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

## Logical Model: Procedure Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureNote | Version: 2.1
Active as of 2023-09-29 | Computable Name: ProcedureNote
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.6:2015-08-01

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient’s tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.

Usage:

- This Logical Model is not used by any profiles in this Implementation Guide

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

This structure is derived from USRealmHeader

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
templateId |  | 2..* | II |
templateId:secondary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.6
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure 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.
code |  | 1..1 | cs | Binding: ProcedureNoteDocumentTypeCodes (required)
Slices for participant |  | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode
participant:participant1 |  | 0..* | Participant1 |
typeCode |  | 1..1 | cs | Fixed Value: IND
functionCode |  | 1..1 | CE |
code |  | 1..1 | cs | Required Pattern: PCP
associatedEntity |  |  |  |
classCode |  | 1..1 | cs | Fixed Value: PROV
associatedPerson |  | 1..1 | Person |
Slices for documentationOf |  | 1..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
serviceEvent |  |  |  |
Slices for performer |  | 1..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode
performer:performer1 |  | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
typeCode |  | 1..1 | cs | Fixed Value: PPRF
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
performer:performer2 |  | 0..* | Performer1 |
typeCode |  | 1..1 | cs | Fixed Value: SPRF
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
documentationOf:documentationOf1 |  | 1..* | DocumentationOf |
serviceEvent | C | 1..1 | ServiceEvent | 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515).
low |  | 1..1 | IVXB_TS |
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
typeCode |  | 1..1 | cs |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs |
statusCode |  | 1..1 | CS |
componentOf |  | 0..1 | ComponentOf |
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II | SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
code |  | 1..1 | CE |
Slices for encounterParticipant |  | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode
encounterParticipant:encounterParticipant1 |  | 0..1 | EncounterParticipant |
typeCode |  | 1..1 | cs | Fixed Value: REF
location |  | 1..1 | InfrastructureRoot | SG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
healthCareFacility |  | 1..1 | HealthCareFacility |
id |  | 1..* | II |
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section
component:component1 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ComplicationsSection | Base for all types and resources
component:component2 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDescriptionSection | Base for all types and resources
component:component3 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureIndicationsSection | Base for all types and resources
component:component4 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | PostprocedureDiagnosisSection | Base for all types and resources
component:component5 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component7 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AnesthesiaSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component15 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalGeneralHistorySection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsAdministeredSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlannedProcedureSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDispositionSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureEstimatedBloodLossSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureFindingsSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureImplantsSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureSpecimensTakenSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component26 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component27 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component28 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
ClinicalDocument.code.code | required | ProcedureNoteDocumentTypeCodes
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-8511 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent | The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). : |
1198-8513 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). : |
1198-8514 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). : |
1198-8515 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). : |
1198-30412 | 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:1198-30412). : |
1198-30414 | 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:1198-30414). : |
1198-30415 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). : |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
realmCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: US
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.6
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible)
@code |  | 1..1 | cs | Binding: ProcedureNoteDocumentTypeCodes (required)
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
recordTarget |  | 1..* | RecordTarget |
patientRole |  | 1..1 | PatientRole |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
author |  | 1..* | Author |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
assignedEntity |  | 1..1 | AssignedEntity |
id | C | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
informant:informant2 |  | 0..* | Informant | informant
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
assignedCustodian |  | 1..1 | AssignedCustodian |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
id |  | 1..* | II |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: S
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
Slices for participant | C | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode
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
functionCode |  | 1..1 | CE |
@code |  | 1..1 | cs | Required Pattern: PCP
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: PROV
associatedPerson |  | 1..1 | Person |
Slices for documentationOf |  | 1..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
serviceEvent |  | 1..1 | ServiceEvent |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
effectiveTime |  | 1..1 | IVL_TS |
low |  | 1..1 | IVXB_TS |
Slices for performer |  | 1..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode
performer:All Slices |  |  |  | Content/Rules for all slices
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
performer:performer1 |  | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PPRF
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
performer:performer2 |  | 0..* | Performer1 |
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: SPRF
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
documentationOf:documentationOf1 |  | 1..* | DocumentationOf |
serviceEvent | C | 1..1 | ServiceEvent | 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
@classCode |  | 1..1 | cs | Binding: ActClass (required)
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515).
low |  | 1..1 | IVXB_TS |
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH
consent |  | 1..1 | Consent |
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: CONS
@moodCode |  | 1..1 | cs | Binding: ActMood (required) Fixed Value: EVN
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf |
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II | SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
code |  | 1..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime |  | 1..1 | IVL_TS |
Slices for encounterParticipant |  | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode
encounterParticipant:encounterParticipant1 |  | 0..1 | EncounterParticipant |
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: REF
location |  | 1..1 | InfrastructureRoot | SG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
healthCareFacility |  | 1..1 | HealthCareFacility |
@classCode |  | 1..1 | cs | Binding: RoleClassServiceDeliveryLocation (required)
id |  | 1..* | II |
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section
component:All Slices |  |  |  | Content/Rules for all slices
section |  | 1..1 | Section |
component:component1 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ComplicationsSection | Base for all types and resources
component:component2 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDescriptionSection | Base for all types and resources
component:component3 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureIndicationsSection | Base for all types and resources
component:component4 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | PostprocedureDiagnosisSection | Base for all types and resources
component:component5 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component7 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AnesthesiaSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component15 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalGeneralHistorySection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsAdministeredSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlannedProcedureSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDispositionSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section | C | 1..1 | ProcedureEstimatedBloodLossSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureFindingsSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section | C | 1..1 | ProcedureImplantsSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section | C | 1..1 | ProcedureSpecimensTakenSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component26 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component27 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component28 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
ClinicalDocument.code | extensible | FHIRDocumentTypeCodes
ClinicalDocument.code.code | required | ProcedureNoteDocumentTypeCodes
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 | Fixed Value: PROV
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCode | required | Fixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCode | required | Fixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode | required | ActClass
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.statusCode | required | ActStatus
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCode | required | Fixed Value: REF
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCode | required | RoleClassServiceDeliveryLocation

