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: Operative Note (V3)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.7 Version: 2.2
Active as of 2022-05-13 Computable Name: OperativeNote
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.7:2015-08-01

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.

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: 29 elements (15 nested mandatory elements)

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.documentationOf.serviceEvent.performer is sliced based on the values of value:assignedEntity, value:typeCode, value:functionCode
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section

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..1II1198-32940: 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:1198-32940).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... serviceEvent I1..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.
1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
..... effectiveTime I1..1USRealmDateandTimeDTUSFIELDED1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488).
1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058).
1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
..... Slices for performer 0..*Performer1This performer represents any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
...... performer:performer1 1..1Performer1This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... typeCode 1..1codeRequired Pattern: PPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity 1..1AssignedEntity
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... performer:performer2 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.
....... typeCode 1..1codeRequired Pattern: SPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity 1..1AssignedEntity
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
.... typeCode 1..1codeRequired Pattern: AUTH
.... consent 1..1Consent
..... classCode 1..1codeRequired Pattern: CONS
..... moodCode 1..1codeRequired Pattern: EVN
..... statusCode 1..1CS
... component 1..1Component2
.... structuredBody 1..1StructuredBody
..... Slices for component 1..*ElementSlice: Unordered, Open by value:ClinicalDocument.section
...... component:component1 1..1Element
....... section 1..1AnesthesiaSection
...... component:component2 1..1Element
....... section 1..1ComplicationsSection
...... component:component3 1..1Element
....... section 1..1PreoperativeDiagnosisSection
...... component:component4 1..1Element
....... section 1..1ProcedureEstimatedBloodLossSection
...... component:component5 1..1Element
....... section 1..1ProcedureFindingsSection
...... component:component6 1..1Element
....... section 1..1ProcedureSpecimensTakenSection
...... component:component7 1..1Element
....... section 1..1ProcedureDescriptionSection
...... component:component8 1..1Element
....... section 1..1PostoperativeDiagnosisSection
...... component:component9 0..1Element
....... section 1..1ProcedureImplantsSection
...... component:component10 0..1Element
....... section 1..1OperativeNoteFluidsSection
...... component:component11 0..1Element
....... section 1..1OperativeNoteSurgicalProcedureSection
...... component:component12 0..1Element
....... section 1..1PlanofTreatmentSection
...... component:component13 0..1Element
....... section 1..1PlannedProcedureSection
...... component:component14 0..1Element
....... section 1..1ProcedureDispositionSection
...... component:component15 0..1Element
....... section 1..1ProcedureIndicationsSection
...... component:component16 0..1Element
....... section 1..1SurgicalDrainsSection

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..1II1198-32940: 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:1198-32940).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... extension 1..1stringRequired Pattern: 2015-08-01
... id I1..1II
... code I1..1CE​The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
.... 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
... Slices for informant 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
Slice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id I1..*II1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr I1..*USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... 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
..... relatedEntity 0..1RelatedEntity
.... informant:informant2 0..*Informant
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 0..1AssignedEntity
..... relatedEntity 1..1RelatedEntity
... 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 0..*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.
.... 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..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by
.... participant:participant1 I0..*Participant11198-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
1198-10007: When 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).
..... 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
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray.
.... 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..*II
..... code 0..1CEBinding: v3 Code System ActCode (extensible)
..... priorityCode 0..1CEBinding: ActPriority (extensible)
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... serviceEvent I1..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.
1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 0..*II
..... code 0..1CE
..... effectiveTime I1..1USRealmDateandTimeDTUSFIELDED1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488).
1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058).
1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
...... 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
..... Slices for performer 0..*Performer1This performer represents any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
...... performer:All Slices Content/Rules for all slices
....... 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
...... performer:performer1 1..1Performer1This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... 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..1CEBinding: Care Team Member Function (preferred)
........ 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 (required)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
...... performer:performer2 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..1CEBinding: Care Team Member Function (preferred)
........ 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 (required)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
... relatedDocument 0..*RelatedDocument
... Slices for authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
Slice: Unordered, Open by value:consent
.... authorization:All Slices Content/Rules for all slices
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..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..1CEBinding: v3 Code System ActCode (extensible)
...... statusCode 1..1CSBinding: ActStatus (required)
....... code 1..1Fixed Value: completed
.... 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 encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... encompassingEncounter 1..1EncompassingEncounter
..... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 1..*II
..... code 0..1CEBinding: ActEncounterCode (extensible)
..... effectiveTime 1..1IVL_TS
..... 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 1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... 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 1..1AnesthesiaSection
...... component:component2 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ComplicationsSection
...... component:component3 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PreoperativeDiagnosisSection
...... component:component4 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1ProcedureEstimatedBloodLossSection
...... component:component5 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureFindingsSection
...... component:component6 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1ProcedureSpecimensTakenSection
...... component:component7 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureDescriptionSection
...... component:component8 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PostoperativeDiagnosisSection
...... component:component9 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1ProcedureImplantsSection
...... component:component10 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1OperativeNoteFluidsSection
...... component:component11 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1OperativeNoteSurgicalProcedureSection
...... component:component12 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PlanofTreatmentSection
...... component:component13 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PlannedProcedureSection
...... component:component14 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureDispositionSection
...... component:component15 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureIndicationsSection
...... component:component16 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1SurgicalDrainsSection

