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: US Realm Header

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader Version: 2.1
Draft as of 2023-09-29 Computable Name: USRealmHeader
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:2023-05-01

This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents. Further specification, such as ClinicalDocument/code, are provided in document templates that conform to this template.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.ClinicalDocument

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1CDAR2.ClinicalDocumentXML 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
Base for all types and resources
... realmCode 1..1CS
.... code 1..1csRequired Pattern: US
... typeId 1..1II
.... root 1..1st
.... extension 1..1stExtension
Fixed Value: POCD_HD000040
... Slices for templateId 1..*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
... code C1..1CE4537-9992: 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).
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime 1..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..1II4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
... versionNumber C0..1INT4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
... recordTarget 1..*RecordTarget
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr 1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... name 1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS4537-5299: **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).
...... sdtcDeceasedInd C0..1BLsdtc:deceasedInd
4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993).
...... sdtcDeceasedTime 0..1TSsdtc:deceasedTime
....... value C0..1ts4537-32991: **SHALL** be precise to to the year (CONF:4537-32991).
4537-32992: **SHOULD** be precise to the day (CONF:4537-32992).
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... sdtcRaceCode C0..*CEThe 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.
Binding: Race Value Set (required)
4537-31347: If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347).
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEethnicGroupCode
Binding: Detailed Ethnicity (required)
...... guardian 0..*Guardian
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr 0..*USRealmAddressADUSFIELDEDBase for all types and resources
....... telecom 0..*TEL
........ use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... birthplace 0..1Birthplace
....... place 1..1Place
........ addr C1..1AD4537-5402: 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).
......... country 0..1ADXPBinding: VSAC 2.16.840.1.113883.3.88.12.80.63 (required)
...... languageCommunication 0..*LanguageCommunication
....... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... id 1..*II
....... root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
...... name 1..*ON
...... telecom 1..*TEL
....... use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr 1..*USRealmAddressADUSFIELDEDBase for all types and resources
... author 1..*Author
.... time 1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:id1 0..1IIid
....... nullFlavor 0..1csFixed Value: UNK
....... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1st
..... code 0..1CE
...... code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
..... addr 1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 0..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... assignedAuthoringDevice 0..1AuthoringDevice
...... manufacturerModelName 1..1SC
...... softwareName 1..1SC
... dataEnterer 0..1DataEnterer
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
...... root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr 1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for informant 0..*InformantSlice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*Informantinformant
..... assignedEntity 1..1AssignedEntity
...... id C1..*II4537-9946: 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).
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr 1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... assignedPerson 1..1Person
....... name 1..*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
....... root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
...... name 1..1ON
...... telecom 1..1TEL
....... use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr 1..1USRealmAddressADUSFIELDEDBase for all types and resources
... informationRecipient 0..*InformationRecipient
.... intendedRecipient 1..1IntendedRecipient
..... id 0..*II
..... informationRecipient 0..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... receivedOrganization 0..1Organization
...... name 1..1ON
... legalAuthenticator 0..1LegalAuthenticator
.... time 1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... signatureCode 1..1CS
..... code 1..1csRequired Pattern: S
.... sdtcSignatureText 0..1EDThe signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
...... root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr 1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase 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 1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... code 1..1csRequired Pattern: S
..... sdtcSignatureText 0..1EDThe signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
....... root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
...... code 0..1CE
....... code 0..1csBinding: Healthcare Provider Taxonomy (preferred)
...... addr 1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... participant C0..*Participant14537-10006: **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).
.... time 0..1IVL_TS
... inFulfillmentOf 0..*InFulfillmentOf
.... order 1..1Order
..... id 1..*II
... documentationOf 0..*DocumentationOf
.... serviceEvent 1..1ServiceEvent
..... effectiveTime 1..1IVL_TS
...... low 1..1IVXB_TS
..... performer 0..*Performer1
...... typeCode 1..1csBinding: x_ServiceEventPerformer (required)
...... functionCode 0..1CE
....... code 0..1csBinding: Care Team Member Function (preferred)
...... assignedEntity 1..1AssignedEntity
....... id 1..*II
........ root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
... authorization 0..*Authorization
.... consent 1..1Consent
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
..... statusCode 1..1CS
...... code 1..1cs
... componentOf 0..1ComponentOf
.... encompassingEncounter 1..1EncompassingEncounter
..... id 1..*II
..... effectiveTime 1..1IVL_TS

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
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.maritalStatusCoderequiredMarital Status
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRace Value Set
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailed Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.countryrequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.63
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informant:informant1.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredx_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)

