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: Consultation Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote | Version: 2.1
Active as of 2023-09-29 | Computable Name: ConsultationNote
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.4:2015-08-01

The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.

A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).

Usage:

- 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: 2.16.840.1.113883.10.20.22.1.4
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required)
Slices for participant |  | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode
participant:participant1 |  | 0..* | Participant1 |
typeCode |  | 1..1 | cs | Fixed Value: CALLBCK
associatedEntity |  | 1..1 | AssociatedEntity |
classCode |  | 1..1 | cs | Fixed Value: ASSIGNED
id |  | 1..* | II |
addr |  | 0..* | AD |
telecom |  | 1..* | TEL |
associatedPerson |  | 1..1 | Person |
name |  | 1..* | PN |
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
order |  | 1..1 | Order |
id |  | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.
componentOf |  | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II |
effectiveTime |  | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources
responsibleParty |  | 0..1 | InfrastructureRoot |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
encounterParticipant |  | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906).
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section
component:component1 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component2 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component3 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component4 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component5 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component7 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | GeneralStatusSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ImmunizationsSection | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component15 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProblemSection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ResultsSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | VitalSignsSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AdvanceDirectivesSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FunctionalStatusSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalEquipmentSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MentalStatusSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | NutritionSection | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
ClinicalDocument.code | required | ConsultDocumentType

