may be as simple as a character string or may consist of several person name parts, such as, "Jim", "Bob", "Walton", and "Jr.". PN differs from EN because the qualifier type cannot include LS (Legal Status).


A name associated with the individual.

ShortBase for all types and resourcesA name associated with the patient
Comments

This patient SHALL contain at least one [1..*] US Realm Patient Name (PTN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1) (CONF:4537-5284).


A patient may have multiple names with different uses or applicable periods. For animals, the name is a "HumanName" in the sense that is assigned and used by humans and has the same patterns. Animal names may be communicated as given names, and optionally may include a family name.

Control10..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PNHumanName(US Realm Patient Name (PTN.US.FIELDED))
Is Modifierfalse
Requirements

Need to be able to track the patient by multiple names. Examples are your official name and a partner name.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
pn-no-ls: No PN name part may have a qualifier of LS. ((delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty())
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278). ()
72. ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode
Comments

This patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1 DYNAMIC (CONF:4537-6394).

Control1..1
BindingThe codes SHALL be taken from Administrative Gender (HL7 V3)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
74. ClinicalDocument.recordTarget.patientRole.patient.birthTime
Comments

This patient SHALL contain exactly one [1..1] birthTime (CONF:4537-5298).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
Invariants4537-5299: **SHALL** be precise to year (CONF:4537-5299). ()
4537-5300: **SHOULD** be precise to day (CONF:4537-5300). ()
4537-32418: **MAY** be precise to the minute (CONF:4537-32418). ()
76. ClinicalDocument.recordTarget.patientRole.patient.raceCode
Comments

This patient SHALL contain exactly one [1..1] raceCode, which SHALL be selected from ValueSet Race Category Excluding Nulls urn:oid:2.16.840.1.113883.3.2074.1.1.3 DYNAMIC (CONF:4537-5322).

Control1..1
BindingThe codes SHALL be taken from Race Category Excluding Nulls
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
78. ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode
Comments

This patient SHALL contain exactly one [1..1] ethnicGroupCode, which SHALL be selected from ValueSet Ethnicity urn:oid:2.16.840.1.114222.4.11.837 DYNAMIC (CONF:4537-5323).

Control1..1
BindingThe codes SHALL be taken from Ethnicity
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
80. ClinicalDocument.author
Comments

SHALL contain at least one [1..*] author (CONF:4537-5444).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author
82. ClinicalDocument.author.time
Definition

A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.

ShortBase for all types and resources
Comments

Such authors SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5445).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS(US Realm Date and Time (DTM.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-10127: **SHALL** be precise to the day (CONF:81-10127). ()
81-10128: **SHOULD** be precise to the minute (CONF:81-10128). ()
81-10129: **MAY** be precise to the second (CONF:81-10129). ()
81-10130: If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). ()
84. ClinicalDocument.author.assignedAuthor
Comments

Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:4537-5448).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssignedAuthor
Invariants4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). ()
86. ClinicalDocument.author.assignedAuthor.id
Comments

This assignedAuthor SHOULD contain zero or one [0..1] id (CONF:4537-32882) such that it, This assignedAuthor SHALL contain at least one [1..*] id (CONF:4537-5449).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
SlicingThis element introduces a set of slices on ClinicalDocument.author.assignedAuthor.id. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ root
88. ClinicalDocument.author.assignedAuthor.id:id1
Slice Nameid1
Shortid
Comments

This assignedAuthor SHOULD contain zero or one [0..1] id (CONF:4537-32882) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
90. ClinicalDocument.author.assignedAuthor.id:id1.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Comments

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-32884).

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Pattern Value2.16.840.1.113883.4.6
92. ClinicalDocument.author.assignedAuthor.addr
Definition

Mailing and home or office addresses. A sequence of address parts, such as street or post office Box, city, postal code, country, etc.

ShortBase for all types and resources
Comments

This assignedAuthor SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5452).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD(US Realm Address (AD.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296). ()
94. ClinicalDocument.author.assignedAuthor.telecom
Comments

This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:4537-5428).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
96. ClinicalDocument.author.assignedAuthor.telecom.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Comments

Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7995).

Control0..1
BindingThe codes SHALL be taken from Telecom Use (US Realm Header)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUse Code
98. ClinicalDocument.informant
Comments

MAY contain zero or more [0..*] informant (CONF:4537-31355) such that it

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
SlicingThis element introduces a set of slices on ClinicalDocument.informant. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ relatedEntity
100. ClinicalDocument.informant:informant1
Slice Nameinformant1
Shortinformant
Comments

MAY contain zero or more [0..*] informant (CONF:4537-8001) such that it

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
102. ClinicalDocument.informant:informant1.assignedEntity
Comments

SHALL contain exactly one [1..1] assignedEntity (CONF:4537-8002).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssignedEntity
104. ClinicalDocument.informant:informant1.assignedEntity.id
Comments

This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-9945).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
Invariants4537-9946: 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). ()
106. ClinicalDocument.informant:informant1.assignedEntity.addr
Definition

Mailing and home or office addresses. A sequence of address parts, such as street or post office Box, city, postal code, country, etc.

ShortBase for all types and resources
Comments

This assignedEntity SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-8220).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD(US Realm Address (AD.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296). ()
108. ClinicalDocument.informant:informant1.assignedEntity.assignedPerson
Comments

This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:4537-8221).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Person
110. ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name
Definition

A name for a person. A sequence of name parts, such as given name or family name, prefix, suffix, etc. Examples for person name values are "Jim Bob Walton, Jr.", "Adam Everyman", etc. A person name may be as simple as a character string or may consist of several person name parts, such as, "Jim", "Bob", "Walton", and "Jr.". PN differs from EN because the qualifier type cannot include LS (Legal Status).


A name associated with the person.

ShortBase for all types and resourcesA name associated with the person
Comments

This assignedPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-8222).


Person may have multiple names with different uses or applicable periods.

Control10..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PNHumanName(US Realm Person Name (PN.US.FIELDED))
Is Modifierfalse
Requirements

Need to be able to track the person by multiple names. Examples are your official name and a partner name.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
pn-no-ls: No PN name part may have a qualifier of LS. ((delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty())
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). ()
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). ()
112. ClinicalDocument.informant:informant2
Slice Nameinformant2
Shortinformant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
114. ClinicalDocument.informant:informant2.relatedEntity
Comments

SHALL contain exactly one [1..1] relatedEntity (CONF:4537-31356).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RelatedEntity
116. ClinicalDocument.custodian
Comments

SHALL contain exactly one [1..1] custodian (CONF:4537-5519).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Custodian
118. ClinicalDocument.custodian.assignedCustodian
Comments

This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:4537-5520).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssignedCustodian
120. ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization
Comments

This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:4537-5521).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CustodianOrganization
122. ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id
Comments

This representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:4537-5522).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
124. ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.name
Comments

This representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:4537-5524).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ON
126. ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom
Comments

This representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:4537-5525).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
128. ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Comments

This telecom SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7998).