Constraints

IdGradePath(s)DetailsRequirements
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).
:
4537-5402warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf 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).
:
4537-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
:
4537-6380errorClinicalDocument.setIdIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
:
4537-6387errorClinicalDocument.versionNumberIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
:
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**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
:
4537-10007warningClinicalDocument.participantWhen 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).
:
4537-31347errorClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeIf sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347).
:
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).
:
4537-32991errorClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value**SHALL** be precise to to the year (CONF:4537-32991).
:
4537-32992warningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value**SHOULD** be precise to the day (CONF:4537-32992).
:
4537-32993errorClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedIndIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1CDAR2.ClinicalDocumentXML 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
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 1..*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
... code C1..1CEBinding: FHIRDocumentTypeCodes (extensible)
4537-9992: 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).
... 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..1II4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
... versionNumber C0..1INT4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
... 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..1TS4537-5299: **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).
...... sdtcDeceasedInd C0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993).
...... sdtcDeceasedTime 0..1TSXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedTime
XML: deceasedTime (urn:hl7-org:sdtc)
....... @value C0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
4537-32991: **SHALL** be precise to to the year (CONF:4537-32991).
4537-32992: **SHOULD** be precise to the day (CONF:4537-32992).
...... 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)
4537-31347: If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347).
...... 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
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressADUSFIELDEDBase for all types and resources
....... telecom 0..*TEL
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... birthplace 0..1Birthplace
....... place 1..1Place
........ addr C1..1AD4537-5402: 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).
......... country 0..1ADXP
...... languageCommunication 0..*LanguageCommunication
....... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... id 1..*II
....... @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
...... name 1..*ON
...... telecom 1..*TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
... author 1..*Author
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor4537-16790: There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:id1 0..1IIid
....... @nullFlavor 0..1csBinding: NullFlavor (required)
Fixed Value: UNK
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
..... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... @code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 0..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... assignedAuthoringDevice 0..1AuthoringDevice
...... manufacturerModelName 1..1SCBinding: Manufacturer Model Name Example (example)
...... softwareName 1..1SCBinding: Software Name Example (example)
... dataEnterer 0..1DataEnterer
.... time 1..1TS
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
...... @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... 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 informant 0..*InformantSlice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*Informantinformant
..... assignedEntity 1..1AssignedEntity
...... id C1..*II4537-9946: 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).
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... 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
....... @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
...... name 1..1ON
...... telecom 1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... informationRecipient 0..*InformationRecipient
.... intendedRecipient 1..1IntendedRecipient
..... @classCode 1..1cs
..... id 0..*II
..... informationRecipient 0..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
..... receivedOrganization 0..1Organization
...... name 1..1ON
... legalAuthenticator 0..1LegalAuthenticator
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... signatureCode 1..1CS
..... @code 1..1csRequired Pattern: S
.... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.
XML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
...... @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... 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 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
..... sdtcSignatureText 0..1EDXML Namespace: urn:hl7-org:sdtc
The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc.
XML: signatureText (urn:hl7-org:sdtc)
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
....... @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... @code 0..1csBinding: Healthcare Provider Taxonomy (preferred)
...... 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
... participant C0..*Participant14537-10006: **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).
.... time 0..1IVL_TS
.... associatedEntity 1..1AssociatedEntity
... inFulfillmentOf 0..*InFulfillmentOf
.... order 1..1Order
..... @classCode 1..1csBinding: ActClass (required)
..... id 1..*II
... documentationOf 0..*DocumentationOf
.... serviceEvent 1..1ServiceEvent
..... @classCode 1..1csBinding: ActClass (required)
..... effectiveTime 1..1IVL_TS
...... low 1..1IVXB_TS
..... performer 0..*Performer1
...... @typeCode 1..1csBinding: x_ServiceEventPerformer (required)
...... functionCode 0..1CE
....... @code 0..1csBinding: Care Team Member Function (preferred)
...... assignedEntity 1..1AssignedEntity
....... id 1..*II
........ @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
... authorization 0..*Authorization
.... consent 1..1Consent
..... id 0..*II
..... code 0..1CEThe type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code.
Binding: v3 Code System ActCode (extensible)
..... statusCode 1..1CSBinding: ActStatus (required)
...... @code 1..1csFixed Value: completed
... componentOf 0..1ComponentOf
.... encompassingEncounter 1..1EncompassingEncounter
..... id 1..*II
..... effectiveTime 1..1IVL_TS
... component 1..1Component

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.codeextensibleFHIRDocumentTypeCodes
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.maritalStatusCoderequiredMarital Status
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCoderequiredRace Value Set
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCoderequiredDetailed Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavorrequiredFixed Value: UNK
ClinicalDocument.author.assignedAuthor.codeextensibleRoleCode
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelNameexampleManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareNameexampleSoftwareNameExample
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informant:informant1.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.codeextensibleRoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredx_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ClinicalDocument.authorization.consent.codeextensibleActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
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).
:
4537-5402warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf 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).
:
4537-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403).
:
4537-6380errorClinicalDocument.setIdIf setId is present versionNumber **SHALL** be present (CONF:4537-6380).
:
4537-6387errorClinicalDocument.versionNumberIf versionNumber is present setId **SHALL** be present (CONF:4537-6387).
:
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**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
:
4537-10007warningClinicalDocument.participantWhen 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).
:
4537-31347errorClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeIf sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347).
:
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).
:
4537-32991errorClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value**SHALL** be precise to to the year (CONF:4537-32991).
:
4537-32992warningClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value**SHOULD** be precise to the day (CONF:4537-32992).
:
4537-32993errorClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedIndIf sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.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())
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1CDAR2.ClinicalDocumentXML 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
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 1..*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
... id C1..1II4537-9991: This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991).
... code C1..1CEBinding: FHIRDocumentTypeCodes (extensible)
4537-9992: 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).
... 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..1II4537-6380: If setId is present versionNumber **SHALL** be present (CONF:4537-6380).
... versionNumber C0..1INT4537-6387: If versionNumber is present setId **SHALL** be present (CONF:4537-6387).
... 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..1TS4537-5299: **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).
...... sdtcDeceasedInd C0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
4537-32993: If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993).
...... 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]
4537-32991: **SHALL** be precise to to the year (CONF:4537-32991).
4537-32992: **SHOULD** be precise to the day (CONF:4537-32992).
...... 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)
4537-31347: If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347).
...... 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..1AD4537-5402: 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).
......... 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