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : |
1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : |
1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : |
1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : |
1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
realmCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: US
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required)
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
recordTarget |  | 1..* | RecordTarget |
patientRole |  | 1..1 | PatientRole |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
author |  | 1..* | Author |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
assignedEntity |  | 1..1 | AssignedEntity |
id | C | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
informant:informant2 |  | 0..* | Informant | informant
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
assignedCustodian |  | 1..1 | AssignedCustodian |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
id |  | 1..* | II |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: S
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode
participant:All Slices |  |  |  | Content/Rules for all slices
associatedEntity |  | 1..1 | AssociatedEntity |
participant:participant1 | C | 0..* | Participant1 |
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED
id |  | 1..* | II |
addr |  | 0..* | AD |
telecom |  | 1..* | TEL |
associatedPerson |  | 1..1 | Person |
name |  | 1..* | PN |
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
order |  | 1..1 | Order |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
id |  | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.
componentOf |  | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II |
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources
responsibleParty |  | 0..1 | InfrastructureRoot |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
encounterParticipant |  | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906).
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section
component:All Slices |  |  |  | Content/Rules for all slices
section |  | 1..1 | Section |
component:component1 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component2 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component3 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component4 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component5 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component7 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | GeneralStatusSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ImmunizationsSection | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component15 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProblemSection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ResultsSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | VitalSignsSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AdvanceDirectivesSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FunctionalStatusSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalEquipmentSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MentalStatusSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | NutritionSection | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
ClinicalDocument.code | required | ConsultDocumentType
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : |
1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : |
1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : |
1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : |
1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
@classCode |  | 0..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
realmCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: US
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required)
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
setId | C | 0..1 | II |
versionNumber | C | 0..1 | INT |
copyTime |  | 0..1 | TS |
recordTarget |  | 1..* | RecordTarget |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
patientRole |  | 1..1 | PatientRole |
@classCode |  | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..1 | II |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
sdtcDesc |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc)
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc)
sdtcDeceasedTime |  | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
sdtcMultipleBirthInd |  | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc)
sdtcMultipleBirthOrderNumber |  | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
maritalStatusCode |  | 0..1 | CE | Binding: Marital Status (required)
religiousAffiliationCode |  | 0..1 | CE | Binding: Religious Affiliation (required)
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
sdtcRaceCode | C | 0..* | CE | XML Namespace: urn:hl7-org:sdtc The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
sdtcEthnicGroupCode |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required)
guardian |  | 0..* | Guardian |
@classCode |  | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required)
addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
guardianPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
guardianOrganization |  | 0..1 | Organization |
birthplace |  | 0..1 | Birthplace |
@classCode |  | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL
templateId |  | 0..* | II |
place |  | 1..1 | Place |
@classCode |  | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 0..1 | EN |
addr | C | 1..1 | AD |
nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required)
@isNotOrdered |  | 0..1 | bl |
@use |  | 0..* | cs |
delimiter |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DEL
country |  | 0..1 | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CNT
state |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STA
county |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CPA
city |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CTY
postalCode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ZIP
streetAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: SAL
houseNumber |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNR
houseNumberNumeric |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNN
direction |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DIR
streetName |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STR
streetNameBase |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STB
streetNameType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STTYP
additionalLocator |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ADL
unitID |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNID
unitType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNIT
careOf |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CAR
censusTract |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CEN
deliveryAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DAL
deliveryInstallationType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINST
deliveryInstallationArea |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTA
deliveryInstallationQualifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTQ
deliveryMode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMOD
deliveryModeIdentifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMODID
buildingNumberSuffix |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNS
postBox |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: POB
precinct |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: PRE
other |  | 0..1 | st |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
languageCommunication |  | 0..* | LanguageCommunication |
templateId |  | 0..* | II |
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
modeCode |  | 0..1 | CE | Binding: LanguageAbilityMode (required)
proficiencyLevelCode |  | 0..1 | CE | Binding: LanguageAbilityProficiency (required)
preferenceInd |  | 0..1 | BL |
providerOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..* | ON |
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
author |  | 1..* | Author |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
assignedAuthoringDevice |  | 0..1 | AuthoringDevice |
@classCode |  | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
code |  | 0..1 | CE | Binding: EntityCode (extensible)
manufacturerModelName |  | 1..1 | SC | Binding: Manufacturer Model Name Example (example)
softwareName |  | 1..1 | SC | Binding: Software Name Example (example)
asMaintainedEntity |  | 0..* | MaintainedEntity |
representedOrganization |  | 0..1 | Organization |
dataEnterer |  | 0..1 | DataEnterer |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 1..1 | TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id | C | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
relatedEntity |  | 0..1 | RelatedEntity |
informant:informant2 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedCustodian |  | 1..1 | AssignedCustodian |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
informationRecipient |  | 0..* | InformationRecipient |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
intendedRecipient |  | 1..1 | IntendedRecipient |
@classCode |  | 1..1 | cs |
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
informationRecipient |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
receivedOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 0..* | II |
name |  | 1..1 | ON |
telecom |  | 0..* | TEL |
addr |  | 0..* | AD |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
legalAuthenticator |  | 0..1 | LegalAuthenticator |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode
participant:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
participant:participant1 | C | 0..* | Participant1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
addr |  | 0..* | AD |
telecom |  | 1..* | TEL |
associatedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 1..* | PN |
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
order |  | 1..1 | Order |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO
templateId |  | 0..* | II |
id |  | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
documentationOf |  | 0..* | DocumentationOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
performer |  | 0..* | Performer1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
authorization |  | 0..* | Authorization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
@classCode |  | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
componentOf |  | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
encompassingEncounter |  | 1..1 | EncompassingEncounter |
@classCode |  | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources
sdtcAdmissionReferralSourceCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode |  | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible)
responsibleParty |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
encounterParticipant |  | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 0..1 | IVL_TS |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906).
location |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
component |  | 1..1 | Component |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501).
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@classCode |  | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section
component:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | Section |
component:component1 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component2 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component3 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component4 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component5 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component7 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | GeneralStatusSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ImmunizationsSection | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component15 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProblemSection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ResultsSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | SocialHistorySection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | VitalSignsSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AdvanceDirectivesSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | FunctionalStatusSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicalEquipmentSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MentalStatusSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | NutritionSection | Base for all types and resources
Documentation for this format

#### 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 | required | ConsultDocumentType
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | Marital Status
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | Race Value Set
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | Detailed Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavor | required | NullFlavor
ClinicalDocument.author.typeCode | required | Fixed Value: AUT
ClinicalDocument.author.contextControlCode | required | Fixed Value: OP
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Fixed Value: UNK
ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.code.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample
ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP
ClinicalDocument.custodian.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor
ClinicalDocument.informationRecipient.typeCode | required | ParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | NullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.participant.nullFlavor | required | NullFlavor
ClinicalDocument.participant.typeCode | required | ParticipationType
ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP
ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor
ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode
ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority
ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | SetOperator
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.authorization.nullFlavor | required | NullFlavor
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization.consent.code | extensible | ActCode
ClinicalDocument.authorization.consent.statusCode | required | ActStatus
ClinicalDocument.componentOf.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | USEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.typeCode | required | ParticipationType
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC
ClinicalDocument.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.typeCode | required | Fixed Value: COMP
ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN
ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component1.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : |
1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : |
1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : |
1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : |
1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:4537-5402). : |
4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : |
4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : |
4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : |
4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