Control0..1
BindingThe codes SHALL be taken from Telecom Use (US Realm Header)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUse Code
130. ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr
Definition

Mailing and home or office addresses. A sequence of address parts, such as street or post office Box, city, postal code, country, etc.

ShortBase for all types and resources
Comments

This representedCustodianOrganization SHALL contain exactly one [1..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5559).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD(US Realm Address (AD.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296). ()
132. ClinicalDocument.authenticator
Comments

MAY contain zero or more [0..*] authenticator (CONF:4537-5607) such that it

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
SlicingThis element introduces a set of slices on ClinicalDocument.authenticator. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ ClinicalDocument.signatureCode
  • value @ ClinicalDocument.assignedEntity
  • value @ ClinicalDocument.time
134. ClinicalDocument.authenticator:authenticator1
Slice Nameauthenticator1
Shortauthenticator
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authenticator
136. ClinicalDocument.authenticator:authenticator1.time
Definition

A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5608).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS(US Realm Date and Time (DTM.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-10127: **SHALL** be precise to the day (CONF:81-10127). ()
81-10128: **SHOULD** be precise to the minute (CONF:81-10128). ()
81-10129: **MAY** be precise to the second (CONF:81-10129). ()
81-10130: If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). ()
138. ClinicalDocument.authenticator:authenticator1.signatureCode
Comments

SHALL contain exactly one [1..1] signatureCode (CONF:4537-5610).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
140. ClinicalDocument.authenticator:authenticator1.signatureCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Comments

This signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: HL7ParticipationSignature urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:4537-5611).

Control1..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
Pattern ValueS
142. ClinicalDocument.authenticator:authenticator1.signatureCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..0
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
144. ClinicalDocument.authenticator:authenticator1.signatureCode.codeSystemName
Definition

The common name of the coding system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
146. ClinicalDocument.authenticator:authenticator1.signatureCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
148. ClinicalDocument.authenticator:authenticator1.signatureCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
150. ClinicalDocument.authenticator:authenticator1.signatureCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
152. ClinicalDocument.authenticator:authenticator1.signatureCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
154. ClinicalDocument.authenticator:authenticator1.signatureCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
156. ClinicalDocument.authenticator:authenticator1.assignedEntity
Comments

SHALL contain exactly one [1..1] assignedEntity (CONF:4537-5612).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssignedEntity
158. ClinicalDocument.authenticator:authenticator1.assignedEntity.id
Comments

This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-5613).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
160. ClinicalDocument.authenticator:authenticator1.assignedEntity.addr
Definition

Mailing and home or office addresses. A sequence of address parts, such as street or post office Box, city, postal code, country, etc.

ShortBase for all types and resources
Comments

This assignedEntity SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5616).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD(US Realm Address (AD.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296). ()
162. ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom
Comments

This assignedEntity SHALL contain at least one [1..*] telecom (CONF:4537-5622).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
164. ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Comments

Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-8000).

Control0..1
BindingThe codes SHALL be taken from Telecom Use (US Realm Header)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUse Code
166. ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson
Comments

This assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:4537-5624).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Person
168. ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name
Definition

A name for a person. A sequence of name parts, such as given name or family name, prefix, suffix, etc. Examples for person name values are "Jim Bob Walton, Jr.", "Adam Everyman", etc. A person name may be as simple as a character string or may consist of several person name parts, such as, "Jim", "Bob", "Walton", and "Jr.". PN differs from EN because the qualifier type cannot include LS (Legal Status).


A name associated with the person.

ShortBase for all types and resourcesA name associated with the person
Comments

This assignedPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-5625).


Person may have multiple names with different uses or applicable periods.

Control10..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PNHumanName(US Realm Person Name (PN.US.FIELDED))
Is Modifierfalse
Requirements

Need to be able to track the person by multiple names. Examples are your official name and a partner name.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
pn-no-ls: No PN name part may have a qualifier of LS. ((delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty())
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). ()
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). ()
170. ClinicalDocument.participant
ShortThe participant element in the Procedure Note header follows the General Header Constraints for participants.
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
Invariants4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). ()
4537-10007: 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). ()
SlicingThis element introduces a set of slices on ClinicalDocument.participant. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ associatedEntity.classCode
  • value @ typeCode
  • value @ functionCode
172. ClinicalDocument.participant.associatedEntity
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssociatedEntity
174. ClinicalDocument.participant:participant1
Slice Nameparticipant1
Comments

MAY contain zero or more [0..*] participant (CONF:1198-8504) such that it

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant1
Invariants4537-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). ()
4537-10007: 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). ()
176. ClinicalDocument.participant:participant1.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="IND" Individual (CodeSystem: HL7ParticipationFunction urn:oid:2.16.840.1.113883.5.88 STATIC) (CONF:1198-8505).

Control1..1
BindingThe codes SHALL be taken from ParticipationType
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueIND
178. ClinicalDocument.participant:participant1.functionCode
Comments

SHALL contain exactly one [1..1] functionCode="PCP" Primary Care Physician (CodeSystem: HL7ParticipationFunction urn:oid:2.16.840.1.113883.5.88 STATIC) (CONF:1198-8506).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
180. ClinicalDocument.participant:participant1.functionCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control1..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
Pattern ValuePCP
182. ClinicalDocument.participant:participant1.functionCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
184. ClinicalDocument.participant:participant1.associatedEntity
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssociatedEntity
186. ClinicalDocument.participant:participant1.associatedEntity.classCode
Comments

SHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8507).

Control1..1
BindingThe codes SHALL be taken from RoleClassAssociative
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePROV
188. ClinicalDocument.participant:participant1.associatedEntity.associatedPerson
Comments

This associatedEntity/@classCode SHALL contain exactly one [1..1] associatedPerson (CONF:1198-8508).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Person
190. ClinicalDocument.documentationOf
ShortA serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
Comments

MAY contain zero or more [0..*] documentationOf (CONF:4537-14835).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
SlicingThis element introduces a set of slices on ClinicalDocument.documentationOf. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ serviceEvent
192. ClinicalDocument.documentationOf.serviceEvent
Comments

The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:4537-14836).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ServiceEvent
194. ClinicalDocument.documentationOf.serviceEvent.classCode
Control1..1
BindingThe codes SHALL be taken from ActClass
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Default ValueACT
196. ClinicalDocument.documentationOf.serviceEvent.effectiveTime
Comments

This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:4537-14837).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
198. ClinicalDocument.documentationOf.serviceEvent.effectiveTime.low
Definition

This is the low limit of the interval.