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-8511 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent | The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). : |
1198-8513 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). : |
1198-8514 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). : |
1198-8515 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). : |
1198-30412 | 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:1198-30412). : |
1198-30414 | 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:1198-30414). : |
1198-30415 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-8741 | warning | ClinicalDocument.component.structuredBody.component:component21.section | The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741). : |
81-8742 | warning | ClinicalDocument.component.structuredBody.component:component24.section | The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742). : |
81-8769 | error | ClinicalDocument.component.structuredBody.component:component23.section | The Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769). : |
81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
@classCode |  | 0..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
realmCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: US
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.6
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: ProcedureNoteDocumentTypeCodes (required)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
setId | C | 0..1 | II |
versionNumber | C | 0..1 | INT |
copyTime |  | 0..1 | TS |
recordTarget |  | 1..* | RecordTarget |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
patientRole |  | 1..1 | PatientRole |
@classCode |  | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..1 | II |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
sdtcDesc |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc)
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc)
sdtcDeceasedTime |  | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
sdtcMultipleBirthInd |  | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc)
sdtcMultipleBirthOrderNumber |  | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
maritalStatusCode |  | 0..1 | CE | Binding: Marital Status (required)
religiousAffiliationCode |  | 0..1 | CE | Binding: Religious Affiliation (required)
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
sdtcRaceCode | C | 0..* | CE | XML Namespace: urn:hl7-org:sdtc The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
sdtcEthnicGroupCode |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required)
guardian |  | 0..* | Guardian |
@classCode |  | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required)
addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
guardianPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
guardianOrganization |  | 0..1 | Organization |
birthplace |  | 0..1 | Birthplace |
@classCode |  | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL
templateId |  | 0..* | II |
place |  | 1..1 | Place |
@classCode |  | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 0..1 | EN |
addr | C | 1..1 | AD |
nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required)
@isNotOrdered |  | 0..1 | bl |
@use |  | 0..* | cs |
delimiter |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DEL
country |  | 0..1 | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CNT
state |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STA
county |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CPA
city |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CTY
postalCode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ZIP
streetAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: SAL
houseNumber |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNR
houseNumberNumeric |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNN
direction |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DIR
streetName |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STR
streetNameBase |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STB
streetNameType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STTYP
additionalLocator |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ADL
unitID |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNID
unitType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNIT
careOf |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CAR
censusTract |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CEN
deliveryAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DAL
deliveryInstallationType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINST
deliveryInstallationArea |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTA
deliveryInstallationQualifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTQ
deliveryMode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMOD
deliveryModeIdentifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMODID
buildingNumberSuffix |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNS
postBox |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: POB
precinct |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: PRE
other |  | 0..1 | st |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
languageCommunication |  | 0..* | LanguageCommunication |
templateId |  | 0..* | II |
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
modeCode |  | 0..1 | CE | Binding: LanguageAbilityMode (required)
proficiencyLevelCode |  | 0..1 | CE | Binding: LanguageAbilityProficiency (required)
preferenceInd |  | 0..1 | BL |
providerOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..* | ON |
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
author |  | 1..* | Author |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
assignedAuthoringDevice |  | 0..1 | AuthoringDevice |
@classCode |  | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
code |  | 0..1 | CE | Binding: EntityCode (extensible)
manufacturerModelName |  | 1..1 | SC | Binding: Manufacturer Model Name Example (example)
softwareName |  | 1..1 | SC | Binding: Software Name Example (example)
asMaintainedEntity |  | 0..* | MaintainedEntity |
representedOrganization |  | 0..1 | Organization |
dataEnterer |  | 0..1 | DataEnterer |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 1..1 | TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id | C | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
relatedEntity |  | 0..1 | RelatedEntity |
informant:informant2 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedCustodian |  | 1..1 | AssignedCustodian |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
informationRecipient |  | 0..* | InformationRecipient |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
intendedRecipient |  | 1..1 | IntendedRecipient |
@classCode |  | 1..1 | cs |
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
informationRecipient |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
receivedOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 0..* | II |
name |  | 1..1 | ON |
telecom |  | 0..* | TEL |
addr |  | 0..* | AD |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
