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: Procedure Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureNote Version: 2.1
Active as of 2023-09-29 Computable Name: ProcedureNote
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.6:2015-08-01

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient’s tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.

Usage:

  • This Logical Model is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... templateId 2..*II
... templateId:secondary 1..1II
.... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.6
.... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEThe 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.
.... code 1..1csBinding: ProcedureNoteDocumentTypeCodes (required)
.... participant:participant1 0..*Participant1
..... typeCode 1..1csFixed Value: IND
..... functionCode 1..1CE
...... code 1..1csRequired Pattern: PCP
..... associatedEntity
...... classCode 1..1csFixed Value: PROV
...... associatedPerson 1..1Person
... Slices for documentationOf 1..*DocumentationOfA 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.
Slice: Unordered, Open by value:serviceEvent
.... documentationOf:All Slices Content/Rules for all slices
..... serviceEvent
...... Slices for performer 1..*Performer1This performer identifies any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode
....... performer:performer1 1..1Performer1This 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.
........ typeCode 1..1csFixed Value: PPRF
........ assignedEntity 1..1AssignedEntity
......... code 0..1CEBinding: Healthcare Provider Taxonomy (required)
....... performer:performer2 0..*Performer1
........ typeCode 1..1csFixed Value: SPRF
........ assignedEntity 1..1AssignedEntity
......... code 0..1CEBinding: Healthcare Provider Taxonomy (required)
.... documentationOf:documentationOf1 1..*DocumentationOf
..... serviceEvent C1..1ServiceEvent1198-8511: 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).
...... effectiveTime C1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
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).
....... low 1..1IVXB_TS
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... typeCode 1..1cs
.... consent 1..1Consent
..... classCode 1..1cs
..... moodCode 1..1cs
..... statusCode 1..1CS
... componentOf 0..1ComponentOf
.... encompassingEncounter 1..1EncompassingEncounter
..... id 1..*IISG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..1CE
..... Slices for encounterParticipant 0..*EncounterParticipantSlice: Unordered, Open by value:typeCode
...... encounterParticipant:encounterParticipant1 0..1EncounterParticipant
....... typeCode 1..1csFixed Value: REF
..... location 1..1InfrastructureRootSG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
...... healthCareFacility 1..1HealthCareFacility
....... id 1..*II
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-30412: 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).
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by value:ClinicalDocument.section
...... component:component1 1..1InfrastructureRoot
....... section 1..1ComplicationsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component4 1..1InfrastructureRoot
....... section 1..1PostprocedureDiagnosisSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:component6 0..1InfrastructureRoot
....... section 1..1AssessmentandPlanSectionBase for all types and resources
...... component:component7 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component8 0..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:component9 0..1InfrastructureRoot
....... section 1..1AnesthesiaSectionBase for all types and resources
...... component:component10 0..1InfrastructureRoot
....... section 1..1ChiefComplaintSectionBase for all types and resources
...... component:component11 0..1InfrastructureRoot
....... section 1..1ChiefComplaintandReasonforVisitSectionBase for all types and resources
...... component:component12 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:component13 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:component14 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:component15 0..1InfrastructureRoot
....... section 1..1MedicalGeneralHistorySectionBase for all types and resources
...... component:component16 0..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:component17 0..1InfrastructureRoot
....... section 1..1MedicationsAdministeredSectionBase for all types and resources
...... component:component18 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:component19 0..1InfrastructureRoot
....... section 1..1PlannedProcedureSectionBase for all types and resources
...... component:component20 0..1InfrastructureRoot
....... section 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component21 0..1InfrastructureRoot
....... section 1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component22 0..1InfrastructureRoot
....... section 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component23 0..1InfrastructureRoot
....... section 1..1ProcedureImplantsSectionBase for all types and resources
...... component:component24 0..1InfrastructureRoot
....... section 1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component25 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:component26 0..1InfrastructureRoot
....... section 1..1ReasonforVisitSectionBase for all types and resources
...... component:component27 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:component28 0..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.code.coderequiredProcedureNoteDocumentTypeCodes
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf:documentationOf1.serviceEventThe 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).
