Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.15 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: CarePlan | |||
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2015-08-01 |
CARE PLAN FRAMEWORK
A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patients and Care Team Members prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patients care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.
A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patients life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care.
The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic.
Key differentiators between a Care Plan CDA and CCD (another snapshot in time document): There are 2 required sections: o Health Concerns o Interventions There are 2 optional sections: o Goals o Outcomes Provides the ability to identify patient and provider priorities with each act Provides a header participant to indicate occurrences of Care Plan review A care plan document can include entry references from the information in these sections to the information (entries) in other sections.
Please see Volume 1 of this guide to view a Care Plan Relationship diagram and story board.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
Summary
Mandatory: 21 elements (34 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | I | 1..1 | II | 1198-32934: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32934). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.15 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | string | Binding: Care Plan Document Type (required) | |
setId | 0..1 | II | ||
versionNumber | 0..1 | INT | ||
Slices for informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. Slice: Unordered, Open by value:intendedRecipient | |
informationRecipient:informationRecipient1 | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
intendedRecipient | 1..1 | IntendedRecipient | ||
id | 1..* | II | ||
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
informationRecipient | 0..1 | Person | ||
name | 1..1 | USRealmPersonNamePNUSFIELDED | ||
receivedOrganization | 0..1 | Organization | ||
id | 0..* | II | ||
name | 1..* | ON | ||
standardIndustryClassCode | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
authenticator:authenticator2 | 0..1 | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
signatureText | 0..1 | 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 signatureText element XML Namespace: urn:hl7-org:sdtc | ||
time | 1..1 | TS | ||
signatureCode | 1..1 | CS | ||
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | ||
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: ONESELF | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.111 | |
Slices for participant | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). Slice: Unordered, Open by value:typeCode | |
participant:participant1 | 0..* | Participant1 | ||
typeCode | 1..1 | code | Required Pattern: VRF | |
functionCode | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 425268008 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
time | 1..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Required Pattern: ASSIGNED | |
id | 1..* | II | ||
code | 0..1 | CE | ||
code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
participant:participant2 | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). | |
typeCode | 1..1 | code | Required Pattern: IND | |
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: INDRoleclassCodes (required) | |
associatedPerson | 1..1 | Person | ||
name | 1..* | EN | ||
Slices for documentationOf | 0..* | DocumentationOf | The serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). Slice: Unordered, Open by value:serviceEvent | |
documentationOf:documentationOf1 | 1..1 | DocumentationOf | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Required Pattern: PCPR | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
Slices for performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. Slice: Unordered, Open by value:assignedEntity | |
performer:performer1 | 1..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | ||
code | 0..1 | CE | ||
assignedPerson | 1..1 | Person | ||
name | 1..1 | USRealmPersonNamePNUSFIELDED | ||
Slices for relatedDocument | 0..* | RelatedDocument | Slice: Unordered, Open by value:parentDocument, value:typeCode | |
relatedDocument:relatedDocument1 | 0..* | RelatedDocument | ||
typeCode | 1..1 | code | Binding: x_ActRelationshipDocument (required) | |
parentDocument | 1..1 | ParentDocument | ||
id | 1..* | II | ||
setId | 1..1 | II | ||
versionNumber | 1..1 | INT | ||
componentOf:componentOf1 | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
encompassingEncounter | 1..1 | EncompassingEncounter | ||
effectiveTime | 1..1 | IVL_TS | ||
component | 1..1 | Component2 | ||
structuredBody | I | 1..1 | StructuredBody | 1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044). |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:component1 | 1..1 | Element | ||
section | 1..1 | HealthConcernsSection | ||
component:component2 | 1..1 | Element | ||
section | 1..1 | GoalsSection | ||
component:component3 | 0..1 | Element | ||
section | 1..1 | InterventionsSection | ||
component:component4 | 0..1 | Element | ||
section | 1..1 | HealthStatusEvaluationsandOutcomesSection | ||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
classCode | 1..1 | code | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
realmCode | 1..1 | CS | Required Pattern: US | |
typeId | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.1.3 | |
extension | 1..1 | string | Required Pattern: POCD_HD000040 | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
templateId:secondary | I | 1..1 | II | 1198-32934: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32934). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.15 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | I | 1..1 | II | |
code | I | 1..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Care Plan Document Type (required) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
title | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
setId | I | 0..1 | II | |
versionNumber | I | 0..1 | INT | |
copyTime | 0..1 | TS | ||
recordTarget | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
patientRole | 1..1 | PatientRole | ||
classCode | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
patient | 1..1 | Patient | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..1 | II | ||
name | I | 1..* | USRealmPatientNamePTNUSFIELDED | |
sdtcDesc | 0..1 | ED | XML: desc (urn:hl7-org:sdtc) | |
administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
birthTime | I | 1..1 | TS | |
sdtcDeceasedInd | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc) | |
sdtcDeceasedTime | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc) | |
sdtcMultipleBirthInd | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc) | |
sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
sdtcRaceCode | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible) | |
ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
sdtcEthnicGroupCode | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible) | |
guardian | 0..* | Guardian | ||
classCode | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
addr | I | 0..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
guardianPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
guardianOrganization | 0..1 | Organization | ||
birthplace | 0..1 | Birthplace | ||
classCode | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
templateId | 0..* | II | ||
place | 1..1 | Place | ||
classCode | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | 0..1 | EN | ||
addr | I | 1..1 | AD | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
isNotOrdered | 0..1 | boolean | ||
use | 0..* | code | ||
delimiter | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DEL | |
country | 0..1 | ADXP | ||
partType | 0..1 | code | Fixed Value: CNT | |
state | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STA | |
county | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CPA | |
city | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CTY | |
postalCode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ZIP | |
streetAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: SAL | |
houseNumber | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNR | |
houseNumberNumeric | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNN | |
direction | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DIR | |
streetName | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STR | |
streetNameBase | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STB | |
streetNameType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STTYP | |
additionalLocator | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ADL | |
unitID | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNID | |
unitType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNIT | |
careOf | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CAR | |
censusTract | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CEN | |
deliveryAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DAL | |
deliveryInstallationType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINST | |
deliveryInstallationArea | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTA | |
deliveryInstallationQualifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTQ | |
deliveryMode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMOD | |
deliveryModeIdentifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMODID | |
buildingNumberSuffix | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNS | |
postBox | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: POB | |
precinct | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: PRE | |
other | 0..1 | string | ||
useablePeriod[x] | 0..* | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS | IVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS | EIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS | PIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS | SXPR_TS | |||
languageCommunication | 0..* | LanguageCommunication | ||
templateId | 0..* | II | ||
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
preferenceInd | 0..1 | BL | ||
providerOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..* | ON | ||
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
assignedAuthor | I | 1..1 | AssignedAuthor | |
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root 1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). |
id:id1 | 0..1 | II | ||
nullFlavor | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
classCode | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
code | 0..1 | CE | Binding: EntityCode (extensible) | |
manufacturerModelName | 1..1 | SC | ||
softwareName | 1..1 | SC | ||
asMaintainedEntity | 0..* | MaintainedEntity | ||
representedOrganization | 0..1 | Organization | ||
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 1..1 | TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for informant | 0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. Slice: Unordered, Open by value:relatedEntity | |
informant:informant1 | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | I | 1..* | II | 1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946). |
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
relatedEntity | 0..1 | RelatedEntity | ||
informant:informant2 | 0..* | Informant | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 1..1 | RelatedEntity | ||
custodian | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedCustodian | 1..1 | AssignedCustodian | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..1 | ON | ||
telecom | 1..1 | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..1 | USRealmAddressADUSFIELDED | |
Slices for informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. Slice: Unordered, Open by value:intendedRecipient | |
informationRecipient:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
intendedRecipient | 1..1 | IntendedRecipient | ||
classCode | 1..1 | code | ||
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
informationRecipient | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
receivedOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..* | II | ||
name | 1..1 | ON | ||
telecom | 0..* | TEL | ||
addr | 0..* | AD | ||
standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
informationRecipient:informationRecipient1 | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
intendedRecipient | 1..1 | IntendedRecipient | ||
classCode | 1..1 | code | ||
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
informationRecipient | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..1 | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
receivedOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..* | II | ||
name | 1..* | ON | ||
telecom | 0..* | TEL | ||
addr | 0..* | AD | ||
standardIndustryClassCode | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
legalAuthenticator | 0..1 | LegalAuthenticator | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: LA | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
signatureCode | 1..1 | CS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: S | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. Slice: Unordered, Open by value:signatureCode, value:assignedEntity | |
authenticator:authenticator1 | 0..* | Authenticator | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
signatureCode | 1..1 | CS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: S | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
authenticator:authenticator2 | 0..1 | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 1..1 | TS | ||
signatureCode | 1..1 | CS | ||
sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 1..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: ONESELF | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.111 | |
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
Slices for participant | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). Slice: Unordered, Open by value:typeCode | |
participant:participant1 | I | 0..* | Participant1 | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: VRF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 1..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: 425268008 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 1..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssociative (required) Required Pattern: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 0..1 | Person | ||
scopingOrganization | 0..1 | Organization | ||
participant:participant2 | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: IND | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
time | 0..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: INDRoleclassCodes (required) | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | 1..* | EN | ||
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
scopingOrganization | 0..1 | Organization | ||
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
order | 1..1 | Order | ||
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
Slices for documentationOf | 0..* | DocumentationOf | The serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). Slice: Unordered, Open by value:serviceEvent | |
documentationOf:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
documentationOf:documentationOf1 | 1..1 | DocumentationOf | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) Required Pattern: PCPR | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
Slices for performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. Slice: Unordered, Open by value:assignedEntity | |
performer:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
performer:performer1 | 1..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..1 | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for relatedDocument | 0..* | RelatedDocument | Slice: Unordered, Open by value:parentDocument, value:typeCode | |
relatedDocument:relatedDocument1 | 0..* | RelatedDocument | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ActRelationshipDocument (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
parentDocument | 1..1 | ParentDocument | ||
classCode | 1..1 | code | Binding: ActClassClinicalDocument (required) Fixed Value: DOCCLIN | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CD | Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) | |
text | 0..1 | ED | ||
setId | 1..1 | II | ||
versionNumber | 1..1 | INT | ||
Slices for authorization | 0..* | Authorization | The authorization element represents information about the patient?s consent.
The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?.
The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent | |
authorization:authorization1 | 0..* | Authorization | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
consent | 1..1 | Consent | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
code | 1..1 | Fixed Value: completed | ||
componentOf:componentOf1 | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
encompassingEncounter | 1..1 | EncompassingEncounter | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
effectiveTime | 1..1 | IVL_TS | ||
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
responsibleParty | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
assignedEntity | 1..1 | AssignedEntity | ||
encounterParticipant | 0..* | EncounterParticipant | ||
location | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
component | 1..1 | Component2 | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextConductionInd | 1..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
nonXMLBody | 0..1 | NonXMLBody | ||
structuredBody | I | 1..1 | StructuredBody | 1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044). |
classCode | 1..1 | code | Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
confidentialityCode | 0..1 | CE | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | Section | ||
component:component1 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HealthConcernsSection | ||
component:component2 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | GoalsSection | ||
component:component3 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | InterventionsSection | ||
component:component4 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HealthStatusEvaluationsandOutcomesSection | ||
Documentation for this format |
This structure is derived from USRealmHeader
Summary
Mandatory: 21 elements (34 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | I | 1..1 | II | 1198-32934: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32934). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.15 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | string | Binding: Care Plan Document Type (required) | |
setId | 0..1 | II | ||
versionNumber | 0..1 | INT | ||
Slices for informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. Slice: Unordered, Open by value:intendedRecipient | |
informationRecipient:informationRecipient1 | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
intendedRecipient | 1..1 | IntendedRecipient | ||
id | 1..* | II | ||
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
informationRecipient | 0..1 | Person | ||
name | 1..1 | USRealmPersonNamePNUSFIELDED | ||
receivedOrganization | 0..1 | Organization | ||
id | 0..* | II | ||
name | 1..* | ON | ||
standardIndustryClassCode | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
authenticator:authenticator2 | 0..1 | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
signatureText | 0..1 | 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 signatureText element XML Namespace: urn:hl7-org:sdtc | ||
time | 1..1 | TS | ||
signatureCode | 1..1 | CS | ||
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | ||
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: ONESELF | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.111 | |
Slices for participant | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). Slice: Unordered, Open by value:typeCode | |
participant:participant1 | 0..* | Participant1 | ||
typeCode | 1..1 | code | Required Pattern: VRF | |
functionCode | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 425268008 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
time | 1..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Required Pattern: ASSIGNED | |
id | 1..* | II | ||
code | 0..1 | CE | ||
code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
participant:participant2 | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). | |
typeCode | 1..1 | code | Required Pattern: IND | |
