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/2.16.840.1.113883.10.20.22.1.2 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: ContinuityofCareDocumentCCD | |||
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.2:2015-08-01 |
This document type was originally based on the Continuity of Care Document (CCD) Release 1.1 which itself was derived from HITSP C32 and CCD Release 1.0.
The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another to support the continuity of care.
The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, and administrative data for a specific patient. The key characteristic of a CCD is that the ServiceEvent is constrained to “PCPR”. This means it does not function to report new ServiceEvents associated with performing care. It reports on care that has already been provided. The CCD provides a historical tally of the care over a range of time and is not a record of new services delivered.
More specific use cases, such as a Discharge Summary, Transfer Summary, Referral Note, Consultation Note, or Progress Note, are available as alternative documents in this guide.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
Summary
Mandatory: 28 elements (13 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:primary | I | 1..1 | II | 1198-32936: 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:1198-32936). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 34133-9 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
assignedAuthor | I | 1..1 | AssignedAuthor | 1198-8456: Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456). 1198-8457: If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457). |
documentationOf | 1..1 | DocumentationOf | The documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | |
serviceEvent | 1..1 | ServiceEvent | The main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to ?PCPR? (care provision) and indicating the duration over which care was provided 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). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present. | |
classCode | 1..1 | code | Required Pattern: PCPR | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | TS | ||
high | 1..1 | TS | ||
performer | 0..* | Performer1 | The serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
typeCode | 1..1 | code | Required Pattern: PRF | |
assignedEntity | 0..1 | AssignedEntity | ||
Slices for id | 1..* | II | Slice: Unordered, Open by | |
id:id1 | I | 1..* | II | 1198-32466: If this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466). |
assignedPerson | 0..1 | Person | ||
component | 1..1 | Component2 | ||
structuredBody | 1..1 | StructuredBody | ||
Slices for component | 1..* | Element | Slice: Unordered, Open by profile:section | |
component:allergies | 1..1 | Element | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesRequired | ||
component:medications | 1..1 | Element | ||
section | 1..1 | MedicationsSectionEntriesRequired | ||
component:problems | 1..1 | Element | ||
section | 1..1 | ProblemSectionEntriesRequired | ||
component:procedures | 0..1 | Element | ||
section | 1..1 | ProceduresSectionentriesrequired | ||
component:results | 1..1 | Element | ||
section | 1..1 | ResultsSectionEntriesRequired | ||
component:advDirectives | 0..1 | Element | ||
section | 1..1 | AdvanceDirectivesSectionEntriesOptional | ||
component:encounters | 0..1 | Element | ||
section | 1..1 | EncountersSectionentriesoptional | ||
component:famHistory | 0..1 | Element | ||
section | 1..1 | FamilyHistorySection | ||
component:functionalStatus | 0..1 | Element | ||
section | 1..1 | FunctionalStatusSection | ||
component:immunizations | 0..1 | Element | ||
section | 1..1 | ImmunizationsSectionEntriesRequired | ||
component:medEquipment | 0..1 | Element | ||
section | 1..1 | MedicalEquipmentSection | ||
component:payers | 0..1 | Element | ||
section | 1..1 | PayersSection | ||
component:planOfTreatment | 0..1 | Element | ||
section | 1..1 | PlanofTreatmentSection | ||
component:socialHist | 1..1 | Element | ||
section | 1..1 | SocialHistorySection | ||
component:vitalSigns | 1..1 | Element | ||
section | 1..1 | VitalSignsSectionEntriesRequired | ||
component:mentalStatus | 0..1 | Element | ||
section | 1..1 | MentalStatusSection | ||
component:nutrition | 0..1 | Element | ||
section | 1..1 | NutritionSection | ||
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 | I | 1..1 | II | 1198-32936: 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:1198-32936). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
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 | Required Pattern: 34133-9 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
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 | 1198-8456: Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456). 1198-8457: If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457). |
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 | |
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. | |
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 | ||
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 | ||
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 | |
participant:participant1 | I | 0..* | Participant1 | 1198-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). 1198-10007: 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). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) | |
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 | ||
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) | |
documentationOf | 1..1 | DocumentationOf | The documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | |
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 | The main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to ?PCPR? (care provision) and indicating the duration over which care was provided 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). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present. | |
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 | 1..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare providers 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 | 0..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