:
1198-8513errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeThe serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513).
:
1198-8514errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeIf a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514).
:
1198-8515errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeWhen 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).
:
1198-30412errorClinicalDocument.component.structuredBodyThis 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).
:
1198-30414errorClinicalDocument.component.structuredBodyThis 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).
:
1198-30415errorClinicalDocument.component.structuredBodyThis 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).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... realmCode 1..1CS
.... @code 1..1csRequired Pattern: US
... typeId 1..1II
.... @root 1..1stFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stExtension
Fixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2023-05-01
.... templateId:secondary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.6
..... @extension 1..1stRequired Pattern: 2015-08-01
... code C1..1CEThe 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.
Binding: FHIRDocumentTypeCodes (extensible)
.... @code 1..1csBinding: ProcedureNoteDocumentTypeCodes (required)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... recordTarget 1..*RecordTarget
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
... author 1..*Author
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:id1 0..1IIid
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
... Slices for informant 0..*InformantSlice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*Informantinformant
..... assignedEntity 1..1AssignedEntity
...... id C1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:informant2 0..*Informantinformant
..... relatedEntity 1..1RelatedEntity
... custodian 1..1Custodian
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganization
...... id 1..*II
...... name 1..1ON
...... telecom 1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... Slices for authenticator 0..*AuthenticatorSlice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
.... authenticator:authenticator1 0..*Authenticatorauthenticator
..... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... @code 1..1csRequired Pattern: S
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant C0..*Participant1The participant element in the Procedure Note header follows the General Header Constraints for participants.
Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode
.... participant:All Slices Content/Rules for all slices
..... associatedEntity 1..1AssociatedEntity
.... participant:participant1 C0..*Participant1
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... functionCode 1..1CE
...... @code 1..1csRequired Pattern: PCP
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: PROV
...... associatedPerson 1..1Person
... Slices for documentationOf 1..*DocumentationOfA 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.
Slice: Unordered, Open by value:serviceEvent
.... documentationOf:All Slices Content/Rules for all slices
..... serviceEvent 1..1ServiceEvent
...... @classCode 1..1csBinding: ActClass (required)
...... effectiveTime 1..1IVL_TS
....... low 1..1IVXB_TS
...... Slices for performer 1..*Performer1This performer identifies any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode
....... performer:All Slices Content/Rules for all slices
........ @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
........ assignedEntity 1..1AssignedEntity
......... id 1..*II
....... performer:performer1 1..1Performer1This 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.
........ @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
Fixed Value: PPRF
........ assignedEntity 1..1AssignedEntity
......... id 1..*II
......... code 0..1CEBinding: Healthcare Provider Taxonomy (required)
....... performer:performer2 0..*Performer1
........ @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
Fixed Value: SPRF
........ assignedEntity 1..1AssignedEntity
......... id 1..*II
......... code 0..1CEBinding: Healthcare Provider Taxonomy (required)
.... documentationOf:documentationOf1 1..*DocumentationOf
..... serviceEvent C1..1ServiceEvent1198-8511: 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).
...... @classCode 1..1csBinding: ActClass (required)
...... effectiveTime C1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
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).
....... low 1..1IVXB_TS
... authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
.... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: AUTH
.... consent 1..1Consent
..... @classCode 1..1csBinding: ActClass (required)
Fixed Value: CONS
..... @moodCode 1..1csBinding: ActMood (required)
Fixed Value: EVN
..... statusCode 1..1CSBinding: ActStatus (required)
...... @code 1..1csFixed Value: completed
... componentOf 0..1ComponentOf
.... encompassingEncounter 1..1EncompassingEncounter
..... id 1..*IISG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
..... code 1..1CEBinding: ActEncounterCode (extensible)
..... effectiveTime 1..1IVL_TS
..... Slices for encounterParticipant 0..*EncounterParticipantSlice: Unordered, Open by value:typeCode
...... encounterParticipant:encounterParticipant1 0..1EncounterParticipant
....... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: REF
..... location 1..1InfrastructureRootSG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
...... healthCareFacility 1..1HealthCareFacility
....... @classCode 1..1csBinding: RoleClassServiceDeliveryLocation (required)
....... id 1..*II
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-30412: 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).