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: INDRoleclassCodes (required) | |
associatedPerson | 1..1 | Person | ||
name | 1..* | EN | ||
Slices for documentationOf | 0..* | DocumentationOf | The serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). Slice: Unordered, Open by value:serviceEvent | |
documentationOf:documentationOf1 | 1..1 | DocumentationOf | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Required Pattern: PCPR | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
Slices for performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. Slice: Unordered, Open by value:assignedEntity | |
performer:performer1 | 1..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
assignedEntity | 1..1 | AssignedEntity | ||
id | 1..* | II | ||
code | 0..1 | CE | ||
assignedPerson | 1..1 | Person | ||
name | 1..1 | USRealmPersonNamePNUSFIELDED | ||
Slices for relatedDocument | 0..* | RelatedDocument | Slice: Unordered, Open by value:parentDocument, value:typeCode | |
relatedDocument:relatedDocument1 | 0..* | RelatedDocument | ||
typeCode | 1..1 | code | Binding: x_ActRelationshipDocument (required) | |
parentDocument | 1..1 | ParentDocument | ||
id | 1..* | II | ||
setId | 1..1 | II | ||
versionNumber | 1..1 | INT | ||
componentOf:componentOf1 | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
encompassingEncounter | 1..1 | EncompassingEncounter | ||
effectiveTime | 1..1 | IVL_TS | ||
component | 1..1 | Component2 | ||
structuredBody | I | 1..1 | StructuredBody | 1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044). |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:component1 | 1..1 | Element | ||
section | 1..1 | HealthConcernsSection | ||
component:component2 | 1..1 | Element | ||
section | 1..1 | GoalsSection | ||
component:component3 | 0..1 | Element | ||
section | 1..1 | InterventionsSection | ||
component:component4 | 0..1 | Element | ||
section | 1..1 | HealthStatusEvaluationsandOutcomesSection | ||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
classCode | 1..1 | code | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
realmCode | 1..1 | CS | Required Pattern: US | |
typeId | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.1.3 | |
extension | 1..1 | string | Required Pattern: POCD_HD000040 | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
templateId:secondary | I | 1..1 | II | 1198-32934: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32934). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.15 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | I | 1..1 | II | |
code | I | 1..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Care Plan Document Type (required) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
title | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
setId | I | 0..1 | II | |
versionNumber | I | 0..1 | INT | |
copyTime | 0..1 | TS | ||
recordTarget | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
patientRole | 1..1 | PatientRole | ||
classCode | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
patient | 1..1 | Patient | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..1 | II | ||
name | I | 1..* | USRealmPatientNamePTNUSFIELDED | |
sdtcDesc | 0..1 | ED | XML: desc (urn:hl7-org:sdtc) | |
administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
birthTime | I | 1..1 | TS | |
sdtcDeceasedInd | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc) | |
sdtcDeceasedTime | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc) | |
sdtcMultipleBirthInd | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc) | |
sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
sdtcRaceCode | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible) | |
ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
sdtcEthnicGroupCode | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible) | |
guardian | 0..* | Guardian | ||
classCode | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
addr | I | 0..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
guardianPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
guardianOrganization | 0..1 | Organization | ||
birthplace | 0..1 | Birthplace | ||
classCode | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
templateId | 0..* | II | ||
place | 1..1 | Place | ||
classCode | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | 0..1 | EN | ||
addr | I | 1..1 | AD | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
isNotOrdered | 0..1 | boolean | ||
use | 0..* | code | ||
delimiter | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DEL | |
country | 0..1 | ADXP | ||
partType | 0..1 | code | Fixed Value: CNT | |
state | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STA | |
county | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CPA | |
city | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CTY | |
postalCode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ZIP | |
streetAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: SAL | |
houseNumber | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNR | |
houseNumberNumeric | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNN | |
direction | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DIR | |
streetName | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STR | |
streetNameBase | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STB | |
streetNameType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STTYP | |
additionalLocator | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ADL | |
unitID | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNID | |
unitType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNIT | |
careOf | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CAR | |
censusTract | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CEN | |
deliveryAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DAL | |
deliveryInstallationType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINST | |
deliveryInstallationArea | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTA | |
deliveryInstallationQualifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTQ | |
deliveryMode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMOD | |
deliveryModeIdentifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMODID | |
buildingNumberSuffix | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNS | |
postBox | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: POB | |
precinct | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: PRE | |
other | 0..1 | string | ||
useablePeriod[x] | 0..* | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS | IVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS | EIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS | PIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS | SXPR_TS | |||
languageCommunication | 0..* | LanguageCommunication | ||
templateId | 0..* | II | ||
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