legalAuthenticator |  | 0..1 | LegalAuthenticator |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for participant | C | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode
participant:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
participant:participant1 | C | 0..* | Participant1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: IND
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 1..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: PCP
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: PROV
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
associatedPerson |  | 1..1 | Person |
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 0..* | InFulfillmentOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
order |  | 1..1 | Order |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
Slices for documentationOf |  | 1..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
Slices for performer |  | 1..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode
performer:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer1 |  | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PPRF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer2 |  | 0..* | Performer1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: SPRF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
documentationOf:documentationOf1 |  | 1..* | DocumentationOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent | C | 1..1 | ServiceEvent | 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515).
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
performer |  | 0..* | Performer1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: CONS
@moodCode |  | 1..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
encompassingEncounter |  | 1..1 | EncompassingEncounter |
@classCode |  | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 1..* | II | SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
code |  | 1..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime |  | 1..1 | IVL_TS |
sdtcAdmissionReferralSourceCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode |  | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible)
responsibleParty |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP
assignedEntity |  | 1..1 | AssignedEntity |
Slices for encounterParticipant |  | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode
encounterParticipant:encounterParticipant1 |  | 0..1 | EncounterParticipant |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: REF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 0..1 | AssignedEntity |
location |  | 1..1 | InfrastructureRoot | SG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
@classCode |  | 1..1 | cs | Binding: RoleClassServiceDeliveryLocation (required)
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: ServiceDeliveryLocationRoleType (extensible)
location |  | 0..1 | Place |
serviceProviderOrganization |  | 0..1 | Organization |
component |  | 1..1 | Component |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody | C | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415).
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@classCode |  | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section
component:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | Section |
component:component1 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ComplicationsSection | Base for all types and resources
component:component2 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureDescriptionSection | Base for all types and resources
component:component3 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureIndicationsSection | Base for all types and resources
component:component4 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PostprocedureDiagnosisSection | Base for all types and resources
component:component5 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component7 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AnesthesiaSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component15 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicalGeneralHistorySection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicationsAdministeredSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PlannedProcedureSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureDispositionSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section | C | 1..1 | ProcedureEstimatedBloodLossSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureFindingsSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section | C | 1..1 | ProcedureImplantsSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section | C | 1..1 | ProcedureSpecimensTakenSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component26 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component27 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component28 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | SocialHistorySection | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN
ClinicalDocument.moodCode | required | Fixed Value: EVN
ClinicalDocument.realmCode.nullFlavor | required | NullFlavor
ClinicalDocument.templateId:us-realm.nullFlavor | required | NullFlavor
ClinicalDocument.templateId:secondary.nullFlavor | required | NullFlavor
ClinicalDocument.code | extensible | FHIRDocumentTypeCodes
ClinicalDocument.code.nullFlavor | required | NullFlavor
ClinicalDocument.code.code | required | ProcedureNoteDocumentTypeCodes
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.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: PROV
ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode
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.documentationOf.serviceEvent.performer:performer1.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCode | required | Fixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCode | required | Fixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf:documentationOf1.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.moodCode | required | Fixed Value: EVN
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.operator | required | SetOperator
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.authorization.nullFlavor | required | NullFlavor
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization.consent.code | extensible | ActCode
ClinicalDocument.authorization.consent.statusCode | required | ActStatus
ClinicalDocument.componentOf.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | USEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCode | required | Fixed Value: REF
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCode | required | RoleClassServiceDeliveryLocation
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.code | extensible | ServiceDeliveryLocationRoleType
ClinicalDocument.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.typeCode | required | Fixed Value: COMP
ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN
ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component1.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component26.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component27.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component28.nullFlavor | required | NullFlavor