Comments

This effectiveTime SHALL contain exactly one [1..1] low (CONF:4537-14838).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVXB-TS
LabelLow Boundary
200. ClinicalDocument.documentationOf.serviceEvent.performer
ShortThis performer identifies any assistants.
Comments

This serviceEvent SHOULD contain zero or more [0..*] performer (CONF:4537-14839).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Performer1
SlicingThis element introduces a set of slices on ClinicalDocument.documentationOf.serviceEvent.performer. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ assignedEntity
  • value @ typeCode
202. ClinicalDocument.documentationOf.serviceEvent.performer.typeCode
Comments

The performer, if present, SHALL contain exactly one [1..1] @typeCode, which SHALL be selected from ValueSet x_ServiceEventPerformer urn:oid:2.16.840.1.113883.1.11.19601 STATIC (CONF:4537-14840).

Control1..1
BindingThe codes SHALL be taken from x_ServiceEventPerformer
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
204. ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity
Comments

The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:4537-14841).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssignedEntity
206. ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id
Comments

This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-14846).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
208. ClinicalDocument.documentationOf.serviceEvent.performer:performer1
Slice Nameperformer1
ShortThis performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
Comments

This serviceEvent SHALL contain exactly one [1..1] performer (CONF:1198-8520) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Performer1
210. ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="PPRF" Primary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8521).

Control1..1
BindingThe codes SHALL be taken from x_ServiceEventPerformer
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePPRF
212. ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity
Comments

SHALL contain exactly one [1..1] assignedEntity (CONF:1198-14911).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssignedEntity
214. ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.id
Comments

This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-14846).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
216. ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code
Comments

This assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-14912).

Control0..1
BindingThe codes SHALL be taken from Healthcare Provider Taxonomy
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
218. ClinicalDocument.documentationOf.serviceEvent.performer:performer2
Slice Nameperformer2
Comments

This serviceEvent MAY contain zero or more [0..*] performer (CONF:1198-32732) such that it

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Performer1
220. ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="SPRF" Secondary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-32734).

Control1..1
BindingThe codes SHALL be taken from x_ServiceEventPerformer
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueSPRF
222. ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity
Comments

SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32733).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AssignedEntity
224. ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id
Comments

This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-14846).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
226. ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code
Comments

This assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32735).

Control0..1
BindingThe codes SHALL be taken from Healthcare Provider Taxonomy
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
228. ClinicalDocument.documentationOf:documentationOf1
Slice NamedocumentationOf1
Comments

SHALL contain at least one [1..*] documentationOf (CONF:1198-8510) such that it

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/DocumentationOf
230. ClinicalDocument.documentationOf:documentationOf1.serviceEvent
Comments

SHALL contain exactly one [1..1] serviceEvent (CONF:1198-10061).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ServiceEvent
Invariants1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). ()
232. ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode
Control1..1
BindingThe codes SHALL be taken from ActClass
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Default ValueACT
234. ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime
Definition

A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.

ShortBase for all types and resources
Comments

This serviceEvent SHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:1198-10062).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS(US Realm Date and Time (DT.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ivl-ts-center: Center cannot co-exist with low or high (center.empty() or (low.empty() and high.empty()))
81-10078: **SHALL** be precise to the day (CONF:81-10078). ()
81-10079: **SHOULD** be precise to the minute (CONF:81-10079). ()
81-10080: **MAY** be precise to the second (CONF:81-10080). ()
81-10081: If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). ()
1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). ()
1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). ()
1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). ()
236. ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.low
Definition

This is the low limit of the interval.

Comments

This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-26449).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVXB-TS
LabelLow Boundary
238. ClinicalDocument.authorization
ShortAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
Comments

MAY contain zero or one [0..1] authorization (CONF:1198-32412).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Authorization
240. ClinicalDocument.authorization.typeCode
Comments

The authorization, if present, SHALL contain exactly one [1..1] @typeCode="AUTH" authorized by (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-32413).

Control1..1
BindingThe codes SHALL be taken from ParticipationType
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueAUTH
242. ClinicalDocument.authorization.consent
Comments

The authorization, if present, SHALL contain exactly one [1..1] consent (CONF:1198-32414).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Consent
244. ClinicalDocument.authorization.consent.classCode
Comments

This consent SHALL contain exactly one [1..1] @classCode="CONS" consent (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-32415).

Control1..1
BindingThe codes SHALL be taken from ActClass
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueCONS
246. ClinicalDocument.authorization.consent.moodCode
Comments

This consent SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-32416).

Control1..1
BindingThe codes SHALL be taken from ActMood
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN
248. ClinicalDocument.authorization.consent.statusCode
Comments

This consent SHALL contain exactly one [1..1] statusCode (CONF:1198-32417).

Control1..1
BindingThe codes SHALL be taken from ActStatus
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
250. ClinicalDocument.authorization.consent.statusCode.code
Comments

This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:4537-16798).

Control1..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed Valuecompleted
252. ClinicalDocument.componentOf
Comments

SHOULD contain zero or one [0..1] componentOf (CONF:1198-30871).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ComponentOf
254. ClinicalDocument.componentOf.encompassingEncounter
Comments

The componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-30872).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/EncompassingEncounter
256. ClinicalDocument.componentOf.encompassingEncounter.id
ShortSG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
Comments

This encompassingEncounter SHOULD contain zero or more [0..*] id (CONF:1198-32395).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
258. ClinicalDocument.componentOf.encompassingEncounter.code
Comments

This encompassingEncounter SHALL contain exactly one [1..1] code (CONF:1198-30873).

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ActEncounterCode
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
260. ClinicalDocument.componentOf.encompassingEncounter.effectiveTime
Comments

This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:4537-9958).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
262. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/EncounterParticipant
SlicingThis element introduces a set of slices on ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ typeCode
264. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1
Slice NameencounterParticipant1
Comments

This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (CONF:1198-30874) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/EncounterParticipant
266. ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="REF" Referrer (CONF:1198-30875).

Control1..1
BindingThe codes SHALL be taken from ParticipationType
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueREF
268. ClinicalDocument.componentOf.encompassingEncounter.location
Definition

The location participant (location class) relates a healthcare facility (HealthCareFacility class) to the encounter to indicate where the encounter took place. The entity playing the role of HealthCareFacility is a place (Place class). The entity scoping the HealthCareFacility role is an organization (Organization class).