doco Documentation for this format

This structure is derived from USRealmHeader

Summary

Mandatory: 29 elements (15 nested mandatory elements)

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.documentationOf.serviceEvent.performer is sliced based on the values of value:assignedEntity, value:typeCode, value:functionCode
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section

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..1II1198-32940: 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:1198-32940).
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CEThe Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... serviceEvent I1..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.
1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
..... effectiveTime I1..1USRealmDateandTimeDTUSFIELDED1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488).
1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058).
1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
..... Slices for performer 0..*Performer1This performer represents any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
...... performer:performer1 1..1Performer1This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... typeCode 1..1codeRequired Pattern: PPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity 1..1AssignedEntity
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
...... performer:performer2 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.
....... typeCode 1..1codeRequired Pattern: SPRF
....... functionCode 0..1CEBinding: Care Team Member Function (preferred)
....... assignedEntity 1..1AssignedEntity
........ code 0..1CEBinding: Healthcare Provider Taxonomy (required)
.... typeCode 1..1codeRequired Pattern: AUTH
.... consent 1..1Consent
..... classCode 1..1codeRequired Pattern: CONS
..... moodCode 1..1codeRequired Pattern: EVN
..... statusCode 1..1CS
... component 1..1Component2
.... structuredBody 1..1StructuredBody
..... Slices for component 1..*ElementSlice: Unordered, Open by value:ClinicalDocument.section
...... component:component1 1..1Element
....... section 1..1AnesthesiaSection
...... component:component2 1..1Element
....... section 1..1ComplicationsSection
...... component:component3 1..1Element
....... section 1..1PreoperativeDiagnosisSection
...... component:component4 1..1Element
....... section 1..1ProcedureEstimatedBloodLossSection
...... component:component5 1..1Element
....... section 1..1ProcedureFindingsSection
...... component:component6 1..1Element
....... section 1..1ProcedureSpecimensTakenSection
...... component:component7 1..1Element
....... section 1..1ProcedureDescriptionSection
...... component:component8 1..1Element
....... section 1..1PostoperativeDiagnosisSection
...... component:component9 0..1Element
....... section 1..1ProcedureImplantsSection
...... component:component10 0..1Element
....... section 1..1OperativeNoteFluidsSection
...... component:component11 0..1Element
....... section 1..1OperativeNoteSurgicalProcedureSection
...... component:component12 0..1Element
....... section 1..1PlanofTreatmentSection
...... component:component13 0..1Element
....... section 1..1PlannedProcedureSection
...... component:component14 0..1Element
....... section 1..1ProcedureDispositionSection
...... component:component15 0..1Element
....... section 1..1ProcedureIndicationsSection
...... component:component16 0..1Element
....... section 1..1SurgicalDrainsSection