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-8511 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent | The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). : |
1198-8513 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). : |
1198-8514 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). : |
1198-8515 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). : |
1198-30412 | 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:1198-30412). : |
1198-30414 | 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:1198-30414). : |
1198-30415 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:4537-5402). : |
4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : |
4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : |
4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : |
4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-8741 | warning | ClinicalDocument.component.structuredBody.component:component21.section | The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741). : |
81-8742 | warning | ClinicalDocument.component.structuredBody.component:component24.section | The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742). : |
81-8769 | error | ClinicalDocument.component.structuredBody.component:component23.section | The Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769). : |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

This structure is derived from USRealmHeader

Summary

Mandatory: 13 elements (11 nested mandatory elements)
Fixed Value: 5 elements

Structures

This structure refers to these other structures:

- US Realm Date and Time (DT.US.FIELDED) (http://hl7.org/cda/us/ccda/StructureDefinition/USRealmDateandTimeDTUSFIELDED)
- Complications Section (http://hl7.org/cda/us/ccda/StructureDefinition/ComplicationsSection)
- Procedure Description Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureDescriptionSection)
- Procedure Indications Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureIndicationsSection)
- Postprocedure Diagnosis Section (http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosisSection)
- Assessment Section (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection)
- Assessment and Plan Section (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection)
- Plan of Treatment Section (http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection)
- Allergies and Intolerances Section (http://hl7.org/cda/us/ccda/StructureDefinition/AllergiesAndIntolerancesSection)
- Anesthesia Section (http://hl7.org/cda/us/ccda/StructureDefinition/AnesthesiaSection)
- Chief Complaint Section (http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection)
- Chief Complaint and Reason for Visit Section (http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection)
- Family History Section (http://hl7.org/cda/us/ccda/StructureDefinition/FamilyHistorySection)
- Past Medical History (http://hl7.org/cda/us/ccda/StructureDefinition/PastMedicalHistory)
- History of Present Illness Section (http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection)
- Medical (General) History Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicalGeneralHistorySection)
- Medications Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsSection)
- Medications Administered Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsAdministeredSection)
- Physical Exam Section (http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection)
- Planned Procedure Section (http://hl7.org/cda/us/ccda/StructureDefinition/PlannedProcedureSection)
- Procedure Disposition Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureDispositionSection)
- Procedure Estimated Blood Loss Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureEstimatedBloodLossSection)
- Procedure Findings Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureFindingsSection)
- Procedure Implants Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureImplantsSection)
- Procedure Specimens Taken Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureSpecimensTakenSection)
- Procedures Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProceduresSection)
- Reason for Visit Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection)
- Review of Systems Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReviewofSystemsSection)
- Social History Section (http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection)

Slices

This structure defines the following Slices:

- The element ClinicalDocument.participant is sliced based on the values of value:associatedEntity.classCode, value:typeCode, value:functionCode
- The element ClinicalDocument.documentationOf is sliced based on the value of value:serviceEvent
- The element ClinicalDocument.documentationOf.serviceEvent.performer is sliced based on the values of value:assignedEntity, value:typeCode
- The element ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant is sliced based on the value of value:typeCode
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section

