Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Diagnostic Imaging Report (V3)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.5 Version: 2.2
Active as of 2022-05-13 Computable Name: DiagnosticImagingReport
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.5:2015-08-01

A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialists interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patients medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

Usage:

  • This Resource Profile 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

Summary

Mandatory: 15 elements (22 nested mandatory elements)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension
  • The element ClinicalDocument.participant is sliced based on the value of value:ClinicalDocument.associatedEntity
  • The element ClinicalDocument.documentationOf is sliced based on the value of value:ClinicalDocument.serviceEvent
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section
  • The element ClinicalDocument.component.structuredBody.component.section.author is sliced based on the value of value:assignedAuthor
  • The element ClinicalDocument.component.structuredBody.component.section.entry is sliced based on the value of value:ClinicalDocument.section.structuredBody.component.section.entry

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeader
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary I1..1II1198-32937: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32937).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.5
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..1II
.... root I1..1string1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+
1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
... code 1..1CEPreferred code is 18748-4 LOINC Diagnostic Imaging Report
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5 (preferred)
... informationRecipient I0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412).
1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
... Slices for participant 0..*Participant1If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF).
Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
.... participant:participant1 0..1Participant1
..... associatedEntity 1..1AssociatedEntity
...... associatedPerson 1..1Person
....... name 1..1USRealmPersonNamePNUSFIELDED
... inFulfillmentOf 0..*InFulfillmentOfAn inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
.... order 1..1Order
..... id 1..*IIDICOM Accession Number in the DICOM imaging and report data
... Slices for documentationOf 0..*DocumentationOfEach serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure.
Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent 1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... classCode 1..1codeRequired Pattern: ACT
...... id 0..*II
...... code I1..1CE1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
...... performer 0..*PhysicianReadingStudyPerformerThe performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
... relatedDocument I0..1RelatedDocumentA DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document.
1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
.... parentDocument 1..1ParentDocument
..... id I1..1II1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031).
1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
... componentOf 0..1ComponentOfThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
.... encompassingEncounter 1..1EncompassingEncounterThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
..... id I1..*II1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
..... effectiveTime 1..1USRealmDateandTimeDTUSFIELDED
..... responsibleParty 0..1Element
...... assignedEntity I1..1AssignedEntity1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
..... encounterParticipant 0..1PhysicianofRecordParticipant
... component 1..1Component2
.... structuredBody 1..1StructuredBody
..... Slices for component 1..*ElementSlice: Unordered, Open by value:ClinicalDocument.section
...... component:component1 1..1Element
....... section 1..1FindingsSectionDIR
...... component:component2 0..1Element
....... section I1..1DICOMObjectCatalogSectionDCM1211811198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
...... component:component3 0..*Element
....... section I1..1Section1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211).
1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
........ code 1..1CE
......... code 1..1stringThe section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined
Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (preferred)
........ title 0..1EDThere is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
........ text I0..1xhtml1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060).
1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061).
1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
........ subject 0..*Element
......... relatedSubject 1..1FetusSubjectContext
........ Slices for author 0..*AuthorThis author element is used when the author of a section is different from the author(s) listed in the Header
Slice: Unordered, Open by value:assignedAuthor
......... author:author1 0..*Author
.......... assignedAuthor 1..1ObserverContext
........ Slices for entry 0..*ElementSlice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
........ entry 0..*ElementIf the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
......... act 1..1ProcedureContext
........ entry:textObs 0..*Element
......... observation 1..1TextObservation
........ entry:entry3 0..*Element
......... observation 1..1CodeObservations
........ entry:entry4 0..*Element
......... observation 1..1QuantityMeasurementObservation
........ entry:entry5 0..*Element
......... observation 1..1SOPInstanceObservation
........ component I0..*Element1198-31210: **SHALL** contain child elements (CONF:1198-31210).

