Consolidated CDA Release 2.2
2.2 - CI Build
Consolidated CDA Release 2.2
2.2 - CI Build
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
| Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.29.1 | Version: 2.2 | |||
| Active as of 2022-05-13 | Computable Name: USRealmHeaderforPatientGeneratedDocument | |||
| Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.29.1:2015-08-01 | ||||
This template is designed to be used in conjunction with the US Realm Header (V2). It includes additional conformances which further constrain the US Realm Header (V2). The Patient Generated Document Header template is not a separate document type. The document body may contain any structured or unstructured content from C-CDA.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
Summary
Mandatory: 14 elements (15 nested mandatory elements)
Slices
This structure defines the following Slices:
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalDocument | 1..1 | USRealmHeader | ||
  Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:secondary | I | 1..1 | II | 1198-32945: 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:1198-32945). |
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
  extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient?s language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child?s parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child?s mom or "father" for the child?s dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
 patientRole | 1..1 | PatientRole | ||
 id | 1..* | II | ||
| patient | 1..1 | Patient | ||
| guardian | 0..* | Guardian | ||
| id | 0..* | II | ||
 code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| languageCommunication | 0..* | LanguageCommunication | ||
| preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
| providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. undefined | |
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient?s advocate. | |
| assignedAuthor | 1..1 | AssignedAuthor | ||
| id | 1..* | II | ||
| code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. | |
| code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| Slices for informant | 0..* | Informant | The informant element describes the source of the information in a medical document.
Assigned health care providers may be a source of information when a document is created. (e.g., a nurse's aide who provides information about a recent significant health care event that occurred within an acute care facility.) In these cases, the assignedEntity element is used.
When the informant is a personal relation, that informant is represented in the relatedEntity element, even if the personal relation is a medical professional. The code element of the relatedEntity describes the relationship between the informant and the patient. The relationship between the informant and the patient needs to be described to help the receiver of the clinical document understand the information in the document.
Each informant can be either an assignedEntity (a clinician serving the patient) OR a relatedEntity (a person with a personal or legal relationship with the patient). The constraints here apply to relatedEntity. Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | The 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. | |
 relatedEntity | 1..1 | RelatedEntity | ||
| code | 0..1 | CE | ||
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
| assignedCustodian | 1..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
| id | 1..* | II | The combined @root and @extension attributes record the custodian organization?s identity in a secure, trusted, and unique way. | |
| informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
| intendedRecipient | 1..1 | IntendedRecipient | ||
| id | 0..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| root | 0..1 | string | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
| legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| code | 0..1 | CE | ||
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | The combined @root and @extension attributes to record the authenticator?s identity in a secure, trusted, and unique way. | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| participant | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants 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) | |
| typeCode | 1..1 | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 | ||
| associatedEntity | 1..1 | |||
| code | 0..1 | Binding: Personal And Legal Relationship Role Type (preferred) | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
| order | 1..1 | Order | ||
| id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
| documentationOf | 0..* | DocumentationOf | ||
| serviceEvent | 1..1 | ServiceEvent | A 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. | |
| code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
| performer | 0..* | Performer1 | The 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. | |
| functionCode | 0..1 | CE | The functionCode SHALL be selected from value set ParticipationType 2.16.840.1.113883.1.11.10901 When indicating the performer was the primary care physician the functionCode shall be =?PCP? | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | The combined @root and @extension attributes record the performer?s identity in a secure, trusted, and unique way. | |
| code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | ||
 classCode | 1..1 | code | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
 realmCode | 1..1 | CS | Required Pattern: US | |
| typeId | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.1.3 | |
| extension | 1..1 | string | Required Pattern: POCD_HD000040 | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
 templateId:primary | 1..1 | II | ||
 nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| templateId:secondary | I | 1..1 | II | 1198-32945: 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:1198-32945). |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | I | 1..1 | II | |
| code | I | 1..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) |
| title | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| setId | I | 0..1 | II | |
| versionNumber | I | 0..1 | INT | |
| copyTime | 0..1 | TS | ||
| recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient?s language of preference and the predominant language used by the organization receiving the CDA.
HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child?s parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child?s mom or "father" for the child?s dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| patientRole | 1..1 | PatientRole | ||
| classCode | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
 useablePeriod | 0..* | |||
 useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..1 | II | ||
| name | I | 1..* | USRealmPatientNamePTNUSFIELDED | |
| sdtcDesc | 0..1 | ED | XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | I | 1..1 | TS | |
| sdtcDeceasedInd | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthInd | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible) | |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible) | |
| guardian | 0..* | Guardian | ||
| classCode | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | I | 0..* | USRealmAddressADUSFIELDED | |
| telecom | 0..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| classCode | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| templateId | 0..* | II | ||
| place | 1..1 | Place | ||
| classCode | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 0..1 | EN | ||
| addr | I | 1..1 | AD | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| isNotOrdered | 0..1 | boolean | ||
| use | 0..* | code | ||
| delimiter | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DEL | |
| country | 0..1 | ADXP | ||
| partType | 0..1 | code | Fixed Value: CNT | |
| state | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STA | |
| county | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CPA | |
| city | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CTY | |
| postalCode | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: ZIP | |
| streetAddressLine | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: SAL | |
| houseNumber | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: BNR | |
| houseNumberNumeric | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: BNN | |
| direction | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DIR | |
| streetName | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STR | |
| streetNameBase | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STB | |
| streetNameType | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STTYP | |
| additionalLocator | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: ADL | |
| unitID | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: UNID | |
| unitType | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: UNIT | |
| careOf | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CAR | |
| censusTract | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CEN | |
| deliveryAddressLine | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DAL | |
| deliveryInstallationType | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DINST | |
| deliveryInstallationArea | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DINSTQ | |
| deliveryMode | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DMOD | |
| deliveryModeIdentifier | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DMODID | |
| buildingNumberSuffix | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: BNS | |
| postBox | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: POB | |
| precinct | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: PRE | |
| other | 0..1 | string | ||
| useablePeriod[x] | 0..* | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS | IVL_TS | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS | EIVL_TS | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS | PIVL_TS | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS | SXPR_TS | |||
| languageCommunication | 0..* | LanguageCommunication | ||
| templateId | 0..* | II | ||
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
| providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. undefined | |
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| name | 1..* | ON | ||
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient?s advocate. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| assignedAuthor | I | 1..1 | AssignedAuthor | |
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root |
| id:id1 | 0..1 | II | ||
| nullFlavor | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. Binding: v3 Code System RoleCode (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 0..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| classCode | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: EntityCode (extensible) | |
| manufacturerModelName | 1..1 | SC | ||
| softwareName | 1..1 | SC | ||
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 1..1 | TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for informant | 0..* | Informant | The informant element describes the source of the information in a medical document.
Assigned health care providers may be a source of information when a document is created. (e.g., a nurse's aide who provides information about a recent significant health care event that occurred within an acute care facility.) In these cases, the assignedEntity element is used.
When the informant is a personal relation, that informant is represented in the relatedEntity element, even if the personal relation is a medical professional. The code element of the relatedEntity describes the relationship between the informant and the patient. The relationship between the informant and the patient needs to be described to help the receiver of the clinical document understand the information in the document.