Differential View

This structure is derived from USRealmHeader

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
templateId |  | 2..* | II |
templateId:secondary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.6
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure 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.
code |  | 1..1 | cs | Binding: ProcedureNoteDocumentTypeCodes (required)
Slices for participant |  | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode
participant:participant1 |  | 0..* | Participant1 |
typeCode |  | 1..1 | cs | Fixed Value: IND
functionCode |  | 1..1 | CE |
code |  | 1..1 | cs | Required Pattern: PCP
associatedEntity |  |  |  |
classCode |  | 1..1 | cs | Fixed Value: PROV
associatedPerson |  | 1..1 | Person |
Slices for documentationOf |  | 1..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
serviceEvent |  |  |  |
Slices for performer |  | 1..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode
performer:performer1 |  | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
typeCode |  | 1..1 | cs | Fixed Value: PPRF
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
performer:performer2 |  | 0..* | Performer1 |
typeCode |  | 1..1 | cs | Fixed Value: SPRF
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
documentationOf:documentationOf1 |  | 1..* | DocumentationOf |
serviceEvent | C | 1..1 | ServiceEvent | 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515).
low |  | 1..1 | IVXB_TS |
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
typeCode |  | 1..1 | cs |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs |
statusCode |  | 1..1 | CS |
componentOf |  | 0..1 | ComponentOf |
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II | SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
code |  | 1..1 | CE |
Slices for encounterParticipant |  | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode
encounterParticipant:encounterParticipant1 |  | 0..1 | EncounterParticipant |
typeCode |  | 1..1 | cs | Fixed Value: REF
location |  | 1..1 | InfrastructureRoot | SG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
healthCareFacility |  | 1..1 | HealthCareFacility |
id |  | 1..* | II |
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section
component:component1 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ComplicationsSection | Base for all types and resources
component:component2 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDescriptionSection | Base for all types and resources
component:component3 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureIndicationsSection | Base for all types and resources
component:component4 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | PostprocedureDiagnosisSection | Base for all types and resources
component:component5 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component7 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AnesthesiaSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component15 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalGeneralHistorySection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsAdministeredSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlannedProcedureSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDispositionSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureEstimatedBloodLossSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureFindingsSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureImplantsSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureSpecimensTakenSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component26 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component27 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component28 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
ClinicalDocument.code.code | required | ProcedureNoteDocumentTypeCodes
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-8511 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent | The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). : |
1198-8513 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). : |
1198-8514 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). : |
1198-8515 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). : |
1198-30412 | 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:1198-30412). : |
1198-30414 | 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:1198-30414). : |
1198-30415 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). : |

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
realmCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: US
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.6
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible)
@code |  | 1..1 | cs | Binding: ProcedureNoteDocumentTypeCodes (required)
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
recordTarget |  | 1..* | RecordTarget |
patientRole |  | 1..1 | PatientRole |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
author |  | 1..* | Author |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
assignedEntity |  | 1..1 | AssignedEntity |
id | C | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
informant:informant2 |  | 0..* | Informant | informant
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
assignedCustodian |  | 1..1 | AssignedCustodian |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
id |  | 1..* | II |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: S
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
Slices for participant | C | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode
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
functionCode |  | 1..1 | CE |
@code |  | 1..1 | cs | Required Pattern: PCP
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: PROV
associatedPerson |  | 1..1 | Person |
Slices for documentationOf |  | 1..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
serviceEvent |  | 1..1 | ServiceEvent |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
effectiveTime |  | 1..1 | IVL_TS |
low |  | 1..1 | IVXB_TS |
Slices for performer |  | 1..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode
performer:All Slices |  |  |  | Content/Rules for all slices
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
performer:performer1 |  | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PPRF
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
performer:performer2 |  | 0..* | Performer1 |
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: SPRF
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
documentationOf:documentationOf1 |  | 1..* | DocumentationOf |
serviceEvent | C | 1..1 | ServiceEvent | 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
@classCode |  | 1..1 | cs | Binding: ActClass (required)
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515).
low |  | 1..1 | IVXB_TS |
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH
consent |  | 1..1 | Consent |
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: CONS
@moodCode |  | 1..1 | cs | Binding: ActMood (required) Fixed Value: EVN
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf |
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II | SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
code |  | 1..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime |  | 1..1 | IVL_TS |
Slices for encounterParticipant |  | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode
encounterParticipant:encounterParticipant1 |  | 0..1 | EncounterParticipant |
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: REF
location |  | 1..1 | InfrastructureRoot | SG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
healthCareFacility |  | 1..1 | HealthCareFacility |
@classCode |  | 1..1 | cs | Binding: RoleClassServiceDeliveryLocation (required)
id |  | 1..* | II |
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section
component:All Slices |  |  |  | Content/Rules for all slices
section |  | 1..1 | Section |
component:component1 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ComplicationsSection | Base for all types and resources
component:component2 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDescriptionSection | Base for all types and resources
component:component3 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureIndicationsSection | Base for all types and resources
component:component4 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | PostprocedureDiagnosisSection | Base for all types and resources
component:component5 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component7 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AnesthesiaSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component15 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalGeneralHistorySection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsAdministeredSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlannedProcedureSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureDispositionSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section | C | 1..1 | ProcedureEstimatedBloodLossSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProcedureFindingsSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section | C | 1..1 | ProcedureImplantsSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section | C | 1..1 | ProcedureSpecimensTakenSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component26 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component27 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component28 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
ClinicalDocument.code | extensible | FHIRDocumentTypeCodes
ClinicalDocument.code.code | required | ProcedureNoteDocumentTypeCodes
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 | Fixed Value: PROV
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCode | required | Fixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCode | required | Fixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode | required | ActClass
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.statusCode | required | ActStatus
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCode | required | Fixed Value: REF
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCode | required | RoleClassServiceDeliveryLocation