This structure is derived from USRealmHeader

Summary

Mandatory: 9 elements (6 nested mandatory elements)
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

- US Realm Date and Time (DT.US.FIELDED) (http://hl7.org/cda/us/ccda/StructureDefinition/USRealmDateandTimeDTUSFIELDED)
- 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)
- Reason for Visit Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection)
- History of Present Illness Section (http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection)
- Physical Exam Section (http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection)
- Allergies and Intolerances Section (http://hl7.org/cda/us/ccda/StructureDefinition/AllergiesAndIntolerancesSection)
- 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)
- General Status Section (http://hl7.org/cda/us/ccda/StructureDefinition/GeneralStatusSection)
- Past Medical History (http://hl7.org/cda/us/ccda/StructureDefinition/PastMedicalHistory)
- Immunizations Section (http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationsSection)
- Medications Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsSection)
- Problem Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProblemSection)
- Procedures Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProceduresSection)
- Results Section (http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection)
- Social History Section (http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection)
- Vital Signs Section (http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsSection)
- Advance Directives Section (http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectivesSection)
- Functional Status Section (http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection)
- Review of Systems Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReviewofSystemsSection)
- Medical Equipment Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicalEquipmentSection)
- Mental Status Section (http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection)
- Nutrition Section (http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection)

Slices

This structure defines the following Slices:

- The element ClinicalDocument.participant is sliced based on the value of value:ClinicalDocument.typeCode
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of profile: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: 2.16.840.1.113883.10.20.22.1.4
extension |  | 1..1 | st | Required Pattern: 2015-08-01
code |  | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required)
Slices for participant |  | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode
participant:participant1 |  | 0..* | Participant1 |
typeCode |  | 1..1 | cs | Fixed Value: CALLBCK
associatedEntity |  | 1..1 | AssociatedEntity |
classCode |  | 1..1 | cs | Fixed Value: ASSIGNED
id |  | 1..* | II |
addr |  | 0..* | AD |
telecom |  | 1..* | TEL |
associatedPerson |  | 1..1 | Person |
name |  | 1..* | PN |
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
order |  | 1..1 | Order |
id |  | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.
componentOf |  | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II |
effectiveTime |  | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources
responsibleParty |  | 0..1 | InfrastructureRoot |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
encounterParticipant |  | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906).
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section
component:component1 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component2 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component3 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component4 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component5 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component7 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | GeneralStatusSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ImmunizationsSection | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component15 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProblemSection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ResultsSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | VitalSignsSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AdvanceDirectivesSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FunctionalStatusSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalEquipmentSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MentalStatusSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | NutritionSection | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
ClinicalDocument.code | required | ConsultDocumentType