Each informant can be either an assignedEntity (a clinician serving the patient) OR a relatedEntity (a person with a personal or legal relationship with the patient). The constraints here apply to relatedEntity. Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | The 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
 assignedEntity | 1..1 | AssignedEntity | ||
 classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | I | 1..* | II | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassMutualRelationship (required) | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: PersonalRelationshipRoleType (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| effectiveTime | 0..1 | IVL_TS | ||
| relatedPerson | 0..1 | Person | ||
| informant:informant2 | 0..* | Informant | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes record the custodian organization?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| addr | I | 1..1 | USRealmAddressADUSFIELDED | |
| informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| classCode | 1..1 | code | ||
| templateId | 0..* | II | ||
| id | 0..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| receivedOrganization | 0..1 | Organization | ||
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| name | 1..1 | ON | ||
| telecom | 0..* | TEL | ||
| addr | 0..* | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: LA | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| signatureCode | 1..1 | CS | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: S | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for authenticator | 0..* | Authenticator | The 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:All Slices | Content/Rules for all slices | |||
 nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 1..1 | TS | ||
| signatureCode | 1..1 | CS | ||
| sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes to record the authenticator?s identity in a secure, trusted, and unique way. | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| authenticator:authenticator1 | 0..* | Authenticator | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| signatureCode | 1..1 | CS | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: S | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for participant | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants 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 | I | 0..* | Participant1 | 1198-10006: **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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | 0..1 | IVL_TS | ||
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| order | 1..1 | Order | ||
| classCode | 1..1 | code | Binding: ActClass (required) | |
| moodCode | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| templateId | 0..* | II | ||
| id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
| code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| documentationOf | 0..* | DocumentationOf | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
| classCode | 1..1 | code | Binding: ActClass (required) | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
| effectiveTime | 1..1 | IVL_TS | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | dateTime | ||
| inclusive | 0..1 | boolean | ||
| operator | 0..1 | code | ||
| low | 1..1 | TS | ||
| high | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| center | 0..1 | TS | ||
| performer | 0..* | Performer1 | The 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | The functionCode SHALL be selected from value set ParticipationType 2.16.840.1.113883.1.11.10901 When indicating the performer was the primary care physician the functionCode shall be =?PCP? | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes record the performer?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| relatedDocument | 0..* | RelatedDocument | ||
| Slices for authorization | 0..* | Authorization | The authorization element represents information about the patient?s consent.
The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?.
The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent | |
| authorization:authorization1 | 0..* | Authorization | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| consent | 1..1 | Consent | ||
| classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The 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..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | Fixed Value: completed | ||
| componentOf | 0..1 | ComponentOf | The 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
| responsibleParty | 0..1 | Element | ||
| typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| encounterParticipant | 0..* | EncounterParticipant | ||
| location | 0..1 | Element | ||
| typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component2 | ||
| Documentation for this format | ||||
This structure is derived from USRealmHeader
Summary
Mandatory: 14 elements (15 nested mandatory elements)
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:secondary | I | 1..1 | II | 1198-32945: 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:1198-32945). |
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element. If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient?s language of preference and the predominant language used by the organization receiving the CDA. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child?s parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child?s mom or "father" for the child?s dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
| patientRole | 1..1 | PatientRole | ||
| id | 1..* | II | ||
| patient | 1..1 | Patient | ||
| guardian | 0..* | Guardian | ||
| id | 0..* | II | ||
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| languageCommunication | 0..* | LanguageCommunication | ||
| preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
| providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. undefined | |
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient?s advocate. | |
| assignedAuthor | 1..1 | AssignedAuthor | ||
| id | 1..* | II | ||
| code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. | |
| code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| Slices for informant | 0..* | Informant | The informant element describes the source of the information in a medical document.
Assigned health care providers may be a source of information when a document is created. (e.g., a nurse's aide who provides information about a recent significant health care event that occurred within an acute care facility.) In these cases, the assignedEntity element is used.
When the informant is a personal relation, that informant is represented in the relatedEntity element, even if the personal relation is a medical professional. The code element of the relatedEntity describes the relationship between the informant and the patient. The relationship between the informant and the patient needs to be described to help the receiver of the clinical document understand the information in the document.
Each informant can be either an assignedEntity (a clinician serving the patient) OR a relatedEntity (a person with a personal or legal relationship with the patient). The constraints here apply to relatedEntity. Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | The 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. | |
| relatedEntity | 1..1 | RelatedEntity | ||
| code | 0..1 | CE | ||
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
| assignedCustodian | 1..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
| id | 1..* | II | The combined @root and @extension attributes record the custodian organization?s identity in a secure, trusted, and unique way. | |
| informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
| intendedRecipient | 1..1 | IntendedRecipient | ||
| id | 0..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| root | 0..1 | string | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
| legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| code | 0..1 | CE | ||
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | The combined @root and @extension attributes to record the authenticator?s identity in a secure, trusted, and unique way. | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| participant | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants 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) | |
| typeCode | 1..1 | Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 | ||
| associatedEntity | 1..1 | |||
| code | 0..1 | Binding: Personal And Legal Relationship Role Type (preferred) | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
| order | 1..1 | Order | ||
| id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
| documentationOf | 0..* | DocumentationOf | ||
| serviceEvent | 1..1 | ServiceEvent | A 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. | |
| code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
| performer | 0..* | Performer1 | The 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. | |
| functionCode | 0..1 | CE | The functionCode SHALL be selected from value set ParticipationType 2.16.840.1.113883.1.11.10901 When indicating the performer was the primary care physician the functionCode shall be =?PCP? | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | The combined @root and @extension attributes record the performer?s identity in a secure, trusted, and unique way. | |
| code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | ||
| classCode | 1..1 | code | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| realmCode | 1..1 | CS | Required Pattern: US | |
| typeId | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.1.3 | |
| extension | 1..1 | string | Required Pattern: POCD_HD000040 | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| templateId:secondary | I | 1..1 | II | 1198-32945: 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:1198-32945). |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.29.1 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | I | 1..1 | II | |
| code | I | 1..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) |
| title | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| setId | I | 0..1 | II | |
| versionNumber | I | 0..1 | INT | |
| copyTime | 0..1 | TS | ||
| recordTarget | 1..1 | RecordTarget | The recordTarget records the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element.
If the document receiver is interested in setting up a translator for the encounter with the patient, the receiver of the document will have to infer the need for a translator, based upon the language skills identified for the patient, the patient?s language of preference and the predominant language used by the organization receiving the CDA.
HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child?s parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child?s mom or "father" for the child?s dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| patientRole | 1..1 | PatientRole | ||
| classCode | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..1 | II | ||
| name | I | 1..* | USRealmPatientNamePTNUSFIELDED | |
| sdtcDesc | 0..1 | ED | XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | I | 1..1 | TS | |
| sdtcDeceasedInd | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc) | |
| sdtcDeceasedTime | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthInd | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
| maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
| religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| sdtcRaceCode | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible) | |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible) | |
| guardian | 0..* | Guardian | ||
| classCode | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | I | 0..* | USRealmAddressADUSFIELDED | |
| telecom | 0..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| classCode | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| templateId | 0..* | II | ||
| place | 1..1 | Place | ||
| classCode | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 0..1 | EN | ||
| addr | I | 1..1 | AD | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| isNotOrdered | 0..1 | boolean | ||
| use | 0..* | code | ||
| delimiter | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DEL | |
| country | 0..1 | ADXP | ||
| partType | 0..1 | code | Fixed Value: CNT | |
| state | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STA | |
| county | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CPA | |
| city | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CTY | |
| postalCode | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: ZIP | |
| streetAddressLine | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: SAL | |
| houseNumber | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: BNR | |
| houseNumberNumeric | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: BNN | |
| direction | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DIR | |
| streetName | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STR | |
| streetNameBase | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STB | |
| streetNameType | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: STTYP | |
| additionalLocator | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: ADL | |
| unitID | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: UNID | |
| unitType | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: UNIT | |
| careOf | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CAR | |
| censusTract | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: CEN | |
| deliveryAddressLine | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DAL | |
| deliveryInstallationType | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DINST | |
| deliveryInstallationArea | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DINSTQ | |
| deliveryMode | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DMOD | |
| deliveryModeIdentifier | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: DMODID | |
| buildingNumberSuffix | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: BNS | |
| postBox | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: POB | |
| precinct | 0..* | ADXP | ||
| partType | 0..1 | code | Fixed Value: PRE | |
| other | 0..1 | string | ||
| useablePeriod[x] | 0..* | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS | IVL_TS | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS | EIVL_TS | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS | PIVL_TS | |||
| useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS | SXPR_TS | |||
| languageCommunication | 0..* | LanguageCommunication | ||
| templateId | 0..* | II | ||
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
| proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
| preferenceInd | 0..1 | BL | Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language. If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1. | |
| providerOrganization | 0..1 | Organization | If present, this organization represents the provider organization where the person is claiming to be a patient. undefined | |
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| name | 1..* | ON | ||
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device, or a person. The person is the patient or the patient?s advocate. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| assignedAuthor | I | 1..1 | AssignedAuthor | |
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root |
| id:id1 | 0..1 | II | ||
| nullFlavor | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient. Binding: v3 Code System RoleCode (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 0..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| classCode | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: EntityCode (extensible) | |
| manufacturerModelName | 1..1 | SC | ||
| softwareName | 1..1 | SC | ||
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated by someone else, into the clinical document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer transfers information from one source to another (e.g., transcription from paper form to electronic system). If the dataEnterer is missing, this role is assumed to be played by the author. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 1..1 | TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for informant | 0..* | Informant | The informant element describes the source of the information in a medical document.