ShortSG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
Comments

This encompassingEncounter SHALL contain at least one [1..*] location (CONF:1198-30876).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
270. ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility
Comments

Such locations SHALL contain exactly one [1..1] healthCareFacility (CONF:1198-30877).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/HealthCareFacility
272. ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCode
Control1..1
BindingThe codes SHALL be taken from RoleClassServiceDeliveryLocation
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Default ValueSDLOC
274. ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.id
Comments

This healthCareFacility SHALL contain at least one [1..*] id (CONF:1198-30878).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
276. ClinicalDocument.component
Comments

SHALL contain exactly one [1..1] component (CONF:1198-9588).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Component
278. ClinicalDocument.component.structuredBody
Comments

This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30352).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/StructuredBody
Invariants1198-30412: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30412). ()
1198-30414: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30414). ()
1198-30415: 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:1198-30415). ()
280. ClinicalDocument.component.structuredBody.component
Control5..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ClinicalDocument.component.structuredBody.component. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ ClinicalDocument.section
282. ClinicalDocument.component.structuredBody.component.section
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section
284. ClinicalDocument.component.structuredBody.component:component1
Slice Namecomponent1
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30353).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
286. ClinicalDocument.component.structuredBody.component:component1.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

This component SHALL contain exactly one [1..1] Complications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.37:2015-08-01) (CONF:1198-30387).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Complications Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
288. ClinicalDocument.component.structuredBody.component:component2
Slice Namecomponent2
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30355) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
290. ClinicalDocument.component.structuredBody.component:component2.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedure Description Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.27) (CONF:1198-30356).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Description Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
292. ClinicalDocument.component.structuredBody.component:component3
Slice Namecomponent3
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30357) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
294. ClinicalDocument.component.structuredBody.component:component3.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedure Indications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.29:2014-06-09) (CONF:1198-30358).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Indications Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
296. ClinicalDocument.component.structuredBody.component:component4
Slice Namecomponent4
Comments

This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-30359) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
298. ClinicalDocument.component.structuredBody.component:component4.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Postprocedure Diagnosis Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.36:2015-08-01) (CONF:1198-30360).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Postprocedure Diagnosis Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
300. ClinicalDocument.component.structuredBody.component:component5
Slice Namecomponent5
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30361) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
302. ClinicalDocument.component.structuredBody.component:component5.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Assessment Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.8) (CONF:1198-30362).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Assessment Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
304. ClinicalDocument.component.structuredBody.component:component6
Slice Namecomponent6
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30363) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
306. ClinicalDocument.component.structuredBody.component:component6.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Assessment and Plan Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.9:2014-06-09) (CONF:1198-30364).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Assessment and Plan Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
308. ClinicalDocument.component.structuredBody.component:component7
Slice Namecomponent7
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30365) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
310. ClinicalDocument.component.structuredBody.component:component7.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Plan of Treatment Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30366).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Plan of Treatment Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
312. ClinicalDocument.component.structuredBody.component:component8
Slice Namecomponent8
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30367) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
314. ClinicalDocument.component.structuredBody.component:component8.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Allergies and Intolerances Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.6.1:2015-08-01) (CONF:1198-30368).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Allergies and Intolerances Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
316. ClinicalDocument.component.structuredBody.component:component9
Slice Namecomponent9
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30369) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
318. ClinicalDocument.component.structuredBody.component:component9.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Anesthesia Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.25:2014-06-09) (CONF:1198-30370).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Anesthesia Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
320. ClinicalDocument.component.structuredBody.component:component10
Slice Namecomponent10
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30371) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
322. ClinicalDocument.component.structuredBody.component:component10.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Chief Complaint Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) (CONF:1198-30372).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Chief Complaint Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
324. ClinicalDocument.component.structuredBody.component:component11
Slice Namecomponent11
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30373) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
326. ClinicalDocument.component.structuredBody.component:component11.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Chief Complaint and Reason for Visit Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.13) (CONF:1198-30374).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Chief Complaint and Reason for Visit Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
328. ClinicalDocument.component.structuredBody.component:component12
Slice Namecomponent12
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30375) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
330. ClinicalDocument.component.structuredBody.component:component12.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Family History Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.15:2015-08-01) (CONF:1198-30376).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Family History Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
332. ClinicalDocument.component.structuredBody.component:component13
Slice Namecomponent13
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30377) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
334. ClinicalDocument.component.structuredBody.component:component13.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Past Medical History (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.20:2015-08-01) (CONF:1198-30378).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Past Medical History)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
336. ClinicalDocument.component.structuredBody.component:component14
Slice Namecomponent14
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30379) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
338. ClinicalDocument.component.structuredBody.component:component14.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] History of Present Illness Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.3.4) (CONF:1198-30380).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(History of Present Illness Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
340. ClinicalDocument.component.structuredBody.component:component15
Slice Namecomponent15
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30381) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
342. ClinicalDocument.component.structuredBody.component:component15.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Medical (General) History Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.39) (CONF:1198-30382).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medical (General) History Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
344. ClinicalDocument.component.structuredBody.component:component16
Slice Namecomponent16
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30383) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
346. ClinicalDocument.component.structuredBody.component:component16.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Medications Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1.1:2014-06-09) (CONF:1198-30384).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medications Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
348. ClinicalDocument.component.structuredBody.component:component17
Slice Namecomponent17
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30388) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
350. ClinicalDocument.component.structuredBody.component:component17.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Medications Administered Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.38:2014-06-09) (CONF:1198-30389).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Medications Administered Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
352. ClinicalDocument.component.structuredBody.component:component18
Slice Namecomponent18
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30390) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
354. ClinicalDocument.component.structuredBody.component:component18.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Physical Exam Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.2.10:2015-08-01) (CONF:1198-30391).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Physical Exam Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
356. ClinicalDocument.component.structuredBody.component:component19
Slice Namecomponent19
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30392) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
358. ClinicalDocument.component.structuredBody.component:component19.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Planned Procedure Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.30:2014-06-09) (CONF:1198-30393).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Planned Procedure Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
360. ClinicalDocument.component.structuredBody.component:component20
Slice Namecomponent20
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30394) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
362. ClinicalDocument.component.structuredBody.component:component20.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedure Disposition Section (identifier: urn:oid:2.16.840.1.113883.10.20.18.2.12) (CONF:1198-30395).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Disposition Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
364. ClinicalDocument.component.structuredBody.component:component21
Slice Namecomponent21
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30396) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
366. ClinicalDocument.component.structuredBody.component:component21.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedure Estimated Blood Loss Section (identifier: urn:oid:2.16.840.1.113883.10.20.18.2.9) (CONF:1198-30397).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Estimated Blood Loss Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-8741: The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741). ()
368. ClinicalDocument.component.structuredBody.component:component22
Slice Namecomponent22
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30398) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
370. ClinicalDocument.component.structuredBody.component:component22.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedure Findings Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.28:2015-08-01) (CONF:1198-30399).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Findings Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
372. ClinicalDocument.component.structuredBody.component:component23
Slice Namecomponent23
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30400) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
374. ClinicalDocument.component.structuredBody.component:component23.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedure Implants Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.40) (CONF:1198-30401).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Implants Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-8769: The Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769). ()
376. ClinicalDocument.component.structuredBody.component:component24
Slice Namecomponent24
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30402) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
378. ClinicalDocument.component.structuredBody.component:component24.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedure Specimens Taken Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.31) (CONF:1198-30403).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedure Specimens Taken Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-8742: The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742). ()
380. ClinicalDocument.component.structuredBody.component:component25
Slice Namecomponent25
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30404) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
382. ClinicalDocument.component.structuredBody.component:component25.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Procedures Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.7.1:2014-06-09) (CONF:1198-30405).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Procedures Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
384. ClinicalDocument.component.structuredBody.component:component26
Slice Namecomponent26
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30406) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
386. ClinicalDocument.component.structuredBody.component:component26.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Reason for Visit Section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30407).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Reason for Visit Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
388. ClinicalDocument.component.structuredBody.component:component27
Slice Namecomponent27
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30408) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
390. ClinicalDocument.component.structuredBody.component:component27.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Review of Systems Section (identifier: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.3.18) (CONF:1198-30409).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Review of Systems Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
392. ClinicalDocument.component.structuredBody.component:component28
Slice Namecomponent28
Comments