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-8511 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent | The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). : |
1198-8513 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). : |
1198-8514 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). : |
1198-8515 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). : |
1198-30412 | 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:1198-30412). : |
1198-30414 | 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:1198-30414). : |
1198-30415 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-8741 | warning | ClinicalDocument.component.structuredBody.component:component21.section | The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741). : |
81-8742 | warning | ClinicalDocument.component.structuredBody.component:component24.section | The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742). : |
81-8769 | error | ClinicalDocument.component.structuredBody.component:component23.section | The Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769). : |
81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
@classCode |  | 0..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
realmCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: US
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.6
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: FHIRDocumentTypeCodes (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: ProcedureNoteDocumentTypeCodes (required)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
setId | C | 0..1 | II |
versionNumber | C | 0..1 | INT |
copyTime |  | 0..1 | TS |
recordTarget |  | 1..* | RecordTarget |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
patientRole |  | 1..1 | PatientRole |
@classCode |  | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..1 | II |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
sdtcDesc |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc)
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc)
sdtcDeceasedTime |  | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
sdtcMultipleBirthInd |  | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc)
sdtcMultipleBirthOrderNumber |  | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
maritalStatusCode |  | 0..1 | CE | Binding: Marital Status (required)
religiousAffiliationCode |  | 0..1 | CE | Binding: Religious Affiliation (required)
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
sdtcRaceCode | C | 0..* | CE | XML Namespace: urn:hl7-org:sdtc The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
sdtcEthnicGroupCode |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required)
guardian |  | 0..* | Guardian |
@classCode |  | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required)
addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
guardianPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
guardianOrganization |  | 0..1 | Organization |
birthplace |  | 0..1 | Birthplace |
@classCode |  | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL
templateId |  | 0..* | II |
place |  | 1..1 | Place |
@classCode |  | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 0..1 | EN |
addr | C | 1..1 | AD |
nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required)
@isNotOrdered |  | 0..1 | bl |
@use |  | 0..* | cs |
delimiter |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DEL
country |  | 0..1 | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CNT
state |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STA
county |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CPA
city |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CTY
postalCode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ZIP
streetAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: SAL
houseNumber |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNR
houseNumberNumeric |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNN
direction |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DIR
streetName |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STR
streetNameBase |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STB
streetNameType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STTYP
additionalLocator |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ADL
unitID |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNID
unitType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNIT
careOf |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CAR
censusTract |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CEN
deliveryAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DAL
deliveryInstallationType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINST
deliveryInstallationArea |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTA
deliveryInstallationQualifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTQ
deliveryMode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMOD
deliveryModeIdentifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMODID
buildingNumberSuffix |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNS
postBox |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: POB
precinct |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: PRE
other |  | 0..1 | st |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
languageCommunication |  | 0..* | LanguageCommunication |
templateId |  | 0..* | II |
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
modeCode |  | 0..1 | CE | Binding: LanguageAbilityMode (required)
proficiencyLevelCode |  | 0..1 | CE | Binding: LanguageAbilityProficiency (required)
preferenceInd |  | 0..1 | BL |
providerOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..* | ON |
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
author |  | 1..* | Author |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
assignedAuthoringDevice |  | 0..1 | AuthoringDevice |
@classCode |  | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
code |  | 0..1 | CE | Binding: EntityCode (extensible)
manufacturerModelName |  | 1..1 | SC | Binding: Manufacturer Model Name Example (example)
softwareName |  | 1..1 | SC | Binding: Software Name Example (example)
asMaintainedEntity |  | 0..* | MaintainedEntity |
representedOrganization |  | 0..1 | Organization |
dataEnterer |  | 0..1 | DataEnterer |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 1..1 | TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id | C | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
relatedEntity |  | 0..1 | RelatedEntity |
informant:informant2 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedCustodian |  | 1..1 | AssignedCustodian |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
informationRecipient |  | 0..* | InformationRecipient |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
intendedRecipient |  | 1..1 | IntendedRecipient |
@classCode |  | 1..1 | cs |
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
informationRecipient |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
receivedOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 0..* | II |
name |  | 1..1 | ON |
telecom |  | 0..* | TEL |
addr |  | 0..* | AD |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
legalAuthenticator |  | 0..1 | LegalAuthenticator |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for participant | C | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode
participant:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
participant:participant1 | C | 0..* | Participant1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: IND
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 1..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: PCP
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: PROV
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
associatedPerson |  | 1..1 | Person |
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 0..* | InFulfillmentOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
order |  | 1..1 | Order |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
Slices for documentationOf |  | 1..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
Slices for performer |  | 1..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode
performer:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer1 |  | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: PPRF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer2 |  | 0..* | Performer1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required) Fixed Value: SPRF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
documentationOf:documentationOf1 |  | 1..* | DocumentationOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent | C | 1..1 | ServiceEvent | 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515).
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
performer |  | 0..* | Performer1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: CONS
@moodCode |  | 1..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
encompassingEncounter |  | 1..1 | EncompassingEncounter |
@classCode |  | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 1..* | II | SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0
code |  | 1..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime |  | 1..1 | IVL_TS |
sdtcAdmissionReferralSourceCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode |  | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible)
responsibleParty |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP
assignedEntity |  | 1..1 | AssignedEntity |
Slices for encounterParticipant |  | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode
encounterParticipant:encounterParticipant1 |  | 0..1 | EncounterParticipant |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: REF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 0..1 | AssignedEntity |
location |  | 1..1 | InfrastructureRoot | SG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=*
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
@classCode |  | 1..1 | cs | Binding: RoleClassServiceDeliveryLocation (required)
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: ServiceDeliveryLocationRoleType (extensible)
location |  | 0..1 | Place |
serviceProviderOrganization |  | 0..1 | Organization |
component |  | 1..1 | Component |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody | C | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415).
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@classCode |  | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by value:ClinicalDocument.section
component:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | Section |
component:component1 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ComplicationsSection | Base for all types and resources
component:component2 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureDescriptionSection | Base for all types and resources
component:component3 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureIndicationsSection | Base for all types and resources
component:component4 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PostprocedureDiagnosisSection | Base for all types and resources
component:component5 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component7 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AnesthesiaSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component15 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicalGeneralHistorySection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicationsAdministeredSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PlannedProcedureSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureDispositionSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section | C | 1..1 | ProcedureEstimatedBloodLossSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProcedureFindingsSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section | C | 1..1 | ProcedureImplantsSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section | C | 1..1 | ProcedureSpecimensTakenSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component26 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component27 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component28 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | SocialHistorySection | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN
ClinicalDocument.moodCode | required | Fixed Value: EVN
ClinicalDocument.realmCode.nullFlavor | required | NullFlavor
ClinicalDocument.templateId:us-realm.nullFlavor | required | NullFlavor
ClinicalDocument.templateId:secondary.nullFlavor | required | NullFlavor
ClinicalDocument.code | extensible | FHIRDocumentTypeCodes
ClinicalDocument.code.nullFlavor | required | NullFlavor
ClinicalDocument.code.code | required | ProcedureNoteDocumentTypeCodes
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.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: PROV
ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode
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.documentationOf.serviceEvent.performer:performer1.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCode | required | Fixed Value: PPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCode | required | Fixed Value: SPRF
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code | required | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.documentationOf:documentationOf1.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.moodCode | required | Fixed Value: EVN
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.operator | required | SetOperator
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.authorization.nullFlavor | required | NullFlavor
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization.consent.code | extensible | ActCode
ClinicalDocument.authorization.consent.statusCode | required | ActStatus
ClinicalDocument.componentOf.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | USEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCode | required | Fixed Value: REF
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCode | required | RoleClassServiceDeliveryLocation
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.code | extensible | ServiceDeliveryLocationRoleType
ClinicalDocument.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.typeCode | required | Fixed Value: COMP
ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN
ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component1.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component26.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component27.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component28.nullFlavor | required | NullFlavor