preferenceInd | 0..1 | BL | ||
providerOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..* | ON | ||
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
assignedAuthor | I | 1..1 | AssignedAuthor | |
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root 1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). |
id:id1 | 0..1 | II | ||
nullFlavor | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
classCode | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
code | 0..1 | CE | Binding: EntityCode (extensible) | |
manufacturerModelName | 1..1 | SC | ||
softwareName | 1..1 | SC | ||
asMaintainedEntity | 0..* | MaintainedEntity | ||
representedOrganization | 0..1 | Organization | ||
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 1..1 | TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for informant | 0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. Slice: Unordered, Open by value:relatedEntity | |
informant:informant1 | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | I | 1..* | II | 1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946). |
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
relatedEntity | 0..1 | RelatedEntity | ||
informant:informant2 | 0..* | Informant | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 1..1 | RelatedEntity | ||
custodian | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedCustodian | 1..1 | AssignedCustodian | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..1 | ON | ||
telecom | 1..1 | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..1 | USRealmAddressADUSFIELDED | |
Slices for informationRecipient | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. Slice: Unordered, Open by value:intendedRecipient | |
informationRecipient:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
intendedRecipient | 1..1 | IntendedRecipient | ||
classCode | 1..1 | code | ||
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
informationRecipient | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
receivedOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..* | II | ||
name | 1..1 | ON | ||
telecom | 0..* | TEL | ||
addr | 0..* | AD | ||
standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
informationRecipient:informationRecipient1 | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
intendedRecipient | 1..1 | IntendedRecipient | ||
classCode | 1..1 | code | ||
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
informationRecipient | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..1 | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
receivedOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..* | II | ||
name | 1..* | ON | ||
telecom | 0..* | TEL | ||
addr | 0..* | AD | ||
standardIndustryClassCode | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
legalAuthenticator | 0..1 | LegalAuthenticator | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: LA | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
signatureCode | 1..1 | CS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: S | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for authenticator | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. Slice: Unordered, Open by value:signatureCode, value:assignedEntity | |
authenticator:authenticator1 | 0..* | Authenticator | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
signatureCode | 1..1 | CS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: S | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
authenticator:authenticator2 | 0..1 | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 1..1 | TS | ||
signatureCode | 1..1 | CS | ||
sdtcSignatureText | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc) | |
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 1..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: ONESELF | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.111 | |
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
Slices for participant | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). Slice: Unordered, Open by value:typeCode | |
participant:participant1 | I | 0..* | Participant1 | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: VRF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 1..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: 425268008 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 1..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssociative (required) Required Pattern: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Personal And Legal Relationship Role Type (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 0..1 | Person | ||
scopingOrganization | 0..1 | Organization | ||
participant:participant2 | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: IND | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
time | 0..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: INDRoleclassCodes (required) | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | 1..* | EN | ||
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
scopingOrganization | 0..1 | Organization | ||
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
order | 1..1 | Order | ||
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
Slices for documentationOf | 0..* | DocumentationOf | The serviceEvent describes the provision of healthcare over a period of time. The duration over which care was provided is indicated in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). Slice: Unordered, Open by value:serviceEvent | |
documentationOf:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
documentationOf:documentationOf1 | 1..1 | DocumentationOf | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) Required Pattern: PCPR | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
Slices for performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. Slice: Unordered, Open by value:assignedEntity | |
performer:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
performer:performer1 | 1..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..1 | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for relatedDocument | 0..* | RelatedDocument | Slice: Unordered, Open by value:parentDocument, value:typeCode | |
relatedDocument:relatedDocument1 | 0..* | RelatedDocument | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ActRelationshipDocument (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
parentDocument | 1..1 | ParentDocument | ||
classCode | 1..1 | code | Binding: ActClassClinicalDocument (required) Fixed Value: DOCCLIN | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CD | Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) | |
text | 0..1 | ED | ||
setId | 1..1 | II | ||
versionNumber | 1..1 | INT | ||
Slices for authorization | 0..* | Authorization | The authorization element represents information about the patient?s consent.
The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?.