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeader
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CSRequired Pattern: US
... typeId 1..1II
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... assigningAuthorityName 0..1string
.... displayable 0..1boolean
.... root 1..1stringRequired Pattern: 2.16.840.1.113883.1.3
.... extension 1..1stringRequired Pattern: POCD_HD000040
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... extension 1..1stringRequired Pattern: 2015-08-01
.... templateId:secondary I1..1II1198-32937: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32937).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.5
..... extension 1..1stringRequired Pattern: 2014-06-09
... id I1..1II
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... assigningAuthorityName 0..1string
.... displayable 0..1boolean
.... root I1..1string1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+
1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
.... extension 0..1string
... code I1..1CE​Preferred code is 18748-4 LOINC Diagnostic Imaging Report
Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5 (preferred)
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1EDThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime I1..1USRealmDateandTimeDTMUSFIELDED
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId I0..1II
... versionNumber I0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: RCT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... patientRole 1..1PatientRole
..... classCode 1..1codeBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..1II
...... name I1..*USRealmPatientNamePTNUSFIELDED
...... sdtcDesc 0..1EDXML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime I1..1TS
...... sdtcDeceasedInd 0..1BLXML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime 0..1TSXML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML: 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 0..*CEXML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (extensible)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (extensible)
...... guardian 0..*Guardian
....... classCode 1..1codeBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... templateId 0..*II
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr I0..*USRealmAddressADUSFIELDED
....... telecom 0..*TEL
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ value 0..1uri
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ use 0..1codeBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name I1..*USRealmPersonNamePNUSFIELDED
........ sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... classCode 1..1codeBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... templateId 0..*II
....... place 1..1Place
........ classCode 1..1codeBinding: EntityClassPlace (required)
Fixed Value: PLC
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name 0..1EN
........ addr I1..1AD
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... isNotOrdered 0..1boolean
......... use 0..*code
......... delimiter 0..*ADXP
.......... partType 0..1codeFixed Value: DEL
......... country 0..1ADXP
.......... partType 0..1codeFixed Value: CNT
......... state 0..*ADXP
.......... partType 0..1codeFixed Value: STA
......... county 0..*ADXP
.......... partType 0..1codeFixed Value: CPA
......... city 0..*ADXP
.......... partType 0..1codeFixed Value: CTY
......... postalCode 0..*ADXP
.......... partType 0..1codeFixed Value: ZIP
......... streetAddressLine 0..*ADXP
.......... partType 0..1codeFixed Value: SAL
......... houseNumber 0..*ADXP
.......... partType 0..1codeFixed Value: BNR
......... houseNumberNumeric 0..*ADXP
.......... partType 0..1codeFixed Value: BNN
......... direction 0..*ADXP
.......... partType 0..1codeFixed Value: DIR
......... streetName 0..*ADXP
.......... partType 0..1codeFixed Value: STR
......... streetNameBase 0..*ADXP
.......... partType 0..1codeFixed Value: STB
......... streetNameType 0..*ADXP
.......... partType 0..1codeFixed Value: STTYP
......... additionalLocator 0..*ADXP
.......... partType 0..1codeFixed Value: ADL
......... unitID 0..*ADXP
.......... partType 0..1codeFixed Value: UNID
......... unitType 0..*ADXP
.......... partType 0..1codeFixed Value: UNIT
......... careOf 0..*ADXP
.......... partType 0..1codeFixed Value: CAR
......... censusTract 0..*ADXP
.......... partType 0..1codeFixed Value: CEN
......... deliveryAddressLine 0..*ADXP
.......... partType 0..1codeFixed Value: DAL
......... deliveryInstallationType 0..*ADXP
.......... partType 0..1codeFixed Value: DINST
......... deliveryInstallationArea 0..*ADXP
.......... partType 0..1codeFixed Value: DINSTA
......... deliveryInstallationQualifier 0..*ADXP
.......... partType 0..1codeFixed Value: DINSTQ
......... deliveryMode 0..*ADXP
.......... partType 0..1codeFixed Value: DMOD
......... deliveryModeIdentifier 0..*ADXP
.......... partType 0..1codeFixed Value: DMODID
......... buildingNumberSuffix 0..*ADXP
.......... partType 0..1codeFixed Value: BNS
......... postBox 0..*ADXP
.......... partType 0..1codeFixed Value: POB
......... precinct 0..*ADXP
.......... partType 0..1codeFixed Value: PRE
......... other 0..1string
......... useablePeriod[x] 0..*
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TSIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TSEIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TSPIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TSSXPR_TS
...... languageCommunication 0..*LanguageCommunication
....... templateId 0..*II
....... 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
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..*ON
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr I1..*USRealmAddressADUSFIELDED
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CE
.... time I1..1USRealmDateandTimeDTMUSFIELDED
.... assignedAuthor I1..1AssignedAuthor
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... Slices for id I1..*IISlice: Unordered, Open by value:root
1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
...... id:id1 0..1II
....... nullFlavor 0..1codeIf id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then
Binding: NullFlavor (required)
Required Pattern: UNK
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 1..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEOnly if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: v3 Code System RoleCode (extensible)
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringBinding: Healthcare Provider Taxonomy (preferred)
...... codeSystem 0..1string
...... codeSystemName 0..1string
...... codeSystemVersion 0..1string
...... displayName 0..1string
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 0..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... assignedAuthoringDevice 0..1AuthoringDevice
...... classCode 1..1codeBinding: EntityClassDevice (required)
Fixed Value: DEV
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... code 0..1CEBinding: EntityCode (extensible)
...... manufacturerModelName 1..1SC
...... softwareName 1..1SC
...... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time 1..1TS
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... custodian 1..1CustodianThe custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... assignedCustodian 1..1AssignedCustodian
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... representedCustodianOrganization 1..1CustodianOrganization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..1ON
...... telecom 1..1TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr I1..1USRealmAddressADUSFIELDED
... informationRecipient I0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412).
1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... intendedRecipient 1..1IntendedRecipient
..... classCode 1..1code
..... templateId 0..*II
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... receivedOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorThe legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: LA
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time I1..1USRealmDateandTimeDTMUSFIELDED
.... signatureCode 1..1CS
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... code 1..1stringRequired Pattern: S
..... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
..... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... Slices for authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Slice: Unordered, Open by value:signatureCode, value:assignedEntity
.... authenticator:authenticator1 0..*Authenticator
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUTHEN
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... time I1..1USRealmDateandTimeDTMUSFIELDED
..... signatureCode 1..1CS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringRequired Pattern: S
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
..... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Healthcare Provider Taxonomy (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I1..*USRealmAddressADUSFIELDED
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name I1..*USRealmPersonNamePNUSFIELDED
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... representedOrganization 0..1Organization
... Slices for participant 0..*Participant1If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF).
Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
.... participant:participant1 I0..1Participant1
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... functionCode 0..1CE
..... time 0..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: RoleClassAssociative (required)
...... templateId 0..*II
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name I1..1USRealmPersonNamePNUSFIELDED
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfAn inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: FLFS
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... order 1..1Order
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMoodIntent (required)
Fixed Value: RQO
..... templateId 0..*II
..... id 1..*IIDICOM Accession Number in the DICOM imaging and report data
..... code 0..1CEBinding: v3 Code System ActCode (extensible)
..... priorityCode 0..1CEBinding: ActPriority (extensible)