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : |
1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : |
1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : |
1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : |
1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
realmCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: US
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required)
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
recordTarget |  | 1..* | RecordTarget |
patientRole |  | 1..1 | PatientRole |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
author |  | 1..* | Author |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
assignedEntity |  | 1..1 | AssignedEntity |
id | C | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
informant:informant2 |  | 0..* | Informant | informant
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
assignedCustodian |  | 1..1 | AssignedCustodian |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
id |  | 1..* | II |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Required Pattern: S
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode
participant:All Slices |  |  |  | Content/Rules for all slices
associatedEntity |  | 1..1 | AssociatedEntity |
participant:participant1 | C | 0..* | Participant1 |
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED
id |  | 1..* | II |
addr |  | 0..* | AD |
telecom |  | 1..* | TEL |
associatedPerson |  | 1..1 | Person |
name |  | 1..* | PN |
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
order |  | 1..1 | Order |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
id |  | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.
componentOf |  | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
encompassingEncounter |  | 1..1 | EncompassingEncounter |
id |  | 1..* | II |
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources
responsibleParty |  | 0..1 | InfrastructureRoot |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
encounterParticipant |  | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906).
component |  | 1..1 | Component |
structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501).
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section
component:All Slices |  |  |  | Content/Rules for all slices
section |  | 1..1 | Section |
component:component1 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component2 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component3 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component4 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component5 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component7 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | GeneralStatusSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ImmunizationsSection | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component15 |  | 1..1 | InfrastructureRoot |
section |  | 1..1 | ProblemSection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ResultsSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | SocialHistorySection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | VitalSignsSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | AdvanceDirectivesSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | FunctionalStatusSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MedicalEquipmentSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | MentalStatusSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
section |  | 1..1 | NutritionSection | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
ClinicalDocument.code | required | ConsultDocumentType
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : |
1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : |
1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : |
1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : |
1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf Base for all types and resources
@classCode |  | 0..1 | cs | Binding: ActClass (extensible) Fixed Value: DOCCLIN
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
realmCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: US
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
typeId |  | 1..1 | II |
@root |  | 1..1 | st | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st | Extension Fixed Value: POCD_HD000040
Slices for templateId |  | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:us-realm |  | 1..1 | II | templateId
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.1
@extension |  | 1..1 | st | Required Pattern: 2023-05-01
templateId:secondary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.1.4
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id | C | 1..1 | II |
code | C | 1..1 | CE | The Consultation Note recommends use of the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: ConsultDocumentType (required)
title |  | 1..1 | ST | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
setId | C | 0..1 | II |
versionNumber | C | 0..1 | INT |
copyTime |  | 0..1 | TS |
recordTarget |  | 1..* | RecordTarget |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RCT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
patientRole |  | 1..1 | PatientRole |
@classCode |  | 0..1 | cs | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..1 | II |
name | C | 1..* | USRealmPatientNamePTNUSFIELDED | Base for all types and resources
sdtcDesc |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc XML: desc (urn:hl7-org:sdtc)
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | C | 1..1 | TS |
sdtcDeceasedInd | C | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedInd XML: deceasedInd (urn:hl7-org:sdtc)
sdtcDeceasedTime |  | 0..1 | TS | XML Namespace: urn:hl7-org:sdtc sdtc:deceasedTime XML: deceasedTime (urn:hl7-org:sdtc)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
sdtcMultipleBirthInd |  | 0..1 | BL | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthInd (urn:hl7-org:sdtc)
sdtcMultipleBirthOrderNumber |  | 0..1 | INT_POS | XML Namespace: urn:hl7-org:sdtc XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
maritalStatusCode |  | 0..1 | CE | Binding: Marital Status (required)
religiousAffiliationCode |  | 0..1 | CE | Binding: Religious Affiliation (required)
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
sdtcRaceCode | C | 0..* | CE | XML Namespace: urn:hl7-org:sdtc The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements. XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (required)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
sdtcEthnicGroupCode |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc ethnicGroupCode XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (required)
guardian |  | 0..* | Guardian |
@classCode |  | 0..1 | cs | Binding: RoleClassAgent (required) Fixed Value: GUARD
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required)
addr | C | 0..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
guardianPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
guardianOrganization |  | 0..1 | Organization |
birthplace |  | 0..1 | Birthplace |
@classCode |  | 0..1 | cs | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL
templateId |  | 0..* | II |
place |  | 1..1 | Place |
@classCode |  | 0..1 | cs | Binding: EntityClassPlace (required) Fixed Value: PLC
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 0..1 | EN |
addr | C | 1..1 | AD |
nullFlavor | C | 0..1 | cs | Primitive Type code Binding: NullFlavor (required)
@isNotOrdered |  | 0..1 | bl |
@use |  | 0..* | cs |
delimiter |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DEL
country |  | 0..1 | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CNT
state |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STA
county |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CPA
city |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CTY
postalCode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ZIP
streetAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: SAL
houseNumber |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNR
houseNumberNumeric |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNN
direction |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DIR
streetName |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STR
streetNameBase |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STB
streetNameType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: STTYP
additionalLocator |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: ADL
unitID |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNID
unitType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: UNIT
careOf |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CAR
censusTract |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: CEN
deliveryAddressLine |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DAL
deliveryInstallationType |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINST
deliveryInstallationArea |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTA
deliveryInstallationQualifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DINSTQ
deliveryMode |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMOD
deliveryModeIdentifier |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: DMODID
buildingNumberSuffix |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: BNS
postBox |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: POB
precinct |  | 0..* | ADXP |
@partType |  | 0..1 | cs | Fixed Value: PRE
other |  | 0..1 | st |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
languageCommunication |  | 0..* | LanguageCommunication |
templateId |  | 0..* | II |
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
modeCode |  | 0..1 | CE | Binding: LanguageAbilityMode (required)
proficiencyLevelCode |  | 0..1 | CE | Binding: LanguageAbilityProficiency (required)
preferenceInd |  | 0..1 | BL |
providerOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..* | ON |
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
author |  | 1..* | Author |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
assignedAuthor | C | 1..1 | AssignedAuthor |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
Slices for id |  | 1..* | II | Slice: Unordered, Open by value:root
id:id1 |  | 0..1 | II | id
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required) Fixed Value: UNK
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
assignedAuthoringDevice |  | 0..1 | AuthoringDevice |
@classCode |  | 0..1 | cs | Binding: EntityClassDevice (required) Fixed Value: DEV
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
code |  | 0..1 | CE | Binding: EntityCode (extensible)
manufacturerModelName |  | 1..1 | SC | Binding: Manufacturer Model Name Example (example)
softwareName |  | 1..1 | SC | Binding: Software Name Example (example)
asMaintainedEntity |  | 0..* | MaintainedEntity |
representedOrganization |  | 0..1 | Organization |
dataEnterer |  | 0..1 | DataEnterer |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 1..1 | TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for informant |  | 0..* | Informant | Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id | C | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 0..* | TEL |
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
relatedEntity |  | 0..1 | RelatedEntity |
informant:informant2 |  | 0..* | Informant | informant
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: INF
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: ENT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedCustodian |  | 1..1 | AssignedCustodian |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
addr | C | 1..1 | USRealmAddressADUSFIELDED | Base for all types and resources
informationRecipient |  | 0..* | InformationRecipient |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
intendedRecipient |  | 1..1 | IntendedRecipient |
@classCode |  | 1..1 | cs |
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
informationRecipient |  | 0..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
receivedOrganization |  | 0..1 | Organization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@classCode |  | 0..1 | cs | Binding: EntityClassOrganization (required) Fixed Value: ORG
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
id |  | 0..* | II |
name |  | 1..1 | ON |
telecom |  | 0..* | TEL |
addr |  | 0..* | AD |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
legalAuthenticator |  | 0..1 | LegalAuthenticator |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: LA
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for authenticator |  | 0..* | Authenticator | Slice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
authenticator:authenticator1 |  | 0..* | Authenticator | authenticator
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTHEN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | C | 1..1 | USRealmDateandTimeDTMUSFIELDED | Base for all types and resources
signatureCode |  | 1..1 | CS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 1..1 | cs | Required Pattern: S
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML Namespace: urn:hl7-org:sdtc The signature can be represented either inline or by reference according to the ED data type. Typical cases for CDA are: 1) Electronic signature: this attribute can represent virtually any electronic signature scheme. 2) Digital signature: this attribute can represent digital signatures by reference to a signature data block that is constructed in accordance to a digital signature standard, such as XML-DSIG, PKCS#7, PGP, etc. XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Healthcare Provider Taxonomy (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | C | 1..* | USRealmAddressADUSFIELDED | Base for all types and resources
telecom |  | 1..* | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | url |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..1 | cs | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | C | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for participant | C | 0..* | Participant1 | This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant. Slice: Unordered, Open by value:ClinicalDocument.typeCode
participant:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
participant:participant1 | C | 0..* | Participant1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CALLBCK
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
@classCode |  | 1..1 | cs | Binding: RoleClassAssociative (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
addr |  | 0..* | AD |
telecom |  | 1..* | TEL |
associatedPerson |  | 1..1 | Person |
@classCode |  | 0..1 | cs | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
@determinerCode |  | 0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 1..* | PN |
sdtcAsPatientRelationship |  | 0..* | CE | XML Namespace: urn:hl7-org:sdtc XML: asPatientRelationship (urn:hl7-org:sdtc)
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 1..* | InFulfillmentOf | The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: FLFS
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
order |  | 1..1 | Order |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMoodIntent (required) Fixed Value: RQO
templateId |  | 0..* | II |
id |  | 1..* | II | Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
documentationOf |  | 0..* | DocumentationOf |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent |
@classCode |  | 1..1 | cs | Binding: ActClass (required)
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: SetOperator (required)
low |  | 1..1 | IVXB_TS |
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high |  | 0..1 | IVXB_TS |
performer |  | 0..* | Performer1 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: x_ServiceEventPerformer (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs | Binding: Care Team Member Function (preferred)
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.6
@extension |  | 0..1 | st |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
authorization |  | 0..* | Authorization |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: AUTH
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
@classCode |  | 0..1 | cs | Binding: ActClass (required) Fixed Value: CONS
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@code |  | 1..1 | cs | Fixed Value: completed
componentOf |  | 1..1 | ComponentOf | A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
encompassingEncounter |  | 1..1 | EncompassingEncounter |
@classCode |  | 0..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime | C | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources
sdtcAdmissionReferralSourceCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode |  | 0..1 | CE | Binding: USEncounterDischargeDisposition (extensible)
responsibleParty |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required) Fixed Value: RESP
assignedEntity | C | 1..1 | AssignedEntity | 1198-32905: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905).
encounterParticipant |  | 0..* | EncounterParticipant | The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 0..1 | IVL_TS |
assignedEntity | C | 1..1 | AssignedEntity | 1198-32906: This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906).
location |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
component |  | 1..1 | Component |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: ActRelationshipHasComponent (required) Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody | C | 1..1 | StructuredBody | 1198-28939: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). 1198-28940: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). 1198-9504: **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). 1198-9501: **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501).
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@classCode |  | 0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCBODY
@moodCode |  | 0..1 | cs | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 5..* | InfrastructureRoot | Slice: Unordered, Open by profile:section
component:All Slices |  |  |  | Content/Rules for all slices
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | Section |
component:component1 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentSection | Base for all types and resources
component:component2 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AssessmentandPlanSection | Base for all types and resources
component:component3 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PlanofTreatmentSection | Base for all types and resources
component:component4 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReasonforVisitSection | Base for all types and resources
component:component5 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | HistoryofPresentIllnessSection | Base for all types and resources
component:component6 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PhysicalExamSection | Base for all types and resources
component:component7 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AllergiesAndIntolerancesSection | Base for all types and resources
component:component8 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintSection | Base for all types and resources
component:component9 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ChiefComplaintandReasonforVisitSection | Base for all types and resources
component:component10 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | FamilyHistorySection | Base for all types and resources
component:component11 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | GeneralStatusSection | Base for all types and resources
component:component12 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | PastMedicalHistory | Base for all types and resources
component:component13 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ImmunizationsSection | Base for all types and resources
component:component14 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicationsSection | Base for all types and resources
component:component15 |  | 1..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProblemSection | Base for all types and resources
component:component16 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ProceduresSection | Base for all types and resources
component:component17 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ResultsSection | Base for all types and resources
component:component18 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | SocialHistorySection | Base for all types and resources
component:component19 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | VitalSignsSection | Base for all types and resources
component:component25 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | AdvanceDirectivesSection | Base for all types and resources
component:component20 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | FunctionalStatusSection | Base for all types and resources
component:component21 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | ReviewofSystemsSection | Base for all types and resources
component:component22 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MedicalEquipmentSection | Base for all types and resources
component:component23 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | MentalStatusSection | Base for all types and resources
component:component24 |  | 0..1 | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Fixed Value: COMP
@contextConductionInd |  | 0..1 | bl | Fixed Value: true
section |  | 1..1 | NutritionSection | Base for all types and resources
Documentation for this format