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by value:ClinicalDocument.section
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:component1 1..1InfrastructureRoot
....... section 1..1ComplicationsSectionBase for all types and resources
...... component:component2 1..1InfrastructureRoot
....... section 1..1ProcedureDescriptionSectionBase for all types and resources
...... component:component3 1..1InfrastructureRoot
....... section 1..1ProcedureIndicationsSectionBase for all types and resources
...... component:component4 1..1InfrastructureRoot
....... section 1..1PostprocedureDiagnosisSectionBase for all types and resources
...... component:component5 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:component6 0..1InfrastructureRoot
....... section 1..1AssessmentandPlanSectionBase for all types and resources
...... component:component7 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:component8 0..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:component9 0..1InfrastructureRoot
....... section 1..1AnesthesiaSectionBase for all types and resources
...... component:component10 0..1InfrastructureRoot
....... section 1..1ChiefComplaintSectionBase for all types and resources
...... component:component11 0..1InfrastructureRoot
....... section 1..1ChiefComplaintandReasonforVisitSectionBase for all types and resources
...... component:component12 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:component13 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:component14 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:component15 0..1InfrastructureRoot
....... section 1..1MedicalGeneralHistorySectionBase for all types and resources
...... component:component16 0..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:component17 0..1InfrastructureRoot
....... section 1..1MedicationsAdministeredSectionBase for all types and resources
...... component:component18 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:component19 0..1InfrastructureRoot
....... section 1..1PlannedProcedureSectionBase for all types and resources
...... component:component20 0..1InfrastructureRoot
....... section 1..1ProcedureDispositionSectionBase for all types and resources
...... component:component21 0..1InfrastructureRoot
....... section C1..1ProcedureEstimatedBloodLossSectionBase for all types and resources
...... component:component22 0..1InfrastructureRoot
....... section 1..1ProcedureFindingsSectionBase for all types and resources
...... component:component23 0..1InfrastructureRoot
....... section C1..1ProcedureImplantsSectionBase for all types and resources
...... component:component24 0..1InfrastructureRoot
....... section C1..1ProcedureSpecimensTakenSectionBase for all types and resources
...... component:component25 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:component26 0..1InfrastructureRoot
....... section 1..1ReasonforVisitSectionBase for all types and resources
...... component:component27 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:component28 0..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
ClinicalDocument.code.coderequiredProcedureNoteDocumentTypeCodes
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredFixed Value: PROV
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredx_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCoderequiredFixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCoderequiredFixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCoderequiredActClass
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUTH
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
ClinicalDocument.componentOf.encompassingEncounter.codeextensibleActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCoderequiredFixed Value: REF
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCoderequiredRoleClassServiceDeliveryLocation

Constraints

IdGradePath(s)DetailsRequirements
1198-8511errorClinicalDocument.documentationOf:documentationOf1.serviceEventThe 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).
:
1198-8513errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeThe serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513).
:
1198-8514errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeIf a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514).
:
1198-8515errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeWhen 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).
:
1198-30412errorClinicalDocument.component.structuredBodyThis 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).
:
1198-30414errorClinicalDocument.component.structuredBodyThis 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).
:
1198-30415errorClinicalDocument.component.structuredBodyThis 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).
:
4537-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:4537-5299).
:
4537-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:4537-5300).
:
4537-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
:
4537-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:4537-9991).
:
4537-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
:
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
:
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
:
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
:
4537-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:4537-32418).
:
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-8741warningClinicalDocument.component.structuredBody.component:component21.sectionThe 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).
:
81-8742warningClinicalDocument.component.structuredBody.component:component24.sectionThe Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
:
81-8769errorClinicalDocument.component.structuredBody.component:component23.sectionThe Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769).
