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/2.16.840.1.113883.10.20.22.1.3 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: HistoryandPhysical | |||
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.3:2015-08-01 |
A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual’s health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient’s lifestyle, habits, and diseases among family members.
The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician’s assessment of the patient’s situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
Summary
Mandatory: 31 elements (12 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | I | 1..1 | II | 1198-32939: 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:1198-32939). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note?, with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | |
code | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22 (required) | |
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. | |
intendedRecipient | 1..1 | IntendedRecipient | ||
participant | I | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
inFulfillmentOf | 0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
componentOf | 1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
encompassingEncounter | 1..1 | EncompassingEncounter | ||
id | 1..* | II | ||
effectiveTime | 1..1 | USRealmDateandTimeDTUSFIELDED | The effectiveTime represents the time interval or point in time in which the encounter took place. | |
responsibleParty | I | 0..1 | Element | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
encounterParticipant | I | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
location | 0..1 | Element | ||
component | 1..1 | Component2 | ||
structuredBody | I | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. 1198-30613: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30613). 1198-30614: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30614). 1198-30615: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30615). 1198-30616: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30616). |
Slices for component | 1..* | Element | Slice: Unordered, Open by profile:section | |
component:component1 | 1..1 | Element | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component2 | 0..1 | Element | ||
section | 1..1 | AssessmentSection | ||
component:component3 | 0..1 | Element | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component4 | 0..1 | Element | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component5 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintSection | ||
component:component6 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component7 | 1..1 | Element | ||
section | 1..1 | FamilyHistorySection | ||
component:component8 | 1..1 | Element | ||
section | 1..1 | GeneralStatusSection | ||
component:component9 | 1..1 | Element | ||
section | 1..1 | PastMedicalHistory | ||
component:component10 | 0..1 | Element | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component11 | 0..1 | Element | ||
section | 1..1 | ImmunizationsSectionEntriesOptional | ||
component:component12 | 0..1 | Element | ||
section | 1..1 | InstructionsSection | ||
component:component13 | 1..1 | Element | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component14 | 1..1 | Element | ||
section | 1..1 | PhysicalExamSection | ||
component:component15 | 0..1 | Element | ||
section | 1..1 | ProblemSectionEntriesOptional | ||
component:component16 | 0..1 | Element | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
section | 1..1 | ReasonforVisitSection | ||
component:component18 | 1..1 | Element | ||
section | 1..1 | ResultsSectionEntriesOptional | ||
component:component19 | 1..1 | Element | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component20 | 1..1 | Element | ||
section | 1..1 | SocialHistorySection | ||
component:component21 | 1..1 | Element | ||
section | 1..1 | VitalSignsSectionEntriesOptional | ||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
classCode | 1..1 | code | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
realmCode | 1..1 | CS | Required Pattern: US | |
typeId | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.1.3 | |
extension | 1..1 | string | Required Pattern: POCD_HD000040 | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
templateId:secondary | I | 1..1 | II | 1198-32939: 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:1198-32939). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | I | 1..1 | II | |
code | I | 1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note?, with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22 (required) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
title | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
setId | I | 0..1 | II | |
versionNumber | I | 0..1 | INT | |
copyTime | 0..1 | TS | ||
recordTarget | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
patientRole | 1..1 | PatientRole | ||
classCode | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
patient | 1..1 | Patient | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..1 | II | ||
name | I | 1..* | USRealmPatientNamePTNUSFIELDED | |
sdtcDesc | 0..1 | ED | XML: desc (urn:hl7-org:sdtc) | |
administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
birthTime | I | 1..1 | TS | |
sdtcDeceasedInd | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc) | |
sdtcDeceasedTime | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc) | |
sdtcMultipleBirthInd | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc) | |
sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
sdtcRaceCode | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible) | |
ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
sdtcEthnicGroupCode | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible) | |
guardian | 0..* | Guardian | ||
classCode | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
addr | I | 0..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
guardianPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
guardianOrganization | 0..1 | Organization | ||
birthplace | 0..1 | Birthplace | ||
classCode | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
templateId | 0..* | II | ||
place | 1..1 | Place | ||
classCode | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | 0..1 | EN | ||
addr | I | 1..1 | AD | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
isNotOrdered | 0..1 | boolean | ||
use | 0..* | code | ||
delimiter | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DEL | |
country | 0..1 | ADXP | ||
partType | 0..1 | code | Fixed Value: CNT | |
state | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STA | |
county | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CPA | |
city | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CTY | |
postalCode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ZIP | |
streetAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: SAL | |
houseNumber | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNR | |
houseNumberNumeric | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNN | |
direction | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DIR | |
streetName | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STR | |
streetNameBase | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STB | |
streetNameType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STTYP | |
additionalLocator | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ADL | |
unitID | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNID | |
unitType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNIT | |
careOf | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CAR | |
censusTract | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CEN | |
deliveryAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DAL | |
deliveryInstallationType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINST | |
deliveryInstallationArea | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTA | |
deliveryInstallationQualifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTQ | |
deliveryMode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMOD | |
deliveryModeIdentifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMODID | |
buildingNumberSuffix | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNS | |
postBox | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: POB | |
precinct | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: PRE | |
other | 0..1 | string | ||
useablePeriod[x] | 0..* | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS | IVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS | EIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS | PIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS | SXPR_TS | |||
languageCommunication | 0..* | LanguageCommunication | ||
templateId | 0..* | II | ||
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
preferenceInd | 0..1 | BL | ||
providerOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..* | ON | ||
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
assignedAuthor | I | 1..1 | AssignedAuthor | |
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root 1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). |
id:id1 | 0..1 | II | ||
nullFlavor | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
classCode | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
code | 0..1 | CE | Binding: EntityCode (extensible) | |
manufacturerModelName | 1..1 | SC | ||
softwareName | 1..1 | SC | ||
asMaintainedEntity | 0..* | MaintainedEntity | ||
representedOrganization | 0..1 | Organization | ||
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 1..1 | TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for informant | 0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. Slice: Unordered, Open by value:relatedEntity | |
informant:informant1 | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | I | 1..* | II | 1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946). |
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
relatedEntity | 0..1 | RelatedEntity | ||
informant:informant2 | 0..* | Informant | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 1..1 | RelatedEntity | ||
custodian | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedCustodian | 1..1 | AssignedCustodian | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..1 | ON | ||
telecom | 1..1 | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..1 | USRealmAddressADUSFIELDED | |
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 | I | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. Slice: Unordered, Open by 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
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 | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
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 | 0..* | DocumentationOf | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
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 | 1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
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 | I | 1..1 | USRealmDateandTimeDTUSFIELDED | The effectiveTime represents the time interval or point in time in which the encounter took place. |
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
responsibleParty | I | 0..1 | Element | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
assignedEntity | 1..1 | AssignedEntity | ||
encounterParticipant | I | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
location | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
component | 1..1 | Component2 | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextConductionInd | 1..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
nonXMLBody | 0..1 | NonXMLBody | ||
structuredBody | I | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. 1198-30613: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30613). 1198-30614: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30614). 1198-30615: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30615). 1198-30616: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30616). |
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:component1 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component2 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentSection | ||
component:component3 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component4 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component5 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintSection | ||
component:component6 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component7 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FamilyHistorySection | ||
component:component8 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | GeneralStatusSection | ||
component:component9 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PastMedicalHistory | ||
component:component10 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component11 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ImmunizationsSectionEntriesOptional | ||
component:component12 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | InstructionsSection | ||
component:component13 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component14 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PhysicalExamSection | ||
component:component15 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProblemSectionEntriesOptional | ||
component:component16 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReasonforVisitSection | ||
component:component18 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ResultsSectionEntriesOptional | ||
component:component19 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component20 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | SocialHistorySection | ||