This structuredBody MAY contain zero or one [0..1] component (CONF:1198-30410) such that it

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
394. ClinicalDocument.component.structuredBody.component:component28.section
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] Social History Section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2015-08-01) (CONF:1198-30411).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Section(Social History Section)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. ClinicalDocument
Definition

Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Control1..1
Is Modifierfalse
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
2. ClinicalDocument.classCode
Control0..1
BindingUnless not suitable, these codes SHALL be taken from ActClass
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDOCCLIN
4. ClinicalDocument.moodCode
Control0..1
BindingThe codes SHALL be taken from ActMood
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN
6. ClinicalDocument.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Comments

SHALL contain exactly one [1..1] realmCode="US" (CONF:4537-16791).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
8. ClinicalDocument.realmCode.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
10. ClinicalDocument.realmCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control1..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
Pattern ValueUS
12. ClinicalDocument.realmCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..0
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
14. ClinicalDocument.realmCode.codeSystemName
Definition

The common name of the coding system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
16. ClinicalDocument.realmCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
18. ClinicalDocument.realmCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
20. ClinicalDocument.realmCode.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring(oid: ISO Object Identifier)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
22. ClinicalDocument.realmCode.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
24. ClinicalDocument.realmCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
26. ClinicalDocument.realmCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
28. ClinicalDocument.realmCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
30. ClinicalDocument.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Comments

SHALL contain exactly one [1..1] typeId (CONF:4537-5361).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
32. ClinicalDocument.typeId.root
Comments

This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" (CONF:4537-5250).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed Value2.16.840.1.113883.1.3
34. ClinicalDocument.typeId.extension
Definition

An Extension

ShortExtension
Comments

This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:4537-5251).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePOCD_HD000040
36. ClinicalDocument.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control2..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
SlicingThis element introduces a set of slices on ClinicalDocument.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
38. ClinicalDocument.templateId:us-realm
Slice Nameus-realm
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

ShorttemplateId
Comments

SHALL contain exactly one [1..1] templateId (CONF:4537-5252) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
40. ClinicalDocument.templateId:us-realm.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
42. ClinicalDocument.templateId:us-realm.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
44. ClinicalDocument.templateId:us-realm.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
46. ClinicalDocument.templateId:us-realm.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Comments

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1" (CONF:4537-10036).

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Pattern Value2.16.840.1.113883.10.20.22.1.1
48. ClinicalDocument.templateId:us-realm.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Comments

SHALL contain exactly one [1..1] @extension="2023-05-01" (CONF:4537-32503).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Pattern Value2023-05-01
50. ClinicalDocument.templateId:secondary
Slice Namesecondary
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Comments

SHALL contain exactly one [1..1] templateId (CONF:1198-8496) such that it

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
52. ClinicalDocument.templateId:secondary.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
54. ClinicalDocument.templateId:secondary.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
56. ClinicalDocument.templateId:secondary.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
58. ClinicalDocument.templateId:secondary.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Comments

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.6" (CONF:1198-10050).

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Pattern Value2.16.840.1.113883.10.20.22.1.6
60. ClinicalDocument.templateId:secondary.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Comments

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32520).

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Pattern Value2015-08-01
62. ClinicalDocument.id
Comments

SHALL contain exactly one [1..1] id (CONF:4537-5363).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
Invariants4537-9991: This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). ()
64. ClinicalDocument.code
ShortThe Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", 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.
Comments

SHALL contain exactly one [1..1] code (CONF:1198-17182).

Control1..1
BindingUnless not suitable, these codes SHALL be taken from FHIRDocumentTypeCodes
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
Invariants4537-9992: This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). ()
4537-32948: This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). ()
66. ClinicalDocument.code.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
68. ClinicalDocument.code.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Comments

This code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureNoteDocumentTypeCodes http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.6.1 DYNAMIC (CONF:1198-17183).

Control1..1
BindingThe codes SHALL be taken from ProcedureNoteDocumentTypeCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
70. ClinicalDocument.code.codeSystem
Definition

Specifies the code system that defines the code.

Control0..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
72. ClinicalDocument.code.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
74. ClinicalDocument.code.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
76. ClinicalDocument.code.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
78. ClinicalDocument.code.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring(oid: ISO Object Identifier)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
80. ClinicalDocument.code.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
82. ClinicalDocument.code.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
84. ClinicalDocument.code.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
86. ClinicalDocument.code.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
88. ClinicalDocument.title
ShortThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
Comments

SHALL contain exactly one [1..1] title (CONF:4537-5254).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
90. ClinicalDocument.effectiveTime
Definition

A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.

ShortBase for all types and resources
Comments

SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:4537-5256).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS(US Realm Date and Time (DTM.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-10127: **SHALL** be precise to the day (CONF:81-10127). ()
81-10128: **SHOULD** be precise to the minute (CONF:81-10128). ()
81-10129: **MAY** be precise to the second (CONF:81-10129). ()
81-10130: If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). ()
92. ClinicalDocument.confidentialityCode
Comments

SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926 DYNAMIC (CONF:4537-5259).