Slices for id | 1..* | II | Slice: Unordered, Open by | |
id:All Slices | Content/Rules for all slices | |||
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 | ||
id:id1 | I | 1..* | II | 1198-32466: If this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466). |
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 | ||
relatedDocument | 0..* | RelatedDocument | ||
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 | 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 | 1..1 | StructuredBody | ||
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 profile: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:allergies | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesRequired | ||
component:medications | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsSectionEntriesRequired | ||
component:problems | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProblemSectionEntriesRequired | ||
component:procedures | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProceduresSectionentriesrequired | ||
component:results | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ResultsSectionEntriesRequired | ||
component:advDirectives | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AdvanceDirectivesSectionEntriesOptional | ||
component:encounters | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | EncountersSectionentriesoptional | ||
component:famHistory | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FamilyHistorySection | ||
component:functionalStatus | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FunctionalStatusSection | ||
component:immunizations | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ImmunizationsSectionEntriesRequired | ||
component:medEquipment | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicalEquipmentSection | ||
component:payers | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PayersSection | ||
component:planOfTreatment | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlanofTreatmentSection | ||
component:socialHist | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | SocialHistorySection | ||
component:vitalSigns | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | VitalSignsSectionEntriesRequired | ||
component:mentalStatus | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MentalStatusSection | ||
component:nutrition | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | NutritionSection | ||
Documentation for this format |
This structure is derived from USRealmHeader
Summary
Mandatory: 28 elements (13 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:primary | I | 1..1 | II | 1198-32936: 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:1198-32936). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 34133-9 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
assignedAuthor | I | 1..1 | AssignedAuthor | 1198-8456: Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456). 1198-8457: If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457). |
documentationOf | 1..1 | DocumentationOf | The documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | |
serviceEvent | 1..1 | ServiceEvent | The main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to ?PCPR? (care provision) and indicating the duration over which care was provided 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). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present. | |
classCode | 1..1 | code | Required Pattern: PCPR | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | TS | ||
high | 1..1 | TS | ||
performer | 0..* | Performer1 | The serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
typeCode | 1..1 | code | Required Pattern: PRF | |
assignedEntity | 0..1 | AssignedEntity | ||
Slices for id | 1..* | II | Slice: Unordered, Open by | |
id:id1 | I | 1..* | II | 1198-32466: If this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466). |
assignedPerson | 0..1 | Person | ||
component | 1..1 | Component2 | ||
structuredBody | 1..1 | StructuredBody | ||
Slices for component | 1..* | Element | Slice: Unordered, Open by profile:section | |
component:allergies | 1..1 | Element | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesRequired | ||
component:medications | 1..1 | Element | ||
section | 1..1 | MedicationsSectionEntriesRequired | ||
component:problems | 1..1 | Element | ||
section | 1..1 | ProblemSectionEntriesRequired | ||
component:procedures | 0..1 | Element | ||
section | 1..1 | ProceduresSectionentriesrequired | ||
component:results | 1..1 | Element | ||
section | 1..1 | ResultsSectionEntriesRequired | ||
component:advDirectives | 0..1 | Element | ||
section | 1..1 | AdvanceDirectivesSectionEntriesOptional | ||
component:encounters | 0..1 | Element | ||
section | 1..1 | EncountersSectionentriesoptional | ||
component:famHistory | 0..1 | Element | ||
section | 1..1 | FamilyHistorySection | ||
component:functionalStatus | 0..1 | Element | ||
section | 1..1 | FunctionalStatusSection | ||
component:immunizations | 0..1 | Element | ||
section | 1..1 | ImmunizationsSectionEntriesRequired | ||
component:medEquipment | 0..1 | Element | ||
section | 1..1 | MedicalEquipmentSection | ||
component:payers | 0..1 | Element | ||
section | 1..1 | PayersSection | ||
component:planOfTreatment | 0..1 | Element | ||
section | 1..1 | PlanofTreatmentSection | ||
component:socialHist | 1..1 | Element | ||
section | 1..1 | SocialHistorySection | ||
component:vitalSigns | 1..1 | Element | ||
section | 1..1 | VitalSignsSectionEntriesRequired | ||
component:mentalStatus | 0..1 | Element | ||
section | 1..1 | MentalStatusSection | ||
component:nutrition | 0..1 | Element | ||
section | 1..1 | NutritionSection | ||
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 | I | 1..1 | II | 1198-32936: 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:1198-32936). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.2 | |
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 | Required Pattern: 34133-9 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