#### 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 | required | ConsultDocumentType
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | Marital Status
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | required | Race Value Set
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | required | Detailed Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavor | required | NullFlavor
ClinicalDocument.author.typeCode | required | Fixed Value: AUT
ClinicalDocument.author.contextControlCode | required | Fixed Value: OP
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Fixed Value: UNK
ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.code.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.manufacturerModelName | example | ManufacturerModelNameExample
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.softwareName | example | SoftwareNameExample
ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP
ClinicalDocument.custodian.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor
ClinicalDocument.informationRecipient.typeCode | required | ParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.nullFlavor | required | NullFlavor
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.participant.nullFlavor | required | NullFlavor
ClinicalDocument.participant.typeCode | required | ParticipationType
ClinicalDocument.participant.contextControlCode | required | Fixed Value: OP
ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor
ClinicalDocument.participant:participant1.typeCode | required | Fixed Value: CALLBCK
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode
ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority
ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.operator | required | SetOperator
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | x_ServiceEventPerformer
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
ClinicalDocument.authorization.nullFlavor | required | NullFlavor
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUTH
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization.consent.code | extensible | ActCode
ClinicalDocument.authorization.consent.statusCode | required | ActStatus
ClinicalDocument.componentOf.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.typeCode | required | Fixed Value: COMP
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | USEncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.typeCode | required | ParticipationType
ClinicalDocument.componentOf.encompassingEncounter.location.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC
ClinicalDocument.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.typeCode | required | Fixed Value: COMP
ClinicalDocument.component.structuredBody.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN
ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
ClinicalDocument.component.structuredBody.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component1.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component2.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component3.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component4.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component5.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component6.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component7.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component8.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component9.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component10.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component11.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component12.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component13.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component14.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component15.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component16.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component17.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component18.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component19.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component25.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component20.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component21.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component22.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component23.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component24.nullFlavor | required | NullFlavor

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-9501 | error | ClinicalDocument.component.structuredBody | **SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section (CONF:1198-9501). : |
1198-9504 | error | ClinicalDocument.component.structuredBody | **SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504). : |
1198-28939 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-28939). : |
1198-28940 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-28940). : |
1198-32905 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32905). : |
1198-32906 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant.assignedEntity | This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906). : |
4537-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:4537-5299). : |
4537-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:4537-5300). : |
4537-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:4537-5402). : |
4537-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:4537-5403). : |
4537-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:4537-6380). : |
4537-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:4537-6387). : |
4537-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946). : |
4537-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:4537-9991). : |
4537-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992). : |
4537-10006 | error | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006). : |
4537-10007 | warning | ClinicalDocument.participant, ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007). : |
4537-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790). : |
4537-31347 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | If sdtc:raceCode is present, then the patient **SHALL** contain [1..1] raceCode (CONF:4537-31347). : |
4537-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:4537-32418). : |
4537-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948). : |
4537-32991 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHALL** be precise to to the year (CONF:4537-32991). : |
4537-32992 | warning | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedTime.value | **SHOULD** be precise to the day (CONF:4537-32992). : |
4537-32993 | error | ClinicalDocument.recordTarget.patientRole.patient.sdtcDeceasedInd | If sdtc:deceasedInd="true", then sdtc:deceasedTime **SHALL** be present (CONF:4537-32993). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.recordTarget.patientRole.patient.guardian.addr, ClinicalDocument.recordTarget.patientRole.providerOrganization.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.dataEnterer.assignedEntity.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.legalAuthenticator.assignedEntity.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
81-10127 | error | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.legalAuthenticator.time, ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
cs-pattern | error | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | cs attributes must not contain any whitespace : matches('^[^\\s]+$') |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ivl-ts-center | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | Center cannot co-exist with low or high : center.empty() or (low.empty() and high.empty()) |
pn-no-ls | error | ClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name, ClinicalDocument.author.assignedAuthor.assignedPerson.name, ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | No PN name part may have a qualifier of LS. : (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty() |