Control1..1
BindingThe codes SHOULD be taken from HL7 BasicConfidentialityKind
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
94. ClinicalDocument.languageCode
Comments

SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:4537-5372).

Control1..1
BindingThe codes SHALL be taken from VSAC 2.16.840.1.113883.1.11.11526
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
96. ClinicalDocument.setId
Comments

MAY contain zero or one [0..1] setId (CONF:4537-5261).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
Invariants4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380). ()
98. ClinicalDocument.versionNumber
Comments

MAY contain zero or one [0..1] versionNumber (CONF:4537-5264).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
Invariants4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387). ()
100. ClinicalDocument.copyTime
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
102. ClinicalDocument.recordTarget
Comments

SHALL contain at least one [1..*] recordTarget (CONF:4537-5266).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/RecordTarget
104. ClinicalDocument.recordTarget.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
106. ClinicalDocument.recordTarget.typeCode
Control0..1
BindingThe codes SHALL be taken from ParticipationType
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueRCT
108. ClinicalDocument.recordTarget.contextControlCode
Control0..1
BindingThe codes SHALL be taken from ContextControl
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueOP
110. ClinicalDocument.recordTarget.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
112. ClinicalDocument.recordTarget.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
114. ClinicalDocument.recordTarget.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
116. ClinicalDocument.recordTarget.patientRole
Comments

Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:4537-5267).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PatientRole
118. ClinicalDocument.recordTarget.patientRole.classCode
Control0..1
BindingThe codes SHALL be taken from RoleClassRelationshipFormal
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePAT
120. ClinicalDocument.recordTarget.patientRole.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
122. ClinicalDocument.recordTarget.patientRole.id
Comments

This patientRole SHALL contain at least one [1..*] id (CONF:4537-5268).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
124. ClinicalDocument.recordTarget.patientRole.sdtcIdentifiedBy
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IdentifiedBy
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameidentifiedBy.
126. ClinicalDocument.recordTarget.patientRole.addr
Definition

Mailing and home or office addresses. A sequence of address parts, such as street or post office Box, city, postal code, country, etc.

ShortBase for all types and resources
Comments

This patientRole SHALL contain at least one [1..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5271).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD(US Realm Address (AD.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296). ()
128. ClinicalDocument.recordTarget.patientRole.telecom
Comments

This patientRole SHALL contain at least one [1..*] telecom (CONF:4537-5280).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
130. ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
132. ClinicalDocument.recordTarget.patientRole.telecom.value
Control0..1
Typeurl(url: Universal Resource Locator)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
134. ClinicalDocument.recordTarget.patientRole.telecom.useablePeriod
Definition

Specifies the periods of time during which the telecommunication address can be used. For a telephone number, this can indicate the time of day in which the party can be reached on that telephone. For a web address, it may specify a time range in which the web content is promised to be available under the given address.

Control0..*
TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS
Default Typehttp://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelUseable Period
136. ClinicalDocument.recordTarget.patientRole.telecom.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Comments

Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-5375).

Control0..1
BindingThe codes SHALL be taken from Telecom Use (US Realm Header)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUse Code
138. ClinicalDocument.recordTarget.patientRole.patient
Comments

This patientRole SHALL contain exactly one [1..1] patient (CONF:4537-5283).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Patient
140. ClinicalDocument.recordTarget.patientRole.patient.classCode
Control0..1
BindingThe codes SHALL be taken from EntityClassLivingSubject
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePSN
142. ClinicalDocument.recordTarget.patientRole.patient.determinerCode
Control0..1
BindingThe codes SHALL be taken from EntityDeterminer
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueINSTANCE
144. ClinicalDocument.recordTarget.patientRole.patient.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
146. ClinicalDocument.recordTarget.patientRole.patient.id
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
148. ClinicalDocument.recordTarget.patientRole.patient.name
Definition

A name for a person. A sequence of name parts, such as given name or family name, prefix, suffix, etc. Examples for person name values are "Jim Bob Walton, Jr.", "Adam Everyman", etc. A person name may be as simple as a character string or may consist of several person name parts, such as, "Jim", "Bob", "Walton", and "Jr.". PN differs from EN because the qualifier type cannot include LS (Legal Status).

ShortBase for all types and resources
Comments

This patient SHALL contain at least one [1..*] US Realm Patient Name (PTN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1) (CONF:4537-5284).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PN(US Realm Patient Name (PTN.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
pn-no-ls: No PN name part may have a qualifier of LS. ((delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty())
81-7278: **SHALL NOT** have mixed content except for white space (CONF:81-7278). ()
150. ClinicalDocument.recordTarget.patientRole.patient.sdtcDesc
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namedesc.
152. ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode
Comments

This patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1 DYNAMIC (CONF:4537-6394).

Control1..1
BindingThe codes SHALL be taken from Administrative Gender (HL7 V3)
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
154. ClinicalDocument.recordTarget.patientRole.patient.birthTime
Comments

This patient SHALL contain exactly one [1..1] birthTime (CONF:4537-5298).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
Invariants4537-5299: **SHALL** be precise to year (CONF:4537-5299). ()
4537-5300: **SHOULD** be precise to day (CONF:4537-5300). ()
4537-32418: **MAY** be precise to the minute (CONF:4537-32418). ()
156. ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd
Shortsdtc:deceasedInd
Comments

This patient MAY contain zero or one [0..1] sdtc:deceasedInd (CONF:4537-32990).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/BL
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namedeceasedInd.
Invariants4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). ()
158. ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime
Shortsdtc:deceasedTime
Comments

This patient MAY contain zero or one [0..1] sdtc:deceasedTime (CONF:4537-32988).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TS
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namedeceasedTime.
160. ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
162. ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value
Definition

A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.

Comments

The sdtc:deceasedTime, if present, SHOULD contain zero or one [0..1] @value (CONF:4537-32989).

Control0..1
Typestring(ts: Point in Time)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Date FormatYYYYMMDDHHMMSS.UUUU[+|-ZZzz]
XML FormatIn the XML format, this property is represented as an attribute.
Invariants4537-32991: **SHALL** be precise to to the year (CONF:4537-32991). ()
4537-32992: **SHOULD** be precise to the day (CONF:4537-32992). ()
164. ClinicalDocument.recordTarget.patientRole.patient.sdtcMultipleBirthInd
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/BL
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namemultipleBirthInd.
166. ClinicalDocument.recordTarget.patientRole.patient.sdtcMultipleBirthOrderNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT-POS
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namemultipleBirthOrderNumber.
168. ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode
Comments

This patient SHOULD contain zero or one [0..1] maritalStatusCode, which SHALL be selected from ValueSet Marital Status urn:oid:2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:4537-5303).