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..1II1198-32940: 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:1198-32940).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.1.7
..... extension 1..1stringRequired Pattern: 2015-08-01
... id I1..1II
... code I1..1CE​The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
.... 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
... Slices for informant 0..*InformantThe informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient.
Slice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*InformantThe informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id I1..*II1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
...... addr I1..*USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... 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
..... relatedEntity 0..1RelatedEntity
.... informant:informant2 0..*Informant
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: INF
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... assignedEntity 0..1AssignedEntity
..... relatedEntity 1..1RelatedEntity
... 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 0..*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.
.... 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..*Participant1The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).
Slice: Unordered, Open by
.... participant:participant1 I0..*Participant11198-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
1198-10007: When 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).
..... 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
... inFulfillmentOf 0..*InFulfillmentOfThe inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray.
.... 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..*II
..... code 0..1CEBinding: v3 Code System ActCode (extensible)
..... priorityCode 0..1CEBinding: ActPriority (extensible)
... documentationOf 1..*DocumentationOfA serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: DOC
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... serviceEvent I1..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.
1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
..... classCode 1..1codeBinding: ActClass (required)
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 0..*II
..... code 0..1CE
..... effectiveTime I1..1USRealmDateandTimeDTUSFIELDED1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488).
1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058).
1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
...... 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
..... Slices for performer 0..*Performer1This performer represents any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
...... performer:All Slices Content/Rules for all slices
....... 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
...... performer:performer1 1..1Performer1This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
....... 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..1CEBinding: Care Team Member Function (preferred)
........ 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 (required)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
...... performer:performer2 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..1CEBinding: Care Team Member Function (preferred)
........ 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 (required)
........ addr 0..*AD
........ telecom 0..*TEL
........ assignedPerson 0..1Person
........ representedOrganization 0..1Organization
... relatedDocument 0..*RelatedDocument
... Slices for authorization 0..1AuthorizationAuthorization represents consent. Consent, if present, shall be represented by authorization/consent.
Slice: Unordered, Open by value:consent
.... authorization:All Slices Content/Rules for all slices
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..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..1CEBinding: v3 Code System ActCode (extensible)
...... statusCode 1..1CSBinding: ActStatus (required)
....... code 1..1Fixed Value: completed
.... 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 encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 0..1codeBinding: ParticipationType (required)
Fixed Value: AUT
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... encompassingEncounter 1..1EncompassingEncounter
..... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
..... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
..... templateId 0..*II
..... id 1..*II
..... code 0..1CEBinding: ActEncounterCode (extensible)
..... effectiveTime 1..1IVL_TS
..... 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 1..1AssignedEntity
..... encounterParticipant 0..*EncounterParticipant
..... 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 1..1AnesthesiaSection
...... component:component2 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ComplicationsSection
...... component:component3 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PreoperativeDiagnosisSection
...... component:component4 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1ProcedureEstimatedBloodLossSection
...... component:component5 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureFindingsSection
...... component:component6 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1ProcedureSpecimensTakenSection
...... component:component7 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureDescriptionSection
...... component:component8 1..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PostoperativeDiagnosisSection
...... component:component9 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1ProcedureImplantsSection
...... component:component10 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1OperativeNoteFluidsSection
...... component:component11 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1OperativeNoteSurgicalProcedureSection
...... component:component12 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PlanofTreatmentSection
...... component:component13 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1PlannedProcedureSection
...... component:component14 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureDispositionSection
...... component:component15 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1ProcedureIndicationsSection
...... component:component16 0..1Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section I1..1SurgicalDrainsSection

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.codeextensible​http://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.code.nullFlavorrequiredNullFlavor
ClinicalDocument.code.coderequiredhttp://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1
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.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.serviceEvent.performer:performer1.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCodepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.coderequiredHealthcareProviderTaxonomy
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCodepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.coderequiredHealthcareProviderTaxonomy
ClinicalDocument.authorization.nullFlavorrequiredNullFlavor
ClinicalDocument.authorization.typeCoderequiredFixed Value: AUT
ClinicalDocument.authorization.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization.consent.codeextensibleActCode
ClinicalDocument.authorization.consent.statusCoderequiredActStatus
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

Constraints

IdGradePathDetailsRequirements
1198-32940errorClinicalDocument.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:1198-32940).
:
1198-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:1198-9991).
:
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).
:
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).
:
1198-8487errorClinicalDocument.documentationOf.serviceEventThe value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
:
81-10078errorClinicalDocument.documentationOf.serviceEvent.effectiveTime**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningClinicalDocument.documentationOf.serviceEvent.effectiveTime**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningClinicalDocument.documentationOf.serviceEvent.effectiveTime**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
1198-8488errorClinicalDocument.documentationOf.serviceEvent.effectiveTimeThe serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488).
:
1198-10058errorClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058).
:
1198-10060errorClinicalDocument.documentationOf.serviceEvent.effectiveTimeWhen only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
:
81-8741warningClinicalDocument.component.structuredBody.component:component4.sectionThe Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741).
:
81-8742warningClinicalDocument.component.structuredBody.component:component6.sectionThe Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742).
:
81-8769errorClinicalDocument.component.structuredBody.component:component9.sectionThe Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769).
:
81-8052warningClinicalDocument.component.structuredBody.component:component10.sectionIf the Operative Note Fluids section is present, there SHALL be a statement providing details of the fluids administered or SHALL explicitly state there were no fluids administered (CONF:81-8052).
:
81-8054warningClinicalDocument.component.structuredBody.component:component11.sectionIf the surgical procedure section is present there SHALL be text indicating the procedure performed (CONF:81-8054).
:
81-8056warningClinicalDocument.component.structuredBody.component:component16.sectionIf the Surgical Drains section is present, there SHALL be a statement providing details of the drains placed or SHALL explicitly state there were no drains placed (CONF:81-8056).
: