Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote | Version: 2.1 | |||
| Active as of 2023-09-29 | Computable Name: ConsultationNote | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.4:2015-08-01 | ||||
The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.
A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalDocument | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources | |
 templateId | 2..* | II | ||
  templateId:secondary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4 | |
  extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required) | |
 Slices for participant | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode | |
 participant:participant1 | 0..* | Participant1 | ||
 typeCode | 1..1 | cs | Fixed Value: CALLBCK | |
 associatedEntity | 1..1 | AssociatedEntity | ||
| classCode | 1..1 | cs | Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| addr | 0..* | AD | ||
| telecom | 1..* | TEL | ||
| associatedPerson | 1..1 | Person | ||
 name | 1..* | PN | ||
| scopingOrganization | 0..1 | Organization | ||
| inFulfillmentOf | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | |
 order | 1..1 | Order | ||
| id | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | |
| componentOf | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| id | 1..* | II | ||
 effectiveTime | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
 component:component1 | 0..1 | InfrastructureRoot | ||
 section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:component2 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:component3 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:component7 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component21 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | required | ConsultDocumentType |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : | |
| 1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : | |
| 1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : | |
| 1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : | |
| 1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources | |
| realmCode | 1..1 | CS | ||
 @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:secondary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required) |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| recordTarget | 1..* | RecordTarget | ||
| patientRole | 1..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| author | 1..* | Author | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | C | 1..* | II | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| informant:informant2 | 0..* | Informant | informant | |
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
 signatureCode | 1..1 | CS | ||
 @code | 1..1 | cs | Required Pattern: S | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode |
| participant:All Slices | Content/Rules for all slices | |||
 associatedEntity | 1..1 | AssociatedEntity | ||
| participant:participant1 | C | 0..* | Participant1 | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK | |
| associatedEntity | 1..1 | AssociatedEntity | ||
| @classCode | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| addr | 0..* | AD | ||
| telecom | 1..* | TEL | ||
| associatedPerson | 1..1 | Person | ||
| name | 1..* | PN | ||
| scopingOrganization | 0..1 | Organization | ||
| inFulfillmentOf | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | |
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| id | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | |
| componentOf | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| id | 1..* | II | ||
| effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
| section | 1..1 | Section | ||
| component:component1 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:component2 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:component3 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:component7 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component21 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.code | required | ConsultDocumentType |
| 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.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : | |
| 1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : | |
| 1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : | |
| 1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : | |
| 1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-9946 | 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:4537-9946). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, 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 *DYNAMIC* (CONF:4537-10007). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, 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.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : | |
| 81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : | |
| 81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : | |
| 81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources | |
| @classCode | 0..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| realmCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: US | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:secondary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required) |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| setId | C | 0..1 | II | |
| versionNumber | C | 0..1 | INT | |
| copyTime | 0..1 | TS | ||
| recordTarget | 1..* | RecordTarget | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| patientRole | 1..1 | PatientRole | ||
| @classCode | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
 useablePeriod | 0..* | |||
 useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..1 | II | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) |
| sdtcDeceasedTime | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] |
| sdtcMultipleBirthInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc 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 | C | 0..* | CE | XML Namespace: urn:hl7-org:sdtc The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required) |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | 0..* | Guardian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| @classCode | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| templateId | 0..* | II | ||
| place | 1..1 | Place | ||
| @classCode | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 0..1 | EN | ||
| addr | C | 1..1 | AD | |
| nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required) |
| @isNotOrdered | 0..1 | bl | ||
| @use | 0..* | cs | ||
| delimiter | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DEL | |
| country | 0..1 | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CNT | |
| state | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STA | |
| county | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CPA | |
| city | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CTY | |
| postalCode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: SAL | |
| houseNumber | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNN | |
| direction | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DIR | |
| streetName | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STR | |
| streetNameBase | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STB | |
| streetNameType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STTYP | |
| additionalLocator | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ADL | |
| unitID | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNID | |
| unitType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNIT | |
| careOf | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CAR | |
| censusTract | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNS | |
| postBox | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: POB | |
| precinct | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: PRE | |
| other | 0..1 | st | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | 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 | ||
| providerOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..* | ON | ||
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | |
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| @classCode | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: EntityCode (extensible) | |
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| @contextControlCode | 0..1 | cs | 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 | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | C | 1..* | II | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| informant:informant2 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| receivedOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| 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 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode |
| participant:All Slices | Content/Rules for all slices | |||
 @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| @contextControlCode | 0..1 | cs | 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 | ||
| participant:participant1 | C | 0..* | Participant1 | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK | |
| @contextControlCode | 0..1 | cs | 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 | ||
| @classCode | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| addr | 0..* | AD | ||
| telecom | 1..* | TEL | ||
| associatedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 1..* | PN | ||
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| scopingOrganization | 0..1 | Organization | ||
| inFulfillmentOf | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| templateId | 0..* | II | ||
| id | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | |
| code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| documentationOf | 0..* | DocumentationOf | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| serviceEvent | 1..1 | ServiceEvent | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | ||