The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent | |
authorization:authorization1 | 0..* | Authorization | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
consent | 1..1 | Consent | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
code | 1..1 | Fixed Value: completed | ||
componentOf:componentOf1 | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
encompassingEncounter | 1..1 | EncompassingEncounter | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: ActEncounterCode (extensible) | |
effectiveTime | 1..1 | IVL_TS | ||
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
responsibleParty | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
assignedEntity | 1..1 | AssignedEntity | ||
encounterParticipant | 0..* | EncounterParticipant | ||
location | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
component | 1..1 | Component2 | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextConductionInd | 1..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
nonXMLBody | 0..1 | NonXMLBody | ||
structuredBody | I | 1..1 | StructuredBody | 1198-31044: This structuredBody **SHALL NOT** contain a Plan of Treatment Section (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044). |
classCode | 1..1 | code | Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
confidentialityCode | 0..1 | CE | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | Section | ||
component:component1 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HealthConcernsSection | ||
component:component2 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | GoalsSection | ||
component:component3 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | InterventionsSection | ||
component:component4 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HealthStatusEvaluationsandOutcomesSection | ||
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN |
ClinicalDocument.moodCode | required | Fixed Value: EVN |
ClinicalDocument.typeId.nullFlavor | required | NullFlavor |
ClinicalDocument.templateId:primary.nullFlavor | required | NullFlavor |
ClinicalDocument.templateId:secondary.nullFlavor | required | NullFlavor |
ClinicalDocument.code | extensible | http://terminology.hl7.org/ValueSet/v3-DocumentType |
ClinicalDocument.code.nullFlavor | required | NullFlavor |
ClinicalDocument.code.code | required | CarePlanDocumentType |
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind |
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor |
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT |
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT |
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor |
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header) |
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN |
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3) |
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus |
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation |
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls |
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | extensible | RaceValueSet |
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity |
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | extensible | DetailedEthnicity |
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD |
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type |
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor |
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header) |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN |
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526 |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode |
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency |
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG |
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor |
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header) |
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
ClinicalDocument.author.nullFlavor | required | NullFlavor |
ClinicalDocument.author.typeCode | required | Fixed Value: AUT |
ClinicalDocument.author.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Pattern: UNK |
ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode |
ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor |
ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor |
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header) |
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN |
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode |
ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor |
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT |
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor |
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor |
ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF |
ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.informant:informant1.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.informant: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.classCode | required | Fixed Value: ORG |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
ClinicalDocument.informationRecipient:informationRecipient1.nullFlavor | required | NullFlavor |
ClinicalDocument.informationRecipient:informationRecipient1.typeCode | required | ParticipationType |
ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN |
ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG |
ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.receivedOrganization.standardIndustryClassCode | required | HealthcareProviderTaxonomy |
ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor |
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA |
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor |
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.legalAuthenticator.assignedEntity.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 | HealthcareProviderTaxonomy |
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor |
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header) |
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.authenticator:authenticator2.nullFlavor | required | NullFlavor |
ClinicalDocument.authenticator:authenticator2.typeCode | required | Fixed Value: AUTHEN |
ClinicalDocument.authenticator:authenticator2.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.authenticator:authenticator2.assignedEntity.code | extensible | RoleCode |
ClinicalDocument.authenticator:authenticator2.assignedEntity.code.nullFlavor | required | NullFlavor |
ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor |
ClinicalDocument.participant:participant1.typeCode | required | Pattern: VRF |
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.participant:participant1.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Pattern: ASSIGNED |
ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode |
ClinicalDocument.participant:participant1.associatedEntity.code.nullFlavor | required | NullFlavor |
ClinicalDocument.participant:participant1.associatedEntity.code.code | preferred | Personal And Legal Relationship Role Type |
ClinicalDocument.participant:participant2.nullFlavor | required | NullFlavor |
ClinicalDocument.participant:participant2.typeCode | required | Pattern: IND |
ClinicalDocument.participant:participant2.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.participant:participant2.associatedEntity.classCode | required | INDRoleclassCodes |
ClinicalDocument.participant:participant2.associatedEntity.code | extensible | RoleCode |
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN |
ClinicalDocument.participant:participant2.associatedEntity.associatedPerson.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor |
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS |
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO |
ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode |
ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority |
ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass |
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.documentationOf:documentationOf1.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode | required | Pattern: PCPR |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.moodCode | required | Fixed Value: EVN |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE |
ClinicalDocument.relatedDocument:relatedDocument1.nullFlavor | required | NullFlavor |
ClinicalDocument.relatedDocument:relatedDocument1.typeCode | required | x_ActRelationshipDocument |
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.classCode | required | Fixed Value: DOCCLIN |
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.moodCode | required | Fixed Value: EVN |
ClinicalDocument.relatedDocument:relatedDocument1.parentDocument.code | extensible | http://terminology.hl7.org/ValueSet/v3-DocumentType |
ClinicalDocument.authorization:authorization1.nullFlavor | required | NullFlavor |
ClinicalDocument.authorization:authorization1.typeCode | required | Fixed Value: AUT |
ClinicalDocument.authorization:authorization1.consent.classCode | required | Fixed Value: CONS |
ClinicalDocument.authorization:authorization1.consent.moodCode | required | Fixed Value: EVN |
ClinicalDocument.authorization:authorization1.consent.code | extensible | ActCode |
ClinicalDocument.authorization:authorization1.consent.statusCode | required | ActStatus |
ClinicalDocument.componentOf:componentOf1.nullFlavor | required | NullFlavor |
ClinicalDocument.componentOf:componentOf1.typeCode | required | Fixed Value: AUT |
ClinicalDocument.componentOf:componentOf1.encompassingEncounter.classCode | required | Fixed Value: ENC |
ClinicalDocument.componentOf:componentOf1.encompassingEncounter.moodCode | required | Fixed Value: EVN |
ClinicalDocument.componentOf:componentOf1.encompassingEncounter.code | extensible | ActEncounterCode |
ClinicalDocument.componentOf:componentOf1.encompassingEncounter.dischargeDispositionCode | extensible | http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition |
ClinicalDocument.componentOf:componentOf1.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
ClinicalDocument.componentOf:componentOf1.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
ClinicalDocument.component.nullFlavor | required | NullFlavor |
ClinicalDocument.component.typeCode | required | Fixed Value: AUT |
ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY |
ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN |
ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage |
Id | Grade | Path | Details | Requirements |
1198-32934 | error | ClinicalDocument.templateId:secondary | When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32934). : | |
1198-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:1198-9991). : | |
1198-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992). : | |
1198-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948). : | |
81-10127 | error | ClinicalDocument.effectiveTime | **SHALL** be precise to the day (CONF:81-10127). : | |
81-10128 | warning | ClinicalDocument.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10128). : | |
81-10129 | warning | ClinicalDocument.effectiveTime | **MAY** be precise to the second (CONF:81-10129). : | |
81-10130 | warning | ClinicalDocument.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
1198-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:1198-6380). : | |
1198-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:1198-6387). : | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
1198-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:1198-5299). : | |
1198-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:1198-5300). : | |
1198-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:1198-32418).
For cases where information about newborn's time of birth needs to be captured. : | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
1198-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:1198-5402). : | |
1198-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:1198-5403). : | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-10127 | error | ClinicalDocument.author.time | **SHALL** be precise to the day (CONF:81-10127). : | |
81-10128 | warning | ClinicalDocument.author.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
81-10129 | warning | ClinicalDocument.author.time | **MAY** be precise to the second (CONF:81-10129). : | |
81-10130 | warning | ClinicalDocument.author.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
1198-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790). : | |
1198-5449 | null | ClinicalDocument.author.assignedAuthor.id | If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). : | |
81-7296 | error | ClinicalDocument.author.assignedAuthor.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-7296 | error | ClinicalDocument.dataEnterer.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
1198-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946). : | |
81-7296 | error | ClinicalDocument.informant:informant1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-7296 | error | ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-9371 | error | ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.informationRecipient.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.informationRecipient:informationRecipient1.intendedRecipient.informationRecipient.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-10127 | error | ClinicalDocument.legalAuthenticator.time | **SHALL** be precise to the day (CONF:81-10127). : | |
81-10128 | warning | ClinicalDocument.legalAuthenticator.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
81-10129 | warning | ClinicalDocument.legalAuthenticator.time | **MAY** be precise to the second (CONF:81-10129). : | |
81-10130 | warning | ClinicalDocument.legalAuthenticator.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
81-7296 | error | ClinicalDocument.legalAuthenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-10127 | error | ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : | |
81-10128 | warning | ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
81-10129 | warning | ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : | |
81-10130 | warning | ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
81-7296 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
1198-10006 | error | ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). : | |
1198-10007 | warning | ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007). : | |
81-9371 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.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.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
1198-31044 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Plan of Treatment Section (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-31044). : |