Control0..1
BindingThe codes SHALL be taken from Marital Status
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
170. ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode
Comments

This patient MAY contain zero or one [0..1] religiousAffiliationCode, which SHALL be selected from ValueSet Religious Affiliation urn:oid:2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:4537-5317).

Control0..1
BindingThe codes SHALL be taken from Religious Affiliation
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
172. ClinicalDocument.recordTarget.patientRole.patient.raceCode
Comments

This patient SHALL contain exactly one [1..1] raceCode, which SHALL be selected from ValueSet Race Category Excluding Nulls urn:oid:2.16.840.1.113883.3.2074.1.1.3 DYNAMIC (CONF:4537-5322).

Control1..1
BindingThe codes SHALL be taken from Race Category Excluding Nulls
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
174. ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode
ShortThe 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.
Comments

This patient MAY contain zero or more [0..*] sdtc:raceCode, which SHALL be selected from ValueSet Race Value Set urn:oid:2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:4537-7263).

Control0..*
BindingThe codes SHALL be taken from Race Value Set
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameraceCode.
Invariants4537-31347: If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). ()
176. ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode
Comments

This patient SHALL contain exactly one [1..1] ethnicGroupCode, which SHALL be selected from ValueSet Ethnicity urn:oid:2.16.840.1.114222.4.11.837 DYNAMIC (CONF:4537-5323).

Control1..1
BindingThe codes SHALL be taken from Ethnicity
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
178. ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode
ShortethnicGroupCode
Comments

This patient MAY contain zero or more [0..*] ethnicGroupCode, which SHALL be selected from ValueSet Detailed Ethnicity urn:oid:2.16.840.1.114222.4.11.877 DYNAMIC (CONF:4537-32901).

Control0..*
BindingThe codes SHALL be taken from Detailed Ethnicity
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameethnicGroupCode.
180. ClinicalDocument.recordTarget.patientRole.patient.guardian
Comments

This patient MAY contain zero or more [0..*] guardian (CONF:4537-5325).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Guardian
182. ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode
Control0..1
BindingThe codes SHALL be taken from RoleClassAgent
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueGUARD
184. ClinicalDocument.recordTarget.patientRole.patient.guardian.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
186. ClinicalDocument.recordTarget.patientRole.patient.guardian.id
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
188. ClinicalDocument.recordTarget.patientRole.patient.guardian.sdtcIdentifiedBy
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IdentifiedBy
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameidentifiedBy.
190. ClinicalDocument.recordTarget.patientRole.patient.guardian.code
Comments

The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:4537-5326).

Control0..1
BindingThe codes SHALL be taken from Personal And Legal Relationship Role Type
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
192. ClinicalDocument.recordTarget.patientRole.patient.guardian.addr
Definition

Mailing and home or office addresses. A sequence of address parts, such as street or post office Box, city, postal code, country, etc.

ShortBase for all types and resources
Comments

The guardian, if present, SHOULD contain zero or more [0..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-5359).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD(US Realm Address (AD.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
81-7296: **SHALL NOT** have mixed content except for white space (CONF:81-7296). ()
194. ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom
Comments

The guardian, if present, SHOULD contain zero or more [0..*] telecom (CONF:4537-5382).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
196. ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
198. ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.value
Control0..1
Typeurl(url: Universal Resource Locator)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
200. ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.useablePeriod
Definition

Specifies the periods of time during which the telecommunication address can be used. For a telephone number, this can indicate the time of day in which the party can be reached on that telephone. For a web address, it may specify a time range in which the web content is promised to be available under the given address.

Control0..*
TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS
Default Typehttp://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelUseable Period
202. ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Comments

The telecom, if present, SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:4537-7993).

Control0..1
BindingThe codes SHALL be taken from Telecom Use (US Realm Header)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUse Code
204. ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson
Comments

The guardian, if present, SHALL contain exactly one [1..1] guardianPerson (CONF:4537-5385).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Person
206. ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode
Control0..1
BindingThe codes SHALL be taken from EntityClassLivingSubject
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePSN
208. ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode
Control0..1
BindingThe codes SHALL be taken from EntityDeterminer
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueINSTANCE
210. ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
212. ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name
Definition

A name for a person. A sequence of name parts, such as given name or family name, prefix, suffix, etc. Examples for person name values are "Jim Bob Walton, Jr.", "Adam Everyman", etc. A person name may be as simple as a character string or may consist of several person name parts, such as, "Jim", "Bob", "Walton", and "Jr.". PN differs from EN because the qualifier type cannot include LS (Legal Status).

ShortBase for all types and resources
Comments

This guardianPerson SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:4537-5386).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PN(US Realm Person Name (PN.US.FIELDED))
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
pn-no-ls: No PN name part may have a qualifier of LS. ((delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty())
81-9371: The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). ()
81-9372: The string **SHALL NOT** contain name parts (CONF:81-9372). ()
214. ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.sdtcAsPatientRelationship
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameasPatientRelationship.
216. ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianOrganization
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Organization
218. ClinicalDocument.recordTarget.patientRole.patient.birthplace
Comments

This patient MAY contain zero or one [0..1] birthplace (CONF:4537-5395).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Birthplace
220. ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode
Control0..1
BindingThe codes SHALL be taken from RoleClassPassive
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueBIRTHPL
222. ClinicalDocument.recordTarget.patientRole.patient.birthplace.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
224. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place
Comments

The birthplace, if present, SHALL contain exactly one [1..1] place (CONF:4537-5396).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Place
226. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode
Control0..1
BindingThe codes SHALL be taken from EntityClassPlace
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePLC
228. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode
Control0..1
BindingThe codes SHALL be taken from EntityDeterminer
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueINSTANCE
230. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
232. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.name
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/EN
234. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr
Comments

This place SHALL contain exactly one [1..1] addr (CONF:4537-5397).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/AD
Invariants4537-5402: 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: 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). ()
236. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

ShortPrimitive Type code
Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
LabelExceptional Value Detail
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cs-pattern: cs attributes must not contain any whitespace (matches('^[^\\s]+$'))
238. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.isNotOrdered
Definition

A boolean value specifying whether the order of the address parts is known or not. While the address parts are always a Sequence, the order in which they are presented may or may not be known. Where this matters, the isNotOrdered property can be used to convey this information.

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelIs Not Ordered
240. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.use
Definition

A set of codes advising a system or user which address in a set of like addresses to select for a given purpose.