:
81-9371errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10078errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ivl-ts-centererrorClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTimeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... @classCode 0..1csBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: US
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..1II
.... @root 1..1stFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stExtension
Fixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2023-05-01
.... templateId:secondary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.6
..... @extension 1..1stRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEThe 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.
Binding: FHIRDocumentTypeCodes (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csBinding: ProcedureNoteDocumentTypeCodes (required)
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId C0..1II
... versionNumber C0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... patientRole 1..1PatientRole
..... @classCode 0..1csBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... sdtcDeceasedInd C0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime 0..1TSXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedTime
XML: deceasedTime (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @value C0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... sdtcMultipleBirthInd 0..1BLXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... sdtcRaceCode C0..*CEXML Namespace: urn:hl7-org:sdtc
The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML Namespace: urn:hl7-org:sdtc
ethnicGroupCode
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (required)
...... guardian 0..*Guardian
....... @classCode 0..1csBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... templateId 0..*II
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressADUSFIELDEDBase for all types and resources
....... telecom 0..*TEL
........ @nullFlavor 0..1csBinding: NullFlavor (required)
........ @value 0..1url
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcAsPatientRelationship 0..*CEXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... @classCode 0..1csBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... templateId 0..*II
....... place 1..1Place
........ @classCode 0..1csBinding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name 0..1EN
........ addr C1..1AD
......... nullFlavor C0..1csPrimitive Type code
Binding: NullFlavor (required)
......... @isNotOrdered 0..1bl
......... @use 0..*cs
......... delimiter 0..*ADXP
.......... @partType 0..1csFixed Value: DEL
......... country 0..1ADXP
.......... @partType 0..1csFixed Value: CNT
......... state 0..*ADXP
.......... @partType 0..1csFixed Value: STA
......... county 0..*ADXP
.......... @partType 0..1csFixed Value: CPA
......... city 0..*ADXP
.......... @partType 0..1csFixed Value: CTY
......... postalCode 0..*ADXP
.......... @partType 0..1csFixed Value: ZIP
......... streetAddressLine 0..*ADXP
.......... @partType 0..1csFixed Value: SAL
......... houseNumber 0..*ADXP
.......... @partType 0..1csFixed Value: BNR
......... houseNumberNumeric 0..*ADXP
.......... @partType 0..1csFixed Value: BNN
......... direction 0..*ADXP
.......... @partType 0..1csFixed Value: DIR
......... streetName 0..*ADXP
.......... @partType 0..1csFixed Value: STR
......... streetNameBase 0..*ADXP
.......... @partType 0..1csFixed Value: STB
......... streetNameType 0..*ADXP
.......... @partType 0..1csFixed Value: STTYP
......... additionalLocator 0..*ADXP
.......... @partType 0..1csFixed Value: ADL
......... unitID 0..*ADXP
.......... @partType 0..1csFixed Value: UNID
......... unitType 0..*ADXP
.......... @partType 0..1csFixed Value: UNIT
......... careOf 0..*ADXP
.......... @partType 0..1csFixed Value: CAR
......... censusTract 0..*ADXP
.......... @partType 0..1csFixed Value: CEN
......... deliveryAddressLine 0..*ADXP
.......... @partType 0..1csFixed Value: DAL
......... deliveryInstallationType 0..*ADXP
.......... @partType 0..1csFixed Value: DINST
......... deliveryInstallationArea 0..*ADXP
.......... @partType 0..1csFixed Value: DINSTA
......... deliveryInstallationQualifier 0..*ADXP
.......... @partType 0..1csFixed Value: DINSTQ
......... deliveryMode 0..*ADXP
.......... @partType 0..1csFixed Value: DMOD
......... deliveryModeIdentifier 0..*ADXP
.......... @partType 0..1csFixed Value: DMODID
......... buildingNumberSuffix 0..*ADXP
.......... @partType 0..1csFixed Value: BNS
......... postBox 0..*ADXP
.......... @partType 0..1csFixed Value: POB
......... precinct 0..*ADXP
.......... @partType 0..1csFixed Value: PRE
......... other 0..1st
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication 0..*LanguageCommunication
.......