... Slices for documentationOf 0..*DocumentationOfEach serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure.
Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
.... documentationOf:All Slices Content/Rules for all slices
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... serviceEvent 1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... classCode 1..1codeBinding: ActClass (required)
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..*II
...... code 0..1CE
...... effectiveTime 1..1IVL_TS
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1dateTime
....... inclusive 0..1boolean
....... operator 0..1code
....... low 1..1TS
....... high 0..1TS
....... width 0..1PQ
....... center 0..1TS
...... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... typeCode 1..1codeBinding: x_ServiceEventPerformer (required)
Fixed Value: DOC
....... realmCode 0..*CS
....... typeId 0..1II
....... templateId 0..*II
....... functionCode 0..1CE
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ code 0..1stringBinding: Care Team Member Function (preferred)
........ codeSystem 0..1string
........ codeSystemName 0..1string
........ codeSystemVersion 0..1string
........ displayName 0..1string
........ sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
........ sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time 0..1IVL_TS
....... assignedEntity 1..1AssignedEntity
........ classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ templateId 0..*II
........ id 1..*II
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... assigningAuthorityName 0..1string
......... displayable 0..1boolean
......... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
......... extension 0..1string
........ sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
.... documentationOf:documentationOf1 1..1DocumentationOf
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... serviceEvent 1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... classCode 1..1codeBinding: ActClass (required)
Required Pattern: ACT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..*II
...... code I1..1CE1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
...... effectiveTime 1..1IVL_TS
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1dateTime
....... inclusive 0..1boolean
....... operator 0..1code
....... low 1..1TS
....... high 0..1TS
....... width 0..1PQ
....... center 0..1TS
...... performer 0..*PhysicianReadingStudyPerformerThe performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... typeCode 1..1codeBinding: x_ServiceEventPerformer (required)
Fixed Value: DOC
....... realmCode 0..*CS
....... typeId 0..1II
....... templateId 0..*II
....... functionCode 0..1CE
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ code 0..1stringBinding: Care Team Member Function (preferred)
........ codeSystem 0..1string
........ codeSystemName 0..1string
........ codeSystemVersion 0..1string
........ displayName 0..1string
........ sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
........ sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time 0..1IVL_TS
....... assignedEntity 1..1AssignedEntity
........ classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ templateId 0..*II
........ id 1..*II
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... assigningAuthorityName 0..1string
......... displayable 0..1boolean
......... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
......... extension 0..1string
........ sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
... relatedDocument I0..1RelatedDocumentA DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document.
1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... parentDocument 1..1ParentDocument
..... classCode 1..1codeBinding: ActClassClinicalDocument (required)
Fixed Value: DOCCLIN
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id I1..1II1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031).
1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
..... code 0..1CD​Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
..... text 0..1ED
..... setId 0..1II
..... versionNumber 0..1INT
... Slices for authorization 0..*AuthorizationThe authorization element represents information about the patient?s consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
Slice: Unordered, Open by value:consent
.... authorization:authorization1 0..*Authorization
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... consent 1..1Consent
...... classCode 1..1codeBinding: ActClass (required)
Fixed Value: CONS
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... 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..1Fixed Value: completed
... componentOf 0..1ComponentOfThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... encompassingEncounter 1..1EncompassingEncounterThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
..... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id I1..*II1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
..... code 0..1CEBinding: ActEncounterCode (extensible)
..... effectiveTime I1..1USRealmDateandTimeDTUSFIELDED
..... sdtcAdmissionReferralSourceCode 0..1CEXML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CE​Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible)
..... responsibleParty 0..1Element
...... typeCode 1..1codeBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity I1..1AssignedEntity1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
..... encounterParticipant 0..1PhysicianofRecordParticipant
..... location 0..1Element
...... typeCode 1..1codeBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component2
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... contextConductionInd 1..1boolean
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... nonXMLBody 0..1NonXMLBody
.... structuredBody 1..1StructuredBody
..... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCBODY
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: HumanLanguage (required)
..... Slices for component 1..*ElementSlice: Unordered, Open by value:ClinicalDocument.section
...... component:All Slices Content/Rules for all slices
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1Section
...... component:component1 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1FindingsSectionDIR
...... component:component2 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1DICOMObjectCatalogSectionDCM1211811198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
...... component:component3 0..*Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1Section1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211).
1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
........ ID 0..1string
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
........ moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
........ templateId 0..*II
........ id 0..1II
........ code 1..1CEBinding: DocumentSectionType (extensible)
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... code 1..1stringThe section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined
Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (preferred)
......... codeSystem 0..1string
......... codeSystemName 0..1string
......... codeSystemVersion 0..1string
......... displayName 0..1string
......... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
......... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
......... originalText 0..1ED
......... translation 0..*CD
........ title 0..1EDThere is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
........ text SI0..1xhtml1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060).
1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061).
1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
........ confidentialityCode 0..1CE
........ languageCode 0..1CSBinding: HumanLanguage (required)
........ subject 0..*Element
......... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
......... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
......... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
......... relatedSubject 1..1FetusSubjectContext
........ Slices for author 0..*AuthorThis author element is used when the author of a section is different from the author(s) listed in the Header
Slice: Unordered, Open by value:assignedAuthor
......... author:author1 0..*Author
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.......... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.......... realmCode 0..*CS
.......... typeId 0..1II
.......... templateId 0..*II
.......... functionCode 0..1CE
.......... time 1..1TS
.......... assignedAuthor I1..1ObserverContext
........ informant 0..*Element
......... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
......... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
......... assignedEntity 0..1AssignedEntity
......... relatedEntity 0..1RelatedEntity
........ Slices for entry I0..*ElementSlice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
......... entry:All Slices Content/Rules for all slices
.......... typeCode 1..1code
.......... contextConductionInd 1..1boolean
.......... (Choice of one) 1..1
........... observation 0..1Observation
........... regionOfInterest 0..1RegionOfInterest
........... observationMedia 0..1ObservationMedia
........... substanceAdministration 0..1SubstanceAdministration
........... supply 0..1Supply
........... procedure 0..1Procedure
........... encounter 0..1Encounter
........... organizer 0..1Organizer
........... act 0..1Act
........ entry I0..*ElementIf the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... act I1..1ProcedureContext
........ entry:textObs I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation 1..1TextObservation
........ entry:entry3 I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation I1..1CodeObservations
........ entry:entry4 I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation 1..1QuantityMeasurementObservation
........ entry:entry5 I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation 1..1SOPInstanceObservation
........ component I0..*Element1198-31210: **SHALL** contain child elements (CONF:1198-31210).
......... typeCode 1..1codeFixed Value: COMP
......... contextConductionInd 1..1boolean
......... section 1..1Section