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 | 1198-8456: Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456). 1198-8457: If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457). |
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 | |
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. | |
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 | ||
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 | ||
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 | |
participant:participant1 | I | 0..* | Participant1 | 1198-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). 1198-10007: 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). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) | |
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 | ||
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) | |
documentationOf | 1..1 | DocumentationOf | The documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care. | |
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 | The main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to ?PCPR? (care provision) and indicating the duration over which care was provided 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). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present. | |
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 | 1..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare providers 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 | 0..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
Slices for id | 1..* | II | Slice: Unordered, Open by | |
id:All Slices | Content/Rules for all slices | |||
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 | ||
id:id1 | I | 1..* | II | 1198-32466: If this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466). |
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 | ||
relatedDocument | 0..* | RelatedDocument | ||
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 | 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 | 1..1 | StructuredBody | ||
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 profile: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:allergies | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesRequired | ||
component:medications | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsSectionEntriesRequired | ||
component:problems | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProblemSectionEntriesRequired | ||
component:procedures | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProceduresSectionentriesrequired | ||
component:results | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ResultsSectionEntriesRequired | ||
component:advDirectives | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AdvanceDirectivesSectionEntriesOptional | ||
component:encounters | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | EncountersSectionentriesoptional | ||
component:famHistory | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FamilyHistorySection | ||
component:functionalStatus | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FunctionalStatusSection | ||
component:immunizations | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ImmunizationsSectionEntriesRequired | ||
component:medEquipment | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicalEquipmentSection | ||
component:payers | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PayersSection | ||
component:planOfTreatment | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlanofTreatmentSection | ||
component:socialHist | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | SocialHistorySection | ||
component:vitalSigns | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | VitalSignsSectionEntriesRequired | ||
component:mentalStatus | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MentalStatusSection | ||
component:nutrition | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | NutritionSection | ||
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.code | extensible | http://terminology.hl7.org/ValueSet/v3-DocumentType |
ClinicalDocument.code.nullFlavor | required | NullFlavor |
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.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.participant:participant1.nullFlavor | required | NullFlavor |
ClinicalDocument.participant:participant1.typeCode | required | ParticipationType |
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
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 | Pattern: PCPR |
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.id:id1.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
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.nullFlavor | required | NullFlavor |
ClinicalDocument.componentOf.typeCode | required | Fixed Value: AUT |
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC |
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN |
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode |
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition |
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP |
ClinicalDocument.componentOf.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 |
1198-32936 | error | ClinicalDocument.templateId:primary | 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:1198-32936). : | |
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). : | |
1198-8456 | error | ClinicalDocument.author.assignedAuthor | Such assignedAuthors **SHALL** contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) (CONF:1198-8456). : | |
1198-8457 | error | ClinicalDocument.author.assignedAuthor | If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@NullFlavor” **SHALL** be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC (CONF:1198-8457). : | |
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). : | |
81-10127 | 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). : | |
1198-32466 | warning | ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id:id1 | If this assignedEntity is an assignedPerson, the assignedEntity/id **SHOULD** contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466). : |