| effectiveTime | 1..1 | IVL_TS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 1..1 | IVXB_TS | ||
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| relatedDocument | 0..* | RelatedDocument | ||
| authorization | 0..* | Authorization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| consent | 1..1 | Consent | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS | |
| @moodCode | 0..1 | cs | 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 | cs | Fixed Value: completed | |
| componentOf | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources |
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible) | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). |
| location | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| nonXMLBody | 0..1 | NonXMLBody | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| confidentialityCode | 0..1 | CE | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | Section | ||
| component:component1 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:component2 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:component3 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:component7 | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component21 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN |
| ClinicalDocument.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.realmCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:secondary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | required | ConsultDocumentType |
| 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.sdtcDeceasedTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | Marital Status |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | Race Value Set |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | Detailed Ethnicity |
| 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.nullFlavor | required | NullFlavor |
| 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 | Fixed Value: UNK |
| ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| 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.informationRecipient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | NullFlavor |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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: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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode |
| ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCode | required | Fixed Value: INSTANCE |
| 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.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.nullFlavor | required | NullFlavor |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.authorization.consent.code | extensible | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.componentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP |
| 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 | USEncounterDischargeDisposition |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.typeCode | required | ParticipationType |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
| ClinicalDocument.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY |
| ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component1.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : | |
| 1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : | |
| 1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : | |
| 1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : | |
| 1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-5402 | 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:4537-5402). : | |
| 4537-5403 | 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:4537-5403). : | |
| 4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : | |
| 4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : | |
| 4537-9946 | 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:4537-9946). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, 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 *DYNAMIC* (CONF:4537-10007). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : | |
| 4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.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, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : | |
| 81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : | |
| 81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : | |
| 81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
This structure is derived from USRealmHeader
Summary
Mandatory: 9 elements (6 nested mandatory elements)
Fixed Value: 2 elements
Structures
This structure refers to these other structures:
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 | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources | |
| templateId | 2..* | II | ||
| templateId:secondary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4 | |
| extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required) | |
| Slices for participant | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode | |
| participant:participant1 | 0..* | Participant1 | ||
| typeCode | 1..1 | cs | Fixed Value: CALLBCK | |
| associatedEntity | 1..1 | AssociatedEntity | ||
| classCode | 1..1 | cs | Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| addr | 0..* | AD | ||
| telecom | 1..* | TEL | ||
| associatedPerson | 1..1 | Person | ||
| name | 1..* | PN | ||
| scopingOrganization | 0..1 | Organization | ||
| inFulfillmentOf | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | |
| order | 1..1 | Order | ||
| id | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | |
| componentOf | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| id | 1..* | II | ||
| effectiveTime | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:component1 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:component2 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:component3 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:component7 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component21 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | required | ConsultDocumentType |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : | |
| 1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : | |
| 1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : | |
| 1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : | |
| 1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources | |
| realmCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: US | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:secondary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required) |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| recordTarget | 1..* | RecordTarget | ||
| patientRole | 1..1 | PatientRole | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| author | 1..* | Author | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | |
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | C | 1..* | II | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| informant:informant2 | 0..* | Informant | informant | |
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| id | 1..* | II | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @code | 1..1 | cs | Required Pattern: S | |
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode |
| participant:All Slices | Content/Rules for all slices | |||
| associatedEntity | 1..1 | AssociatedEntity | ||
| participant:participant1 | C | 0..* | Participant1 | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK | |
| associatedEntity | 1..1 | AssociatedEntity | ||
| @classCode | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| addr | 0..* | AD | ||
| telecom | 1..* | TEL | ||
| associatedPerson | 1..1 | Person | ||
| name | 1..* | PN | ||
| scopingOrganization | 0..1 | Organization | ||
| inFulfillmentOf | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | |
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| id | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | |
| componentOf | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| id | 1..* | II | ||
| effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). |
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
| section | 1..1 | Section | ||
| component:component1 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:component2 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:component3 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:component7 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component21 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.code | required | ConsultDocumentType |
| 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.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
| ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : | |
| 1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : | |
| 1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : | |
| 1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : | |
| 1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-9946 | 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:4537-9946). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, 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 *DYNAMIC* (CONF:4537-10007). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, 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.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : | |
| 81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : | |
| 81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : | |
| 81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalDocument | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources | |
| @classCode | 0..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| realmCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: US | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| typeId | 1..1 | II | ||
| @root | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | Extension Fixed Value: POCD_HD000040 | |
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:us-realm | 1..1 | II | templateId | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| templateId:secondary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required) |
| title | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
| languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
| setId | C | 0..1 | II | |
| versionNumber | C | 0..1 | INT | |
| copyTime | 0..1 | TS | ||
| recordTarget | 1..* | RecordTarget | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| patientRole | 1..1 | PatientRole | ||
| @classCode | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| patient | 1..1 | Patient | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..1 | II | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| sdtcDesc | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc) | |
| administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
| birthTime | C | 1..1 | TS | |
| sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc) |
| sdtcDeceasedTime | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] |
| sdtcMultipleBirthInd | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc) | |
| sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc 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 | C | 0..* | CE | XML Namespace: urn:hl7-org:sdtc The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required) |
| ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
| sdtcEthnicGroupCode | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required) | |
| guardian | 0..* | Guardian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
| addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| guardianPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| guardianOrganization | 0..1 | Organization | ||
| birthplace | 0..1 | Birthplace | ||
| @classCode | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
| templateId | 0..* | II | ||
| place | 1..1 | Place | ||
| @classCode | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 0..1 | EN | ||
| addr | C | 1..1 | AD | |
| nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required) |
| @isNotOrdered | 0..1 | bl | ||
| @use | 0..* | cs | ||
| delimiter | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DEL | |
| country | 0..1 | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CNT | |
| state | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STA | |
| county | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CPA | |
| city | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CTY | |
| postalCode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ZIP | |
| streetAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: SAL | |
| houseNumber | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNR | |
| houseNumberNumeric | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNN | |
| direction | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DIR | |
| streetName | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STR | |
| streetNameBase | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STB | |
| streetNameType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: STTYP | |
| additionalLocator | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: ADL | |
| unitID | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNID | |
| unitType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: UNIT | |
| careOf | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CAR | |
| censusTract | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: CEN | |
| deliveryAddressLine | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DAL | |
| deliveryInstallationType | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINST | |
| deliveryInstallationArea | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTA | |
| deliveryInstallationQualifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DINSTQ | |
| deliveryMode | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMOD | |
| deliveryModeIdentifier | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: DMODID | |
| buildingNumberSuffix | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: BNS | |
| postBox | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: POB | |
| precinct | 0..* | ADXP | ||
| @partType | 0..1 | cs | Fixed Value: PRE | |
| other | 0..1 | st | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | 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 | ||
| providerOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..* | ON | ||
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| author | 1..* | Author | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| assignedAuthor | C | 1..1 | AssignedAuthor | |
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| Slices for id | 1..* | II | Slice: Unordered, Open by value:root | |
| id:id1 | 0..1 | II | id | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
| @classCode | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| code | 0..1 | CE | Binding: EntityCode (extensible) | |
| manufacturerModelName | 1..1 | SC | Binding: Manufacturer Model Name Example (example) | |
| softwareName | 1..1 | SC | Binding: Software Name Example (example) | |
| asMaintainedEntity | 0..* | MaintainedEntity | ||
| representedOrganization | 0..1 | Organization | ||
| dataEnterer | 0..1 | DataEnterer | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| @contextControlCode | 0..1 | cs | 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 | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for informant | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity | |
| informant:informant1 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | C | 1..* | II | |
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 0..* | TEL | ||
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| informant:informant2 | 0..* | Informant | informant | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 1..1 | RelatedEntity | ||
| custodian | 1..1 | Custodian | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| assignedCustodian | 1..1 | AssignedCustodian | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| representedCustodianOrganization | 1..1 | CustodianOrganization | ||
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| name | 1..1 | ON | ||
| telecom | 1..1 | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources |
| informationRecipient | 0..* | InformationRecipient | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 0..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| receivedOrganization | 0..1 | Organization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @classCode | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| 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 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for authenticator | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time | |
| authenticator:authenticator1 | 0..* | Authenticator | authenticator | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources |
| signatureCode | 1..1 | CS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: S | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| sdtcSignatureText | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc) | |
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources |
| telecom | 1..* | TEL | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | url | ||
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| @use | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required) | |
| assignedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources |
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| representedOrganization | 0..1 | Organization | ||
| Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode |
| participant:All Slices | Content/Rules for all slices | |||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| @contextControlCode | 0..1 | cs | 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 | ||
| participant:participant1 | C | 0..* | Participant1 | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK | |
| @contextControlCode | 0..1 | cs | 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 | ||
| @classCode | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| addr | 0..* | AD | ||
| telecom | 1..* | TEL | ||
| associatedPerson | 1..1 | Person | ||
| @classCode | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
| @determinerCode | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| name | 1..* | PN | ||
| sdtcAsPatientRelationship | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc) | |
| scopingOrganization | 0..1 | Organization | ||
| inFulfillmentOf | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| order | 1..1 | Order | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO | |
| templateId | 0..* | II | ||
| id | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template. | |
| code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| documentationOf | 0..* | DocumentationOf | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| serviceEvent | 1..1 | ServiceEvent | ||
| @classCode | 1..1 | cs | Binding: ActClass (required) | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| code | 0..1 | CE | ||
| effectiveTime | 1..1 | IVL_TS | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 1..1 | IVXB_TS | ||
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_TS | ||
| performer | 0..* | Performer1 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: x_ServiceEventPerformer (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | Binding: Care Team Member Function (preferred) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| @classCode | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6 | |
| @extension | 0..1 | st | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| relatedDocument | 0..* | RelatedDocument | ||
| authorization | 0..* | Authorization | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| consent | 1..1 | Consent | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS | |
| @moodCode | 0..1 | cs | 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 | cs | Fixed Value: completed | |
| componentOf | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| encompassingEncounter | 1..1 | EncompassingEncounter | ||
| @classCode | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
| effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources |
| sdtcAdmissionReferralSourceCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
| dischargeDispositionCode | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible) | |
| responsibleParty | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP | |
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). |
| encounterParticipant | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 0..1 | cs | Binding: ParticipationType (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| time | 0..1 | IVL_TS | ||
| assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). |
| location | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
| healthCareFacility | 1..1 | HealthCareFacility | ||
| component | 1..1 | Component | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| nonXMLBody | 0..1 | NonXMLBody | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @classCode | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY | |
| @moodCode | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN | |
| confidentialityCode | 0..1 | CE | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section | |
| component:All Slices | Content/Rules for all slices | |||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | Section | ||
| component:component1 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:component2 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:component3 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:component4 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ReasonforVisitSection | Base for all types and resources | |
| component:component5 | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:component6 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:component7 | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:component8 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ChiefComplaintSection | Base for all types and resources | |
| component:component9 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources | |
| component:component10 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:component11 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:component12 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:component13 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:component14 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:component15 | 1..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:component16 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:component17 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:component18 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:component19 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:component25 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:component20 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:component21 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:component22 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:component23 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:component24 | 0..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Fixed Value: COMP | |
| @contextConductionInd | 0..1 | bl | Fixed Value: true | |
| section | 1..1 | NutritionSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN |
| ClinicalDocument.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.realmCode.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:us-realm.nullFlavor | required | NullFlavor |
| ClinicalDocument.templateId:secondary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | required | ConsultDocumentType |
| 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.sdtcDeceasedTime.nullFlavor | required | NullFlavor |
| ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | Marital Status |
| ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation |
| ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | Race Value Set |
| ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
| ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | Detailed Ethnicity |
| 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.nullFlavor | required | NullFlavor |
| 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 | Fixed Value: UNK |
| ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode |
| ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor |
| ClinicalDocument.author.assignedAuthor.code.code | preferred | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample |
| ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
| 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.informationRecipient.classCode | required | Fixed Value: PSN |
| ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
| ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | NullFlavor |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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: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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| 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.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant.typeCode | required | ParticipationType |
| ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode |
| ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCode | required | Fixed Value: INSTANCE |
| 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.effectiveTime.operator | required | SetOperator |
| ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
| ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer |
| 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 | Healthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| ClinicalDocument.authorization.nullFlavor | required | NullFlavor |
| ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH |
| ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS |
| ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.authorization.consent.code | extensible | ActCode |
| ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
| ClinicalDocument.componentOf.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP |
| 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 | USEncounterDischargeDisposition |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.typeCode | required | ParticipationType |
| ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor |
| ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
| ClinicalDocument.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.typeCode | required | Fixed Value: COMP |
| ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY |
| ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN |
| ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component1.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : | |
| 1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : | |
| 1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : | |
| 1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : | |
| 1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : | |
| 1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : | |
| 4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : | |
| 4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : | |
| 4537-5402 | 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:4537-5402). : | |
| 4537-5403 | 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:4537-5403). : | |
| 4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : | |
| 4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : | |
| 4537-9946 | 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:4537-9946). : | |
| 4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : | |
| 4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : | |
| 4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, 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 *DYNAMIC* (CONF:4537-10007). : | |
| 4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : | |
| 4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : | |
| 4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : | |
| 4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : | |
| 4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : | |
| 4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : | |
| 4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : | |
| 81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
| 81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
| 81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.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, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : | |
| 81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : | |
| 81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : | |
| 81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : | |
| 81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
| 81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
| 81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
| 81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
| cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
This structure is derived from USRealmHeader
Summary
Mandatory: 9 elements (6 nested mandatory elements)
Fixed Value: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1 based on FHIR 5.0.0. Generated 2023-09-29
Links: Table of Contents |
QA Report
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