Assigned health care providers may be a source of information when a document is created. (e.g., a nurse's aide who provides information about a recent significant health care event that occurred within an acute care facility.) In these cases, the assignedEntity element is used.
When the informant is a personal relation, that informant is represented in the relatedEntity element, even if the personal relation is a medical professional. The code element of the relatedEntity describes the relationship between the informant and the patient. The relationship between the informant and the patient needs to be described to help the receiver of the clinical document understand the information in the document.
Each informant can be either an assignedEntity (a clinician serving the patient) OR a relatedEntity (a person with a personal or legal relationship with the patient). The constraints here apply to relatedEntity. Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | The 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | I | 1..* | II | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassMutualRelationship (required) | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: PersonalRelationshipRoleType (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| effectiveTime | 0..1 | IVL_TS | ||
| relatedPerson | 0..1 | Person | ||
| informant:informant2 | 0..* | Informant | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), 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. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | The representedCustodianOrganization may be the person when the document is not maintained by an organization. | |
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes record the custodian organization?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| addr | I | 1..1 | USRealmAddressADUSFIELDED | |
| informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to be the scoping organization for that chart. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| classCode | 1..1 | code | ||
| templateId | 0..* | II | ||
| id | 0..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document. | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| receivedOrganization | 0..1 | Organization | ||
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| name | 1..1 | ON | ||
| telecom | 0..* | TEL | ||
| addr | 0..* | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| legalAuthenticator | 0..1 | LegalAuthenticator | In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored 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. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: LA | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| signatureCode | 1..1 | CS | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: S | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes to record the information recipient?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for authenticator | 0..* | Authenticator | The 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:All Slices | Content/Rules for all slices | |||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 1..1 | TS | ||
| signatureCode | 1..1 | CS | ||
| sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes to record the authenticator?s identity in a secure, trusted, and unique way. | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| authenticator:authenticator1 | 0..* | Authenticator | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
| signatureCode | 1..1 | CS | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: S | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | I | 1..* | USRealmAddressADUSFIELDED | |
| telecom | 1..* | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | uri | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
| sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for participant | 0..* | Participant1 | The participant element identifies other supporting participants, including parents, relatives, caregivers, insurance policyholders, guarantors, and other participants 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 | I | 0..* | Participant1 | 1198-10006: **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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | 0..1 | IVL_TS | ||
| associatedEntity | 1..1 | AssociatedEntity | ||
| inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| order | 1..1 | Order | ||
| classCode | 1..1 | code | Binding: ActClass (required) | |
| moodCode | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| templateId | 0..* | II | ||
| id | 1..* | II | A scheduled appointment or service event in a practice management system may be represented using this id element. | |
| code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| documentationOf | 0..* | DocumentationOf | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
| classCode | 1..1 | code | Binding: ActClass (required) | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The code should be selected from a value set established by the document-level template for a specific type of Patient Generated Document. | |
| effectiveTime | 1..1 | IVL_TS | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | 0..1 | dateTime | ||
| inclusive | 0..1 | boolean | ||
| operator | 0..1 | code | ||
| low | 1..1 | TS | ||
| high | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| center | 0..1 | TS | ||
| performer | 0..* | Performer1 | The 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | The functionCode SHALL be selected from value set ParticipationType 2.16.840.1.113883.1.11.10901 When indicating the performer was the primary care physician the functionCode shall be =?PCP? | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | The combined @root and @extension attributes record the performer?s identity in a secure, trusted, and unique way. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
| extension | 0..1 | string | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | If the assignedEntity is an individual, the code SHOULD be selected from value set PersonalandLegalRelationshipRoleType value set Binding: Personal And Legal Relationship Role Type (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| relatedDocument | 0..* | RelatedDocument | ||
| Slices for authorization | 0..* | Authorization | The authorization element represents information about the patient?s consent.
The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?.
The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent | |
| authorization:authorization1 | 0..* | Authorization | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| consent | 1..1 | Consent | ||
| classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | The 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..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | Fixed Value: completed | ||
| componentOf | 0..1 | ComponentOf | The 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..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC | |
| moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
| effectiveTime | 1..1 | IVL_TS | ||
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
| responsibleParty | 0..1 | Element | ||
| typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| encounterParticipant | 0..* | EncounterParticipant | ||
| location | 0..1 | Element | ||
| typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component2 | ||
| Documentation for this format | ||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN |
| ClinicalDocument.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.typeId.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:primary.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:secondary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | extensible | http://terminology.hl7.org/ValueSet/v3-DocumentType |
| ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind |
| ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT |
| ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT |
| ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | extensible | RaceValueSet |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | extensible | DetailedEthnicity |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
| ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| ClinicalDocument.author.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.typeCode | required | Fixed Value: AUT |
| ClinicalDocument.author.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Pattern: UNK |
| ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | Personal And Legal Relationship Role Type |
| ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode |
| ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.code | preferred | Personal And Legal Relationship Role Type |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor |
| ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.informant:informant1.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informant:informant1.relatedEntity.classCode | required | RoleClassMutualRelationship |
| ClinicalDocument.informant:informant1.relatedEntity.code | extensible | PersonalRelationshipRoleType |
| ClinicalDocument.informant:informant1.relatedEntity.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.informant:informant1.relatedEntity.code.code | preferred | Personal And Legal Relationship Role Type |
| ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor |
| ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF |
| ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.custodian.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT |
| ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor |
| ClinicalDocument.informationRecipient.typeCode | required | ParticipationType |
| ClinicalDocument.informationRecipient.intendedRecipient.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA |
| ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
| ClinicalDocument.legalAuthenticator.assignedEntity.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.code.code | preferred | Personal And Legal Relationship Role Type |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.authenticator.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator.typeCode | required | Fixed Value: AUTHEN |
| ClinicalDocument.authenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.authenticator.assignedEntity.code | preferred | Personal And Legal Relationship Role Type |
| ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN |
| ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant:participant1.typeCode | required | ParticipationType |
| ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO |
| ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode |
| ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority |
| ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC |
| ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass |
| ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: DOC |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | Personal And Legal Relationship Role Type |
| ClinicalDocument.authorization:authorization1.nullFlavor | required | NullFlavor |
| ClinicalDocument.authorization:authorization1.typeCode | required | Fixed Value: AUT |
| ClinicalDocument.authorization:authorization1.consent.classCode | required | Fixed Value: CONS |
| ClinicalDocument.authorization:authorization1.consent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.authorization:authorization1.consent.code | extensible | ActCode |
| ClinicalDocument.authorization:authorization1.consent.statusCode | required | ActStatus |
| ClinicalDocument.componentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: AUT |
| ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC |
| ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode |
| ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
| Id | Grade | Path | Details | Requirements |
| 1198-32945 | error | ClinicalDocument.templateId:secondary | 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:1198-32945). : | |
| 1198-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:1198-9991). : | |
| 1198-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992). : | |
| 1198-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| 1198-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:1198-6380). : | |
| 1198-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:1198-6387). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 1198-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:1198-5299). : | |
| 1198-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:1198-5300). : | |
| 1198-32418 | warning | ClinicalDocument.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. : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 1198-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:1198-5402). : | |
| 1198-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:1198-5403). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-10127 | error | ClinicalDocument.author.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.author.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.author.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.author.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| 1198-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790). : | |
| 1198-5449 | null | ClinicalDocument.author.assignedAuthor.id | If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). : | |
| 81-7296 | error | ClinicalDocument.author.assignedAuthor.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-7296 | error | ClinicalDocument.dataEnterer.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 1198-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | 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). : | |
| 81-7296 | error | ClinicalDocument.informant:informant1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-7296 | error | ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10127 | error | ClinicalDocument.legalAuthenticator.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.legalAuthenticator.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.legalAuthenticator.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.legalAuthenticator.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| 81-7296 | error | ClinicalDocument.legalAuthenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10127 | error | ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| 81-7296 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
| 81-9372 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 1198-10006 | error | ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). : | |
| 1198-10007 | warning | ClinicalDocument.participant:participant1 | 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). : |
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccdar2dot2#2.2 based on FHIR 4.0.1. Generated 2022-05-13
Links: Table of Contents |
QA Report
| Version History 
|
|
Propose a change