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeader
... component 1..1Component2
.... structuredBody 1..1StructuredBody
..... component:component3 0..*Element
...... section I1..1Section1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211).
1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
....... text I0..1xhtml1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060).
1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061).
1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).

doco Documentation for this format

This structure is derived from USRealmHeader

Summary

Mandatory: 15 elements (22 nested mandatory elements)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension
  • The element ClinicalDocument.participant is sliced based on the value of value:ClinicalDocument.associatedEntity
  • The element ClinicalDocument.documentationOf is sliced based on the value of value:ClinicalDocument.serviceEvent
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section
  • The element ClinicalDocument.component.structuredBody.component.section.author is sliced based on the value of value:assignedAuthor
  • The element ClinicalDocument.component.structuredBody.component.section.entry is sliced based on the value of value:ClinicalDocument.section.structuredBody.component.section.entry

Differential View

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeader
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary I1..1II1198-32937: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32937).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.5
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..1II
.... root I1..1string1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+
1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
... code 1..1CEPreferred code is 18748-4 LOINC Diagnostic Imaging Report
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5 (preferred)
... informationRecipient I0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412).
1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
... Slices for participant 0..*Participant1If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF).
Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
.... participant:participant1 0..1Participant1
..... associatedEntity 1..1AssociatedEntity
...... associatedPerson 1..1Person
....... name 1..1USRealmPersonNamePNUSFIELDED
... inFulfillmentOf 0..*InFulfillmentOfAn inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
.... order 1..1Order
..... id 1..*IIDICOM Accession Number in the DICOM imaging and report data
... Slices for documentationOf 0..*DocumentationOfEach serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure.
Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
.... documentationOf:documentationOf1 1..1DocumentationOf
..... serviceEvent 1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... classCode 1..1codeRequired Pattern: ACT
...... id 0..*II
...... code I1..1CE1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
...... performer 0..*PhysicianReadingStudyPerformerThe performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
... relatedDocument I0..1RelatedDocumentA DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document.
1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
.... parentDocument 1..1ParentDocument
..... id I1..1II1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031).
1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
... componentOf 0..1ComponentOfThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
.... encompassingEncounter 1..1EncompassingEncounterThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
..... id I1..*II1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
..... effectiveTime 1..1USRealmDateandTimeDTUSFIELDED
..... responsibleParty 0..1Element
...... assignedEntity I1..1AssignedEntity1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
..... encounterParticipant 0..1PhysicianofRecordParticipant
... component 1..1Component2
.... structuredBody 1..1StructuredBody
..... Slices for component 1..*ElementSlice: Unordered, Open by value:ClinicalDocument.section
...... component:component1 1..1Element
....... section 1..1FindingsSectionDIR
...... component:component2 0..1Element
....... section I1..1DICOMObjectCatalogSectionDCM1211811198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
...... component:component3 0..*Element
....... section I1..1Section1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211).
1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
........ code 1..1CE
......... code 1..1stringThe section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined
Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (preferred)
........ title 0..1EDThere is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
........ text I0..1xhtml1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060).
1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061).
1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
........ subject 0..*Element
......... relatedSubject 1..1FetusSubjectContext
........ Slices for author 0..*AuthorThis author element is used when the author of a section is different from the author(s) listed in the Header
Slice: Unordered, Open by value:assignedAuthor
......... author:author1 0..*Author
.......... assignedAuthor 1..1ObserverContext
........ Slices for entry 0..*ElementSlice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
........ entry 0..*ElementIf the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
......... act 1..1ProcedureContext
........ entry:textObs 0..*Element
......... observation 1..1TextObservation
........ entry:entry3 0..*Element
......... observation 1..1CodeObservations
........ entry:entry4 0..*Element
......... observation 1..1QuantityMeasurementObservation
........ entry:entry5 0..*Element
......... observation 1..1SOPInstanceObservation
........ component I0..*Element1198-31210: **SHALL** contain child elements (CONF:1198-31210).

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeader
... classCode 1..1codeBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CSRequired Pattern: US
... typeId 1..1II
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... assigningAuthorityName 0..1string
.... displayable 0..1boolean
.... root 1..1stringRequired Pattern: 2.16.840.1.113883.1.3
.... extension 1..1stringRequired Pattern: POCD_HD000040
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... extension 1..1stringRequired Pattern: 2015-08-01
.... templateId:secondary I1..1II1198-32937: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32937).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.5
..... extension 1..1stringRequired Pattern: 2014-06-09
... id I1..1II
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... assigningAuthorityName 0..1string
.... displayable 0..1boolean
.... root I1..1string1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+
1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
.... extension 0..1string
... code I1..1CE​Preferred code is 18748-4 LOINC Diagnostic Imaging Report
Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5 (preferred)
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1EDThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime I1..1USRealmDateandTimeDTMUSFIELDED
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId I0..1II
... versionNumber I0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTargetThe recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: RCT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... patientRole 1..1PatientRole
..... classCode 1..1codeBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..1II
...... name I1..*USRealmPatientNamePTNUSFIELDED
...... sdtcDesc 0..1EDXML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime I1..1TS
...... sdtcDeceasedInd 0..1BLXML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime 0..1TSXML: deceasedTime (urn:hl7-org:sdtc)
...... sdtcMultipleBirthInd 0..1BLXML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML: 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 0..*CEXML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (extensible)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (extensible)
...... guardian 0..*Guardian
....... classCode 1..1codeBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... templateId 0..*II
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr I0..*USRealmAddressADUSFIELDED
....... telecom 0..*TEL
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ value 0..1uri
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ use 0..1codeBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name I1..*USRealmPersonNamePNUSFIELDED
........ sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... classCode 1..1codeBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... templateId 0..*II
....... place 1..1Place
........ classCode 1..1codeBinding: EntityClassPlace (required)
Fixed Value: PLC
........ determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name 0..1EN
........ addr I1..1AD
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... isNotOrdered 0..1boolean
......... use 0..*code
......... delimiter 0..*ADXP
.......... partType 0..1codeFixed Value: DEL
......... country 0..1ADXP
.......... partType 0..1codeFixed Value: CNT
......... state 0..*ADXP
.......... partType 0..1codeFixed Value: STA
......... county 0..*ADXP
.......... partType 0..1codeFixed Value: CPA
......... city 0..*ADXP
.......... partType 0..1codeFixed Value: CTY
......... postalCode 0..*ADXP
.......... partType 0..1codeFixed Value: ZIP
......... streetAddressLine 0..*ADXP
.......... partType 0..1codeFixed Value: SAL
......... houseNumber 0..*ADXP
.......... partType 0..1codeFixed Value: BNR
......... houseNumberNumeric 0..*ADXP
.......... partType 0..1codeFixed Value: BNN
......... direction 0..*ADXP
.......... partType 0..1codeFixed Value: DIR
......... streetName 0..*ADXP
.......... partType 0..1codeFixed Value: STR
......... streetNameBase 0..*ADXP
.......... partType 0..1codeFixed Value: STB
......... streetNameType 0..*ADXP
.......... partType 0..1codeFixed Value: STTYP
......... additionalLocator 0..*ADXP
.......... partType 0..1codeFixed Value: ADL
......... unitID 0..*ADXP
.......... partType 0..1codeFixed Value: UNID
......... unitType 0..*ADXP
.......... partType 0..1codeFixed Value: UNIT
......... careOf 0..*ADXP
.......... partType 0..1codeFixed Value: CAR
......... censusTract 0..*ADXP
.......... partType 0..1codeFixed Value: CEN
......... deliveryAddressLine 0..*ADXP
.......... partType 0..1codeFixed Value: DAL
......... deliveryInstallationType 0..*ADXP
.......... partType 0..1codeFixed Value: DINST
......... deliveryInstallationArea 0..*ADXP
.......... partType 0..1codeFixed Value: DINSTA
......... deliveryInstallationQualifier 0..*ADXP
.......... partType 0..1codeFixed Value: DINSTQ
......... deliveryMode 0..*ADXP
.......... partType 0..1codeFixed Value: DMOD
......... deliveryModeIdentifier 0..*ADXP
.......... partType 0..1codeFixed Value: DMODID
......... buildingNumberSuffix 0..*ADXP
.......... partType 0..1codeFixed Value: BNS
......... postBox 0..*ADXP
.......... partType 0..1codeFixed Value: POB
......... precinct 0..*ADXP
.......... partType 0..1codeFixed Value: PRE
......... other 0..1string
......... useablePeriod[x] 0..*
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TSIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TSEIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TSPIVL_TS
.......... useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TSSXPR_TS
...... languageCommunication 0..*LanguageCommunication
....... templateId 0..*II
....... 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
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..*ON
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr I1..*USRealmAddressADUSFIELDED
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*AuthorThe author element represents the creator of the clinical document. The author may be a device or a person.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CE
.... time I1..1USRealmDateandTimeDTMUSFIELDED
.... assignedAuthor I1..1AssignedAuthor
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... Slices for id I1..*IISlice: Unordered, Open by value:root
1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
...... id:id1 0..1II
....... nullFlavor 0..1codeIf id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then
Binding: NullFlavor (required)
Required Pattern: UNK
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 1..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEOnly if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
Binding: v3 Code System RoleCode (extensible)
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringBinding: Healthcare Provider Taxonomy (preferred)
...... codeSystem 0..1string
...... codeSystemName 0..1string
...... codeSystemVersion 0..1string
...... displayName 0..1string
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 0..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... assignedAuthoringDevice 0..1AuthoringDevice
...... classCode 1..1codeBinding: EntityClassDevice (required)
Fixed Value: DEV
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... code 0..1CEBinding: EntityCode (extensible)
...... manufacturerModelName 1..1SC
...... softwareName 1..1SC
...... asMaintainedEntity 0..*MaintainedEntity
..... representedOrganization 0..1Organization
... dataEnterer 0..1DataEntererThe dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time 1..1TS
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... custodian 1..1CustodianThe custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: ENT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... assignedCustodian 1..1AssignedCustodian
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... representedCustodianOrganization 1..1CustodianOrganization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... name 1..1ON
...... telecom 1..1TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... addr I1..1USRealmAddressADUSFIELDED
... informationRecipient I0..*InformationRecipientThe informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412).
1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... intendedRecipient 1..1IntendedRecipient
..... classCode 1..1code
..... templateId 0..*II
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 0..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... receivedOrganization 0..1Organization
...... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..*II
...... name 1..1ON
...... telecom 0..*TEL
...... addr 0..*AD
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... legalAuthenticator 0..1LegalAuthenticatorThe legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: LA
.... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... time I1..1USRealmDateandTimeDTMUSFIELDED
.... signatureCode 1..1CS
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... code 1..1stringRequired Pattern: S
..... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
..... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
.... assignedEntity 1..1AssignedEntity
..... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... id 1..*II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
...... extension 0..1string
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr I1..*USRealmAddressADUSFIELDED
..... telecom 1..*TEL
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1uri
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 1..1Person
...... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name I1..*USRealmPersonNamePNUSFIELDED
...... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
..... representedOrganization 0..1Organization
... Slices for authenticator 0..*AuthenticatorThe authenticator identifies a participant or participants who attest to the accuracy of the information in the document.
Slice: Unordered, Open by value:signatureCode, value:assignedEntity
.... authenticator:authenticator1 0..*Authenticator
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUTHEN
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... time I1..1USRealmDateandTimeDTMUSFIELDED
..... signatureCode 1..1CS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... code 1..1stringRequired Pattern: S
...... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
...... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
..... sdtcSignatureText 0..1EDXML: signatureText (urn:hl7-org:sdtc)
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... assigningAuthorityName 0..1string
....... displayable 0..1boolean
....... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
....... extension 0..1string
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Healthcare Provider Taxonomy (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I1..*USRealmAddressADUSFIELDED
...... telecom 1..*TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1uri
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..1codeBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name I1..*USRealmPersonNamePNUSFIELDED
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... representedOrganization 0..1Organization
... Slices for participant 0..*Participant1If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF).
Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
.... participant:participant1 I0..1Participant1
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... functionCode 0..1CE
..... time 0..1IVL_TS
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1codeBinding: RoleClassAssociative (required)
...... templateId 0..*II
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... associatedPerson 1..1Person
....... classCode 1..1codeBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name I1..1USRealmPersonNamePNUSFIELDED
....... sdtcAsPatientRelationship 0..*CEXML: asPatientRelationship (urn:hl7-org:sdtc)
...... scopingOrganization 0..1Organization
... inFulfillmentOf 0..*InFulfillmentOfAn inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: FLFS
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... order 1..1Order
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMoodIntent (required)
Fixed Value: RQO
..... templateId 0..*II
..... id 1..*IIDICOM Accession Number in the DICOM imaging and report data
..... code 0..1CEBinding: v3 Code System ActCode (extensible)
..... priorityCode 0..1CEBinding: ActPriority (extensible)
... Slices for documentationOf 0..*DocumentationOfEach serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure.
Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
.... documentationOf:All Slices Content/Rules for all slices
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... serviceEvent 1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... classCode 1..1codeBinding: ActClass (required)
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..*II
...... code 0..1CE
...... effectiveTime 1..1IVL_TS
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1dateTime
....... inclusive 0..1boolean
....... operator 0..1code
....... low 1..1TS
....... high 0..1TS
....... width 0..1PQ
....... center 0..1TS
...... performer 0..*Performer1The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... typeCode 1..1codeBinding: x_ServiceEventPerformer (required)
Fixed Value: DOC
....... realmCode 0..*CS
....... typeId 0..1II
....... templateId 0..*II
....... functionCode 0..1CE
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ code 0..1stringBinding: Care Team Member Function (preferred)
........ codeSystem 0..1string
........ codeSystemName 0..1string
........ codeSystemVersion 0..1string
........ displayName 0..1string
........ sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
........ sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time 0..1IVL_TS
....... assignedEntity 1..1AssignedEntity
........ classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ templateId 0..*II
........ id 1..*II
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... assigningAuthorityName 0..1string
......... displayable 0..1boolean
......... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
......... extension 0..1string
........ sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
.... documentationOf:documentationOf1 1..1DocumentationOf
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... serviceEvent 1..1ServiceEventA serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
...... classCode 1..1codeBinding: ActClass (required)
Required Pattern: ACT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..*II
...... code I1..1CE1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
...... effectiveTime 1..1IVL_TS
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value 0..1dateTime
....... inclusive 0..1boolean
....... operator 0..1code
....... low 1..1TS
....... high 0..1TS
....... width 0..1PQ
....... center 0..1TS
...... performer 0..*PhysicianReadingStudyPerformerThe performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... typeCode 1..1codeBinding: x_ServiceEventPerformer (required)
Fixed Value: DOC
....... realmCode 0..*CS
....... typeId 0..1II
....... templateId 0..*II
....... functionCode 0..1CE
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ code 0..1stringBinding: Care Team Member Function (preferred)
........ codeSystem 0..1string
........ codeSystemName 0..1string
........ codeSystemVersion 0..1string
........ displayName 0..1string
........ sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
........ sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
........ originalText 0..1ED
........ translation 0..*CD
....... time 0..1IVL_TS
....... assignedEntity 1..1AssignedEntity
........ classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
........ templateId 0..*II
........ id 1..*II
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... assigningAuthorityName 0..1string
......... displayable 0..1boolean
......... root 0..1stringRequired Pattern: 2.16.840.1.113883.4.6
......... extension 0..1string
........ sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
........ code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
... relatedDocument I0..1RelatedDocumentA DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document.
1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... parentDocument 1..1ParentDocument
..... classCode 1..1codeBinding: ActClassClinicalDocument (required)
Fixed Value: DOCCLIN
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id I1..1II1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031).
1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
..... code 0..1CD​Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
..... text 0..1ED
..... setId 0..1II
..... versionNumber 0..1INT
... Slices for authorization 0..*AuthorizationThe authorization element represents information about the patient?s consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document.
Slice: Unordered, Open by value:consent
.... authorization:authorization1 0..*Authorization
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... consent 1..1Consent
...... classCode 1..1codeBinding: ActClass (required)
Fixed Value: CONS
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... 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..1Fixed Value: completed
... componentOf 0..1ComponentOfThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... encompassingEncounter 1..1EncompassingEncounterThe id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
..... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id I1..*II1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
..... code 0..1CEBinding: ActEncounterCode (extensible)
..... effectiveTime I1..1USRealmDateandTimeDTUSFIELDED
..... sdtcAdmissionReferralSourceCode 0..1CEXML: admissionReferralSourceCode (urn:hl7-org:sdtc)
..... dischargeDispositionCode 0..1CE​Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible)
..... responsibleParty 0..1Element
...... typeCode 1..1codeBinding: ParticipationType (required)
Fixed Value: RESP
...... assignedEntity I1..1AssignedEntity1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
..... encounterParticipant 0..1PhysicianofRecordParticipant
..... location 0..1Element
...... typeCode 1..1codeBinding: ParticipationTargetLocation (required)
Fixed Value: LOC
...... healthCareFacility 1..1HealthCareFacility
... component 1..1Component2
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... contextConductionInd 1..1boolean
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... nonXMLBody 0..1NonXMLBody
.... structuredBody 1..1StructuredBody
..... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCBODY
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: HumanLanguage (required)
..... Slices for component 1..*ElementSlice: Unordered, Open by value:ClinicalDocument.section
...... component:All Slices Content/Rules for all slices
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1Section
...... component:component1 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1FindingsSectionDIR
...... component:component2 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1DICOMObjectCatalogSectionDCM1211811198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
...... component:component3 0..*Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1Section1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211).
1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
........ ID 0..1string
........ nullFlavor 0..1codeBinding: NullFlavor (required)
........ classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
........ moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
........ templateId 0..*II
........ id 0..1II
........ code 1..1CEBinding: DocumentSectionType (extensible)
......... nullFlavor 0..1codeBinding: NullFlavor (required)
......... code 1..1stringThe section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined
Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (preferred)
......... codeSystem 0..1string
......... codeSystemName 0..1string
......... codeSystemVersion 0..1string
......... displayName 0..1string
......... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
......... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
......... originalText 0..1ED
......... translation 0..*CD
........ title 0..1EDThere is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
........ text SI0..1xhtml1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060).
1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061).
1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
........ confidentialityCode 0..1CE
........ languageCode 0..1CSBinding: HumanLanguage (required)
........ subject 0..*Element
......... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
......... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
......... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
......... relatedSubject 1..1FetusSubjectContext
........ Slices for author 0..*AuthorThis author element is used when the author of a section is different from the author(s) listed in the Header
Slice: Unordered, Open by value:assignedAuthor
......... author:author1 0..*Author
.......... nullFlavor 0..1codeBinding: NullFlavor (required)
.......... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.......... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
.......... realmCode 0..*CS
.......... typeId 0..1II
.......... templateId 0..*II
.......... functionCode 0..1CE
.......... time 1..1TS
.......... assignedAuthor I1..1ObserverContext
........ informant 0..*Element
......... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
......... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
......... assignedEntity 0..1AssignedEntity
......... relatedEntity 0..1RelatedEntity
........ Slices for entry I0..*ElementSlice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
......... entry:All Slices Content/Rules for all slices
.......... typeCode 1..1code
.......... contextConductionInd 1..1boolean
.......... (Choice of one) 1..1
........... observation 0..1Observation
........... regionOfInterest 0..1RegionOfInterest
........... observationMedia 0..1ObservationMedia
........... substanceAdministration 0..1SubstanceAdministration
........... supply 0..1Supply
........... procedure 0..1Procedure
........... encounter 0..1Encounter
........... organizer 0..1Organizer
........... act 0..1Act
........ entry I0..*ElementIf the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... act I1..1ProcedureContext
........ entry:textObs I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation 1..1TextObservation
........ entry:entry3 I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation I1..1CodeObservations
........ entry:entry4 I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation 1..1QuantityMeasurementObservation
........ entry:entry5 I0..*Element
......... typeCode 1..1code
......... contextConductionInd 1..1boolean
......... observation 1..1SOPInstanceObservation
........ component I0..*Element1198-31210: **SHALL** contain child elements (CONF:1198-31210).
......... typeCode 1..1codeFixed Value: COMP
......... contextConductionInd 1..1boolean
......... section 1..1Section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.typeId.nullFlavorrequiredNullFlavor
ClinicalDocument.templateId:primary.nullFlavorrequiredNullFlavor
ClinicalDocument.templateId:secondary.nullFlavorrequiredNullFlavor
ClinicalDocument.id.nullFlavorrequiredNullFlavor
ClinicalDocument.codeextensible​http://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.code.nullFlavorrequiredNullFlavor
ClinicalDocument.code.codepreferredhttp://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeextensibleRaceValueSet
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCodeextensibleDetailedEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredNullFlavor
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.classCoderequiredFixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredNullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavorrequiredPattern: UNK
ClinicalDocument.author.assignedAuthor.codeextensibleRoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeextensibleEntityCode
ClinicalDocument.dataEnterer.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant1.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant2.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.custodian.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavorrequiredNullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.typeCoderequiredFixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.codeextensibleRoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant1.nullFlavorrequiredNullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredParticipationType
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredRoleClassAssociative
ClinicalDocument.participant:participant1.associatedEntity.codeextensibleRoleCode
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeextensibleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeextensibleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredActClass
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.documentationOf:documentationOf1.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCoderequiredPattern: ACT
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.relatedDocument.nullFlavorrequiredNullFlavor
ClinicalDocument.relatedDocument.typeCoderequiredParticipationType
ClinicalDocument.relatedDocument.parentDocument.classCoderequiredFixed Value: DOCCLIN
ClinicalDocument.relatedDocument.parentDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.relatedDocument.parentDocument.codeextensible​http://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.authorization:authorization1.nullFlavorrequiredNullFlavor
ClinicalDocument.authorization:authorization1.typeCoderequiredFixed Value: AUT
ClinicalDocument.authorization:authorization1.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.codeextensibleActCode
ClinicalDocument.authorization:authorization1.consent.statusCoderequiredActStatus
ClinicalDocument.componentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: AUT
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.codeextensibleActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeextensible​http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
ClinicalDocument.component.nullFlavorrequiredNullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: AUT
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
ClinicalDocument.component.structuredBody.languageCoderequiredHumanLanguage
ClinicalDocument.component.structuredBody.component:component3.section.nullFlavorrequiredNullFlavor
ClinicalDocument.component.structuredBody.component:component3.section.classCoderequiredFixed Value: DOCSECT
ClinicalDocument.component.structuredBody.component:component3.section.moodCoderequiredFixed Value: EVN
ClinicalDocument.component.structuredBody.component:component3.section.codeextensibleDocumentSectionType
ClinicalDocument.component.structuredBody.component:component3.section.code.nullFlavorrequiredNullFlavor
ClinicalDocument.component.structuredBody.component:component3.section.code.codepreferredhttp://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59
ClinicalDocument.component.structuredBody.component:component3.section.languageCoderequiredHumanLanguage
ClinicalDocument.component.structuredBody.component:component3.section.subject.typeCoderequiredFixed Value: SBJ
ClinicalDocument.component.structuredBody.component:component3.section.subject.contextControlCoderequiredFixed Value: OP