This structure is derived from USRealmHeader

Summary

Mandatory: 9 elements (6 nested mandatory elements)
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

- US Realm Date and Time (DT.US.FIELDED) (http://hl7.org/cda/us/ccda/StructureDefinition/USRealmDateandTimeDTUSFIELDED)
- 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)
- Reason for Visit Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection)
- History of Present Illness Section (http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection)
- Physical Exam Section (http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection)
- Allergies and Intolerances Section (http://hl7.org/cda/us/ccda/StructureDefinition/AllergiesAndIntolerancesSection)
- 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)
- General Status Section (http://hl7.org/cda/us/ccda/StructureDefinition/GeneralStatusSection)
- Past Medical History (http://hl7.org/cda/us/ccda/StructureDefinition/PastMedicalHistory)
- Immunizations Section (http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationsSection)
- Medications Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsSection)
- Problem Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProblemSection)
- Procedures Section (http://hl7.org/cda/us/ccda/StructureDefinition/ProceduresSection)
- Results Section (http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection)
- Social History Section (http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistorySection)
- Vital Signs Section (http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignsSection)
- Advance Directives Section (http://hl7.org/cda/us/ccda/StructureDefinition/AdvanceDirectivesSection)
- Functional Status Section (http://hl7.org/cda/us/ccda/StructureDefinition/FunctionalStatusSection)
- Review of Systems Section (http://hl7.org/cda/us/ccda/StructureDefinition/ReviewofSystemsSection)
- Medical Equipment Section (http://hl7.org/cda/us/ccda/StructureDefinition/MedicalEquipmentSection)
- Mental Status Section (http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection)
- Nutrition Section (http://hl7.org/cda/us/ccda/StructureDefinition/NutritionSection)

Slices

This structure defines the following Slices:

- The element ClinicalDocument.participant is sliced based on the value of value:ClinicalDocument.typeCode
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of profile:section

Other representations of profile: CSV, Excel