Control0..*
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUse Code
242. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.delimiter
Definition

Delimiters are printed without framing white space. If no value component is provided, the delimiter appears as a line break.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
244. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.delimiter.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDEL
246. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.country
Definition

Country

Comments

This addr SHOULD contain zero or one [0..1] country, which SHALL be selected from ValueSet Country urn:oid:2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:4537-5404).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
248. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.country.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueCNT
250. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.state
Definition

A sub-unit of a country with limited sovereignty in a federally organized country.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
252. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.state.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueSTA
254. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.county
Definition

A sub-unit of a state or province. (49 of the United States of America use the term "county;" Louisiana uses the term "parish".)

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
256. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.county.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueCPA
258. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.city
Definition

The name of the city, town, village, or other community or delivery center

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
260. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.city.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueCTY
262. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postalCode
Definition

A postal code designating a region defined by the postal service.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
264. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postalCode.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueZIP
266. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetAddressLine
Definition

Street address line

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
268. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetAddressLine.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueSAL
270. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumber
Definition

The number of a building, house or lot alongside the street. Also known as "primary street number". This does not number the street but rather the building.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
272. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumber.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueBNR
274. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumberNumeric
Definition

The numeric portion of a building number

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
276. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.houseNumberNumeric.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueBNN
278. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.direction
Definition

Direction (e.g., N, S, W, E)

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
280. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.direction.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDIR
282. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetName
Definition

Name of a roadway or artery recognized by a municipality (including street type and direction)

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
284. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetName.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueSTR
286. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameBase
Definition

The base name of a roadway or artery recognized by a municipality (excluding street type and direction)

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
288. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameBase.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueSTB
290. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameType
Definition

The designation given to the street. (e.g. Street, Avenue, Crescent, etc.)

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
292. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.streetNameType.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueSTTYP
294. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.additionalLocator
Definition

This can be a unit designator, such as apartment number, suite number, or floor. There may be several unit designators in an address (e.g., "3rd floor, Appt. 342"). This can also be a designator pointing away from the location, rather than specifying a smaller location within some larger one (e.g., Dutch "t.o." means "opposite to" for house boats located across the street facing houses).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
296. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.additionalLocator.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueADL
298. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitID
Definition

The number or name of a specific unit contained within a building or complex, as assigned by that building or complex.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
300. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitID.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueUNID
302. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitType
Definition

Indicates the type of specific unit contained within a building or complex. E.g. Appartment, Floor

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
304. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.unitType.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueUNIT
306. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.careOf
Definition

The name of the party who will take receipt at the specified address, and will take on responsibility for ensuring delivery to the target recipient

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
308. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.careOf.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueCAR
310. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.censusTract
Definition

A geographic sub-unit delineated for demographic purposes.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
312. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.censusTract.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueCEN
314. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryAddressLine
Definition

A delivery address line is frequently used instead of breaking out delivery mode, delivery installation, etc. An address generally has only a delivery address line or a street address line, but not both.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
316. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryAddressLine.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDAL
318. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationType
Definition

Indicates the type of delivery installation (the facility to which the mail will be delivered prior to final shipping via the delivery mode.) Example: post office, letter carrier depot, community mail center, station, etc.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
320. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationType.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDINST
322. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationArea
Definition

The location of the delivery installation, usually a town or city, and is only required if the area is different from the municipality. Area to which mail delivery service is provided from any postal facility or service such as an individual letter carrier, rural route, or postal route.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
324. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationArea.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDINSTA
326. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationQualifier
Definition

A number, letter or name identifying a delivery installation. E.g., for Station A, the delivery installation qualifier would be 'A'.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
328. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryInstallationQualifier.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDINSTQ
330. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryMode
Definition

Indicates the type of service offered, method of delivery. For example: post office box, rural route, general delivery, etc.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
332. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryMode.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDMOD
334. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryModeIdentifier
Definition

Represents the routing information such as a letter carrier route number. It is the identifying number of the designator (the box number or rural route number).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
336. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.deliveryModeIdentifier.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueDMODID
338. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.buildingNumberSuffix
Definition

Any alphabetic character, fraction or other text that may appear after the numeric portion of a building number

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
340. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.buildingNumberSuffix.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueBNS
342. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postBox
Definition

A numbered box located in a post station.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
344. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.postBox.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePOB
346. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.precinct
Definition

A subsection of a municipality

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ADXP
348. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.precinct.partType
Definition

Specifies the type of the address part

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePRE
350. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.other
Definition

Textual representation of (part of) the address

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as unadorned text.
352. ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.useablePeriod
Definition

A General Timing Specification (GTS) specifying the periods of time during which the address can be used. This is used to specify different addresses for different times of the week or year.

Control0..*
TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS
Default Typehttp://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelUseable Period
354. ClinicalDocument.recordTarget.patientRole.patient.languageCommunication
Comments

This patient SHOULD contain zero or more [0..*] languageCommunication (CONF:4537-5406).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/LanguageCommunication
356. ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
358. ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode
Comments

The languageCommunication, if present, SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:4537-5407).

Control1..1
BindingThe codes SHALL be taken from VSAC 2.16.840.1.113883.1.11.11526
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
360. ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode
Comments

The languageCommunication, if present, MAY contain zero or one [0..1] modeCode, which SHALL be selected from ValueSet LanguageAbilityMode urn:oid:2.16.840.1.113883.1.11.12249 DYNAMIC (CONF:4537-5409).

Control0..1
BindingThe codes SHALL be taken from LanguageAbilityMode
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
362. ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode
Comments

The languageCommunication, if present, SHOULD contain zero or one [0..1] proficiencyLevelCode, which SHALL be selected from ValueSet LanguageAbilityProficiency urn:oid:2.16.840.1.113883.1.11.12199 DYNAMIC (CONF:4537-9965).

Control0..1
BindingThe codes SHALL be taken from LanguageAbilityProficiency
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
364. ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.preferenceInd
Comments

The languageCommunication, if present, SHOULD contain zero or one [0..1] preferenceInd (CONF:4537-5414).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/BL
366. ClinicalDocument.recordTarget.patientRole.providerOrganization
Comments

This patientRole MAY contain zero or one [0..1] providerOrganization (CONF:4537-5416).

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Organization
368. ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
370. ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode
Control0..1
BindingThe codes SHALL be taken from EntityClassOrganization
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueORG
372. ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode
Control0..1
BindingThe codes SHALL be taken from EntityDeterminer
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueINSTANCE
374. ClinicalDocument.recordTarget.patientRole.providerOrganization.realmCode
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
376. ClinicalDocument.recordTarget.patientRole.providerOrganization.typeId
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
378. ClinicalDocument.recordTarget.patientRole.providerOrganization.templateId