ClinicalDocument.component.structuredBody.component:component3.section.subject.awarenessCodeextensibleTargetAwareness
ClinicalDocument.component.structuredBody.component:component3.section.author:author1.nullFlavorrequiredNullFlavor
ClinicalDocument.component.structuredBody.component:component3.section.author:author1.typeCoderequiredFixed Value: AUT
ClinicalDocument.component.structuredBody.component:component3.section.author:author1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.component.structuredBody.component:component3.section.informant.typeCoderequiredFixed Value: INF
ClinicalDocument.component.structuredBody.component:component3.section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
1198-32937errorClinicalDocument.templateId:secondaryWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32937).
:
1198-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:1198-9991).
:
1198-30934errorClinicalDocument.id.rootThe ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+
:
1198-30935errorClinicalDocument.id.rootOIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
:
1198-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992).
:
1198-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948).
:
81-10127errorClinicalDocument.effectiveTime**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTimeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
1198-6380errorClinicalDocument.setIdIf setId is present versionNumber **SHALL** be present (CONF:1198-6380).
:
1198-6387errorClinicalDocument.versionNumberIf versionNumber is present setId **SHALL** be present (CONF:1198-6387).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
1198-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:1198-5299).
:
1198-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:1198-5300).
:
1198-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:1198-32418). For cases where information about newborn's time of birth needs to be captured.
:
81-7296errorClinicalDocument.recordTarget.patientRole.patient.guardian.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.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.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
1198-5402warningClinicalDocument.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:1198-5402).
:
1198-5403warningClinicalDocument.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:1198-5403).
:
81-7296errorClinicalDocument.recordTarget.patientRole.providerOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-10127errorClinicalDocument.author.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.author.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.author.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.author.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
1198-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790).
:
1198-5449nullClinicalDocument.author.assignedAuthor.idIf this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
:
81-7296errorClinicalDocument.author.assignedAuthor.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.author.assignedAuthor.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.author.assignedAuthor.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-7296errorClinicalDocument.dataEnterer.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
1198-9946warningClinicalDocument.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:1198-9946).
:
81-7296errorClinicalDocument.informant:informant1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.informant:informant1.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.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-7296errorClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
1198-8412warningClinicalDocument.informationRecipientThe physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412).
:
1198-8413warningClinicalDocument.informationRecipientWhen no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
:
81-9371errorClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.legalAuthenticator.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.legalAuthenticator.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.legalAuthenticator.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.legalAuthenticator.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
81-7296errorClinicalDocument.legalAuthenticator.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
81-7296errorClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.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.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
1198-10006errorClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
:
1198-10007warningClinicalDocument.participant:participant1When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
:
81-9371errorClinicalDocument.participant:participant1.associatedEntity.associatedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.participant:participant1.associatedEntity.associatedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
1198-8420errorClinicalDocument.documentationOf:documentationOf1.serviceEvent.codeThe value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
:
1198-8433warningClinicalDocument.relatedDocumentWhen a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
:
1198-10031errorClinicalDocument.relatedDocument.parentDocument.idOIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031).
:
1198-10032errorClinicalDocument.relatedDocument.parentDocument.idOIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
:
1198-30942warningClinicalDocument.componentOf.encompassingEncounter.idIn the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
:
81-10078errorClinicalDocument.componentOf.encompassingEncounter.effectiveTime**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningClinicalDocument.componentOf.encompassingEncounter.effectiveTime**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningClinicalDocument.componentOf.encompassingEncounter.effectiveTime**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
1198-30947warningClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity**SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
:
81-8532warningClinicalDocument.component.structuredBody.component:component1.sectionThis section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532).
:
81-8527warningClinicalDocument.component.structuredBody.component:component2.sectionA DICOM Object Catalog SHALL be present if the document contains references to DICOM Images. If present, it SHALL be the first section in the document (CONF:81-8527).
:
1198-31206errorClinicalDocument.component.structuredBody.component:component2.sectionThe DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
:
1198-31211errorClinicalDocument.component.structuredBody.component:component3.sectionAll sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211).
:
1198-31212errorClinicalDocument.component.structuredBody.component:component3.section**SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
:
1198-31060errorClinicalDocument.component.structuredBody.component:component3.section.textIf clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060).
:
1198-31061errorClinicalDocument.component.structuredBody.component:component3.section.textAll text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061).
:
1198-31062warningClinicalDocument.component.structuredBody.component:component3.section.textThe text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
:
81-9198errorClinicalDocument.component.structuredBody.component:component3.section.author:author1.assignedAuthorEither assignedPerson or assignedAuthoringDevice SHALL be present (CONF:81-9198).
:
only-one-statementerrorClinicalDocument.component.structuredBody.component:component3.section.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
81-9199warningClinicalDocument.component.structuredBody.component:component3.section.entry.actProcedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
:
only-one-statementerrorClinicalDocument.component.structuredBody.component:component3.section.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
81-9199warningClinicalDocument.component.structuredBody.component:component3.section.entry.actProcedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
:
only-one-statementerrorClinicalDocument.component.structuredBody.component:component3.section.entry:textObsSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorClinicalDocument.component.structuredBody.component:component3.section.entry:entry3SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
81-9310warningClinicalDocument.component.structuredBody.component:component3.section.entry:entry3.observationCode Observations SHALL be rendered into section/text in separate paragraphs (CONF:81-9310).
:
only-one-statementerrorClinicalDocument.component.structuredBody.component:component3.section.entry:entry4SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorClinicalDocument.component.structuredBody.component:component3.section.entry:entry5SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
1198-31210errorClinicalDocument.component.structuredBody.component:component3.section.component**SHALL** contain child elements (CONF:1198-31210).
: