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/ReferralNote | Version: 2.1 | |||
| Active as of 2023-09-29 | Computable Name: ReferralNote | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.14:2015-08-01 | ||||
A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.
Examples of referral situations are when a patient is referred from a family physician to a cardiologist for cardiac evaluation or when patient is sent by a cardiologist to an emergency department for angina or when a patient is referred by a nurse practitioner to an audiologist for hearing screening or when a patient is referred by a hospitalist to social services.
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:primary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.14 | |
  extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | The Referral Note recommends use of the document type code 57133-1 "Referral 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author). Binding: ReferralDocumentType (required) | |
| informationRecipient | 1..1 | InformationRecipient | ||
 intendedRecipient | 1..1 | IntendedRecipient | ||
 addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 1..1 | Person | ||
 name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
 Slices for participant | 0..* | Participant1 | This participant represents the clinician to contact for questions about the referral note. 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:typeCode | |
 participant:participant1 | 0..* | Participant1 | ||
 typeCode | 1..1 | cs | Fixed Value: IND | |
 associatedEntity | 1..1 | AssociatedEntity | ||
| classCode | 1..1 | cs | Binding: INDRoleclassCodes (required) | |
| associatedPerson | 1..1 | Person | ||
 name | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources | |
 participant:participant2 | 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 | ||
| component | ||||
| structuredBody | C | 1..1 | StructuredBody | 1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). 1198-29103: 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:1198-29103). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:section.code | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:advanceDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:historyOfPresentIllness | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:familyHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:problem | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:reviewOfSystems | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:physicalExam | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:medicalEquip | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:allergiesAndIntolerances | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:assessment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:assessmentAndPlan | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:medicalHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:generalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:reasonForReferral | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforReferralSection | Base for all types and resources | |
| component:payers | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | required | ReferralDocumentType |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | INDRoleclassCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-29102 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). : | |
| 1198-29103 | 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:1198-29103). : |
| 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:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.14 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Referral Note recommends use of the document type code 57133-1 "Referral 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author). Binding: ReferralDocumentType (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 |
| informationRecipient | 1..1 | InformationRecipient | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | 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 clinician to contact for questions about the referral note. 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: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: IND | |
| associatedEntity | 1..1 | AssociatedEntity | ||
| @classCode | 1..1 | cs | Binding: INDRoleclassCodes (required) | |
| associatedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| participant:participant2 | 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 | ||
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). 1198-29103: 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:1198-29103). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:section.code | |
| component:All Slices | Content/Rules for all slices | |||
| section | 1..1 | Section | ||
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:advanceDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:historyOfPresentIllness | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:familyHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:problem | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:reviewOfSystems | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:physicalExam | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:medicalEquip | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:allergiesAndIntolerances | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:assessment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:assessmentAndPlan | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:medicalHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:generalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:reasonForReferral | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforReferralSection | Base for all types and resources | |
| component:payers | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.code | required | ReferralDocumentType |
| 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: IND |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | INDRoleclassCodes |
| ClinicalDocument.participant:participant2.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant2.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-29102 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). : | |
| 1198-29103 | 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:1198-29103). : | |
| 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, ClinicalDocument.participant:participant2 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2 | 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, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.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.informationRecipient.intendedRecipient.informationRecipient.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.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 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()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
| 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:primary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | required | ReferralDocumentType |
| 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: IND |
| ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | INDRoleclassCodes |
| 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.participant:participant2.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant:participant2.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant2.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant2.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.participant:participant2.associatedEntity.code | extensible | RoleCode |
| ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.participant:participant2.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.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:planOfTreatment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:advanceDirectives.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:historyOfPresentIllness.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:immunizations.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:problem.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:procedures.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:results.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:functionalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:nutrition.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:mentalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medicalEquip.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:assessment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medicalHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:generalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medications.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:reasonForReferral.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:payers.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-29102 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). : | |
| 1198-29103 | 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:1198-29103). : | |
| 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, ClinicalDocument.participant:participant2 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2 | 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, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.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). : | |
| 81-10127 | 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()) | |
| 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, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.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: 11 elements (8 nested mandatory elements)
Fixed Value: 3 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:primary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.14 | |
| extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| code | 1..1 | CE | The Referral Note recommends use of the document type code 57133-1 "Referral 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author). Binding: ReferralDocumentType (required) | |
| informationRecipient | 1..1 | InformationRecipient | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 1..1 | Person | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| Slices for participant | 0..* | Participant1 | This participant represents the clinician to contact for questions about the referral note. 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:typeCode | |
| participant:participant1 | 0..* | Participant1 | ||
| typeCode | 1..1 | cs | Fixed Value: IND | |
| associatedEntity | 1..1 | AssociatedEntity | ||
| classCode | 1..1 | cs | Binding: INDRoleclassCodes (required) | |
| associatedPerson | 1..1 | Person | ||
| name | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources | |
| participant:participant2 | 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 | ||
| component | ||||
| structuredBody | C | 1..1 | StructuredBody | 1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). 1198-29103: 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:1198-29103). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:section.code | |
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:advanceDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:historyOfPresentIllness | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:familyHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:problem | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:reviewOfSystems | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:physicalExam | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:medicalEquip | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:allergiesAndIntolerances | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:assessment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:assessmentAndPlan | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:medicalHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:generalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:reasonForReferral | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforReferralSection | Base for all types and resources | |
| component:payers | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalDocument.code | required | ReferralDocumentType |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | INDRoleclassCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-29102 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). : | |
| 1198-29103 | 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:1198-29103). : |
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:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.14 | |
| @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
| id | C | 1..1 | II | |
| code | C | 1..1 | CE | The Referral Note recommends use of the document type code 57133-1 "Referral 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. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author). Binding: ReferralDocumentType (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 |
| informationRecipient | 1..1 | InformationRecipient | ||
| intendedRecipient | 1..1 | IntendedRecipient | ||
| @classCode | 1..1 | cs | ||
| addr | 0..* | AD | ||
| telecom | 0..* | TEL | ||
| informationRecipient | 1..1 | Person | ||
| name | C | 1..* | USRealmPersonNamePNUSFIELDED | 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 clinician to contact for questions about the referral note. 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: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: IND | |
| associatedEntity | 1..1 | AssociatedEntity | ||
| @classCode | 1..1 | cs | Binding: INDRoleclassCodes (required) | |
| associatedPerson | 1..1 | Person | ||
| name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources |
| participant:participant2 | 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 | ||
| component | 1..1 | Component | ||
| structuredBody | C | 1..1 | StructuredBody | 1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). 1198-29103: 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:1198-29103). |
| Slices for component | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:section.code | |
| component:All Slices | Content/Rules for all slices | |||
| section | 1..1 | Section | ||
| component:planOfTreatment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PlanofTreatmentSection | Base for all types and resources | |
| component:advanceDirectives | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AdvanceDirectivesSection | Base for all types and resources | |
| component:historyOfPresentIllness | 0..1 | InfrastructureRoot | ||
| section | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources | |
| component:familyHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FamilyHistorySection | Base for all types and resources | |
| component:immunizations | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ImmunizationsSection | Base for all types and resources | |
| component:problem | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ProblemSection | Base for all types and resources | |
| component:procedures | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ProceduresSection | Base for all types and resources | |
| component:results | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ResultsSection | Base for all types and resources | |
| component:reviewOfSystems | 0..1 | InfrastructureRoot | ||
| section | 1..1 | ReviewofSystemsSection | Base for all types and resources | |
| component:socialHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | SocialHistorySection | Base for all types and resources | |
| component:vitalSigns | 0..1 | InfrastructureRoot | ||
| section | 1..1 | VitalSignsSection | Base for all types and resources | |
| component:functionalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | FunctionalStatusSection | Base for all types and resources | |
| component:physicalExam | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PhysicalExamSection | Base for all types and resources | |
| component:nutrition | 0..1 | InfrastructureRoot | ||
| section | 1..1 | NutritionSection | Base for all types and resources | |
| component:mentalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MentalStatusSection | Base for all types and resources | |
| component:medicalEquip | 0..1 | InfrastructureRoot | ||
| section | 1..1 | MedicalEquipmentSection | Base for all types and resources | |
| component:allergiesAndIntolerances | 1..1 | InfrastructureRoot | ||
| section | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources | |
| component:assessment | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentSection | Base for all types and resources | |
| component:assessmentAndPlan | 0..1 | InfrastructureRoot | ||
| section | 1..1 | AssessmentandPlanSection | Base for all types and resources | |
| component:medicalHistory | 0..1 | InfrastructureRoot | ||
| section | 1..1 | PastMedicalHistory | Base for all types and resources | |
| component:generalStatus | 0..1 | InfrastructureRoot | ||
| section | 1..1 | GeneralStatusSection | Base for all types and resources | |
| component:medications | 1..1 | InfrastructureRoot | ||
| section | 1..1 | MedicationsSection | Base for all types and resources | |
| component:reasonForReferral | 1..1 | InfrastructureRoot | ||
| section | 1..1 | ReasonforReferralSection | Base for all types and resources | |
| component:payers | 1..1 | InfrastructureRoot | ||
| section | 1..1 | PayersSection | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClinicalDocument.code | required | ReferralDocumentType |
| 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: IND |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | INDRoleclassCodes |
| ClinicalDocument.participant:participant2.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant2.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-29102 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). : | |
| 1198-29103 | 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:1198-29103). : | |
| 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, ClinicalDocument.participant:participant2 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2 | 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, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.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.informationRecipient.intendedRecipient.informationRecipient.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.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
| 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()) | |
| pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |
Snapshot View
| 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:primary.nullFlavor | required | NullFlavor |
| ClinicalDocument.code | required | ReferralDocumentType |
| 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: IND |
| ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant1.associatedEntity.classCode | required | INDRoleclassCodes |
| 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.participant:participant2.nullFlavor | required | NullFlavor |
| ClinicalDocument.participant:participant2.typeCode | required | Fixed Value: CALLBCK |
| ClinicalDocument.participant:participant2.contextControlCode | required | Fixed Value: OP |
| ClinicalDocument.participant:participant2.associatedEntity.classCode | required | Fixed Value: ASSIGNED |
| ClinicalDocument.participant:participant2.associatedEntity.code | extensible | RoleCode |
| ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN |
| ClinicalDocument.participant:participant2.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.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:planOfTreatment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:advanceDirectives.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:historyOfPresentIllness.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:familyHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:immunizations.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:problem.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:procedures.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:results.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:reviewOfSystems.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:socialHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:vitalSigns.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:functionalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:physicalExam.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:nutrition.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:mentalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medicalEquip.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:allergiesAndIntolerances.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:assessment.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:assessmentAndPlan.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medicalHistory.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:generalStatus.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:medications.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:reasonForReferral.nullFlavor | required | NullFlavor |
| ClinicalDocument.component.structuredBody.component:payers.nullFlavor | required | NullFlavor |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-29102 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102). : | |
| 1198-29103 | 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:1198-29103). : | |
| 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, ClinicalDocument.participant:participant2 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : | |
| 4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2 | 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, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.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). : | |
| 81-10127 | 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()) | |
| 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, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.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: 11 elements (8 nested mandatory elements)
Fixed Value: 3 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
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