component:component21 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | VitalSignsSectionEntriesOptional | ||
Documentation for this format |
This structure is derived from USRealmHeader
Summary
Mandatory: 31 elements (12 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USRealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:secondary | I | 1..1 | II | 1198-32939: 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:1198-32939). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note?, with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | |
code | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22 (required) | |
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. | |
intendedRecipient | 1..1 | IntendedRecipient | ||
participant | I | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
inFulfillmentOf | 0..* | InFulfillmentOf | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
componentOf | 1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
encompassingEncounter | 1..1 | EncompassingEncounter | ||
id | 1..* | II | ||
effectiveTime | 1..1 | USRealmDateandTimeDTUSFIELDED | The effectiveTime represents the time interval or point in time in which the encounter took place. | |
responsibleParty | I | 0..1 | Element | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
encounterParticipant | I | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
location | 0..1 | Element | ||
component | 1..1 | Component2 | ||
structuredBody | I | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. 1198-30613: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30613). 1198-30614: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30614). 1198-30615: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30615). 1198-30616: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30616). |
Slices for component | 1..* | Element | Slice: Unordered, Open by profile:section | |
component:component1 | 1..1 | Element | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component2 | 0..1 | Element | ||
section | 1..1 | AssessmentSection | ||
component:component3 | 0..1 | Element | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component4 | 0..1 | Element | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component5 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintSection | ||
component:component6 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component7 | 1..1 | Element | ||
section | 1..1 | FamilyHistorySection | ||
component:component8 | 1..1 | Element | ||
section | 1..1 | GeneralStatusSection | ||
component:component9 | 1..1 | Element | ||
section | 1..1 | PastMedicalHistory | ||
component:component10 | 0..1 | Element | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component11 | 0..1 | Element | ||
section | 1..1 | ImmunizationsSectionEntriesOptional | ||
component:component12 | 0..1 | Element | ||
section | 1..1 | InstructionsSection | ||
component:component13 | 1..1 | Element | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component14 | 1..1 | Element | ||
section | 1..1 | PhysicalExamSection | ||
component:component15 | 0..1 | Element | ||
section | 1..1 | ProblemSectionEntriesOptional | ||
component:component16 | 0..1 | Element | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
section | 1..1 | ReasonforVisitSection | ||
component:component18 | 1..1 | Element | ||
section | 1..1 | ResultsSectionEntriesOptional | ||
component:component19 | 1..1 | Element | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component20 | 1..1 | Element | ||
section | 1..1 | SocialHistorySection | ||
component:component21 | 1..1 | Element | ||
section | 1..1 | VitalSignsSectionEntriesOptional | ||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalDocument | 1..1 | USRealmHeader | ||
classCode | 1..1 | code | Binding: ActClass (extensible) Fixed Value: DOCCLIN | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
realmCode | 1..1 | CS | Required Pattern: US | |
typeId | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.1.3 | |
extension | 1..1 | string | Required Pattern: POCD_HD000040 | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.1 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
templateId:secondary | I | 1..1 | II | 1198-32939: 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:1198-32939). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.3 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | I | 1..1 | II | |
code | I | 1..1 | CE | The H&P Note recommends use of a single document type code, 34117-2 "History and physical note?, with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible) |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22 (required) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
title | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code | |
effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
confidentialityCode | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred) | |
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
setId | I | 0..1 | II | |
versionNumber | I | 0..1 | INT | |
copyTime | 0..1 | TS | ||
recordTarget | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
patientRole | 1..1 | PatientRole | ||
classCode | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
patient | 1..1 | Patient | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 0..1 | II | ||
name | I | 1..* | USRealmPatientNamePTNUSFIELDED | |
sdtcDesc | 0..1 | ED | XML: desc (urn:hl7-org:sdtc) | |
administrativeGenderCode | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required) | |
birthTime | I | 1..1 | TS | |
sdtcDeceasedInd | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc) | |
sdtcDeceasedTime | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc) | |
sdtcMultipleBirthInd | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc) | |
sdtcMultipleBirthOrderNumber | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc) | |
maritalStatusCode | 0..1 | CE | Binding: Marital Status (required) | |
religiousAffiliationCode | 0..1 | CE | Binding: Religious Affiliation (required) | |
raceCode | 1..1 | CE | Binding: Race Category Excluding Nulls (required) | |
sdtcRaceCode | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible) | |
ethnicGroupCode | 1..1 | CE | Binding: Ethnicity (required) | |
sdtcEthnicGroupCode | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible) | |
guardian | 0..* | Guardian | ||
classCode | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required) | |
addr | I | 0..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
guardianPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
guardianOrganization | 0..1 | Organization | ||
birthplace | 0..1 | Birthplace | ||
classCode | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL | |
templateId | 0..* | II | ||
place | 1..1 | Place | ||