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-8511 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent | The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). : |
1198-8513 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). : |
1198-8514 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). : |
1198-8515 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). : |
1198-30412 | 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:1198-30412). : |
1198-30414 | 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:1198-30414). : |
1198-30415 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:4537-5402). : |
4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : |
4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : |
4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : |
4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-8741 | warning | ClinicalDocument.component.structuredBody.component:component21.section | The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741). : |
81-8742 | warning | ClinicalDocument.component.structuredBody.component:component24.section | The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742). : |
81-8769 | error | ClinicalDocument.component.structuredBody.component:component23.section | The Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769). : |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

This structure is derived from USRealmHeader

Summary

Mandatory: 13 elements (11 nested mandatory elements)
Fixed Value: 5 elements

Structures

This structure refers to these other structures:

- US Realm Date and Time (DT.US.FIELDED) (http://hl7.org/cda/us/ccda/StructureDefinition/USRealmDateandTimeDTUSFIELDED)
- Complications Section (http://hl7.org/cda/us/ccda/StructureDefinition/ComplicationsSection)
- Procedure Description Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureDescriptionSection)
- Procedure Indications Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureIndicationsSection)
- Postprocedure Diagnosis Section (http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosisSection)
- Assessment Section (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection)
- Assessment and Plan Section (http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection)
- Plan of Treatment Section (http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection)
- Allergies and Intolerances Section (http://hl7.org/cda/us/ccda/StructureDefinition/AllergiesAndIntolerancesSection)
- Anesthesia Section (http://hl7.org/cda/us/ccda/StructureDefinition/AnesthesiaSection)
- Chief Complaint Section (http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection)
- Chief Complaint and Reason for Visit Section (http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection)
- Family History Section (http://hl7.org/cda/us/ccda/StructureDefinition/FamilyHistorySection)
- Past Medical History (http://hl7.org/cda/us/ccda/StructureDefinition/PastMedicalHistory)
- History of Present Illness Section (http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection)
- Medical (General) History Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicalGeneralHistorySection)
- Medications Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsSection)
- Medications Administered Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsAdministeredSection)
- Physical Exam Section (http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection)
- Planned Procedure Section (http://hl7.org/cda/us/ccda/StructureDefinition/PlannedProcedureSection)
- Procedure Disposition Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureDispositionSection)
- Procedure Estimated Blood Loss Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureEstimatedBloodLossSection)
- Procedure Findings Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureFindingsSection)
- Procedure Implants Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureImplantsSection)
- Procedure Specimens Taken Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureSpecimensTakenSection)
- Procedures Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProceduresSection)
- Reason for Visit Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection)
- Review of Systems Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReviewofSystemsSection)
- Social History Section (http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection)

Slices

This structure defines the following Slices:

- The element ClinicalDocument.participant is sliced based on the values of value:associatedEntity.classCode, value:typeCode, value:functionCode
- The element ClinicalDocument.documentationOf is sliced based on the value of value:serviceEvent
- The element ClinicalDocument.documentationOf.serviceEvent.performer is sliced based on the values of value:assignedEntity, value:typeCode
- The element ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant is sliced based on the value of value:typeCode
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section

Other representations of profile: CSV, Excel