classCode | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | 0..1 | EN | ||
addr | I | 1..1 | AD | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
isNotOrdered | 0..1 | boolean | ||
use | 0..* | code | ||
delimiter | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DEL | |
country | 0..1 | ADXP | ||
partType | 0..1 | code | Fixed Value: CNT | |
state | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STA | |
county | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CPA | |
city | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CTY | |
postalCode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ZIP | |
streetAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: SAL | |
houseNumber | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNR | |
houseNumberNumeric | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNN | |
direction | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DIR | |
streetName | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STR | |
streetNameBase | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STB | |
streetNameType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: STTYP | |
additionalLocator | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: ADL | |
unitID | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNID | |
unitType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: UNIT | |
careOf | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CAR | |
censusTract | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: CEN | |
deliveryAddressLine | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DAL | |
deliveryInstallationType | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINST | |
deliveryInstallationArea | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTA | |
deliveryInstallationQualifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DINSTQ | |
deliveryMode | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMOD | |
deliveryModeIdentifier | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: DMODID | |
buildingNumberSuffix | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: BNS | |
postBox | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: POB | |
precinct | 0..* | ADXP | ||
partType | 0..1 | code | Fixed Value: PRE | |
other | 0..1 | string | ||
useablePeriod[x] | 0..* | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS | IVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS | EIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS | PIVL_TS | |||
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS | SXPR_TS | |||
languageCommunication | 0..* | LanguageCommunication | ||
templateId | 0..* | II | ||
languageCode | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required) | |
modeCode | 0..1 | CE | Binding: LanguageAbilityMode (required) | |
proficiencyLevelCode | 0..1 | CE | Binding: LanguageAbilityProficiency (required) | |
preferenceInd | 0..1 | BL | ||
providerOrganization | 0..1 | Organization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..* | ON | ||
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
author | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED | |
assignedAuthor | I | 1..1 | AssignedAuthor | |
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root 1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). |
id:id1 | 0..1 | II | ||
nullFlavor | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (extensible) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Binding: Healthcare Provider Taxonomy (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 0..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
assignedAuthoringDevice | 0..1 | AuthoringDevice | ||
classCode | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
code | 0..1 | CE | Binding: EntityCode (extensible) | |
manufacturerModelName | 1..1 | SC | ||
softwareName | 1..1 | SC | ||
asMaintainedEntity | 0..* | MaintainedEntity | ||
representedOrganization | 0..1 | Organization | ||
dataEnterer | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 1..1 | TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 1..* | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
Slices for informant | 0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. Slice: Unordered, Open by value:relatedEntity | |
informant:informant1 | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | I | 1..* | II | 1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946). |
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | I | 1..* | USRealmAddressADUSFIELDED | |
telecom | 0..* | TEL | ||
assignedPerson | 1..1 | Person | ||
classCode | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
name | I | 1..* | USRealmPersonNamePNUSFIELDED | |
sdtcAsPatientRelationship | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc) | |
representedOrganization | 0..1 | Organization | ||
relatedEntity | 0..1 | RelatedEntity | ||
informant:informant2 | 0..* | Informant | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 1..1 | RelatedEntity | ||
custodian | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
assignedCustodian | 1..1 | AssignedCustodian | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
representedCustodianOrganization | 1..1 | CustodianOrganization | ||
classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
name | 1..1 | ON | ||
telecom | 1..1 | TEL | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | uri | ||
useablePeriod | 0..* | |||
useablePeriod | IVL_TS | |||
useablePeriod | EIVL_TS | |||
useablePeriod | PIVL_TS | |||
useablePeriod | SXPR_TS | |||
use | 0..1 | code | Binding: Telecom Use (US Realm Header) (required) | |
addr | I | 1..1 | USRealmAddressADUSFIELDED | |
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 | I | 0..* | Participant1 | The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations. Slice: Unordered, Open by 1198-8333: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333). A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. |
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 | inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral. | |
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 | 0..* | DocumentationOf | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
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 | 1..1 | ComponentOf | The H&P Note is always associated with an encounter. | |
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 | I | 1..1 | USRealmDateandTimeDTUSFIELDED | The effectiveTime represents the time interval or point in time in which the encounter took place. |
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
responsibleParty | I | 0..1 | Element | The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. 1198-8348: The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). |
typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
assignedEntity | 1..1 | AssignedEntity | ||
encounterParticipant | I | 0..* | EncounterParticipant | The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 1198-8343: An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). |
location | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
component | 1..1 | Component2 | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextConductionInd | 1..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
nonXMLBody | 0..1 | NonXMLBody | ||
structuredBody | I | 1..1 | StructuredBody | In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional. 1198-30613: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30613). 1198-30614: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30614). 1198-30615: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30615). 1198-30616: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30616). |
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:component1 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component2 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentSection | ||
component:component3 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component4 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component5 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintSection | ||
component:component6 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component7 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FamilyHistorySection | ||
component:component8 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | GeneralStatusSection | ||
component:component9 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PastMedicalHistory | ||
component:component10 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component11 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ImmunizationsSectionEntriesOptional | ||
component:component12 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | InstructionsSection | ||
component:component13 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component14 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PhysicalExamSection | ||
component:component15 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProblemSectionEntriesOptional | ||
component:component16 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReasonforVisitSection | ||
component:component18 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ResultsSectionEntriesOptional | ||
component:component19 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component20 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | SocialHistorySection | ||
component:component21 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | VitalSignsSectionEntriesOptional | ||
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
ClinicalDocument.classCode | extensible | Fixed Value: DOCCLIN |
ClinicalDocument.moodCode | required | Fixed Value: EVN |
ClinicalDocument.typeId.nullFlavor | required | NullFlavor |
ClinicalDocument.templateId:primary.nullFlavor | required | NullFlavor |
ClinicalDocument.templateId:secondary.nullFlavor | required | NullFlavor |
ClinicalDocument.code | extensible | http://terminology.hl7.org/ValueSet/v3-DocumentType |
ClinicalDocument.code.nullFlavor | required | NullFlavor |
ClinicalDocument.code.code | required | http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22 |
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 | ActClass |
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.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 |
1198-32939 | error | ClinicalDocument.templateId:secondary | When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32939). : | |
1198-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:1198-9991). : | |
1198-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992). : | |
1198-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948). : | |
81-10127 | error | ClinicalDocument.effectiveTime | **SHALL** be precise to the day (CONF:81-10127). : | |
81-10128 | warning | ClinicalDocument.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10128). : | |
81-10129 | warning | ClinicalDocument.effectiveTime | **MAY** be precise to the second (CONF:81-10129). : | |
81-10130 | warning | ClinicalDocument.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
1198-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:1198-6380). : | |
1198-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:1198-6387). : | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : | |
1198-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:1198-5299). : | |
1198-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:1198-5300). : | |
1198-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:1198-32418).
For cases where information about newborn's time of birth needs to be captured. : | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
1198-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:1198-5402). : | |
1198-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:1198-5403). : | |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-10127 | error | ClinicalDocument.author.time | **SHALL** be precise to the day (CONF:81-10127). : | |
81-10128 | warning | ClinicalDocument.author.time | **SHOULD** be precise to the minute (CONF:81-10128). : | |
81-10129 | warning | ClinicalDocument.author.time | **MAY** be precise to the second (CONF:81-10129). : | |
81-10130 | warning | ClinicalDocument.author.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : | |
1198-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790). : | |
1198-5449 | null | ClinicalDocument.author.assignedAuthor.id | If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). : | |
81-7296 | error | ClinicalDocument.author.assignedAuthor.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-7296 | error | ClinicalDocument.dataEnterer.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
1198-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946). : | |
81-7296 | error | ClinicalDocument.informant:informant1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-7296 | error | ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : | |
81-9371 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : | |
81-9372 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : | |
81-10127 | 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). : | |
1198-8333 | warning | ClinicalDocument.participant | When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded. : | |
1198-10006 | error | ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). : | |
1198-10007 | warning | ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007). : | |
81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : | |
81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : | |
81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : | |
81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : | |
1198-8348 | error | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty | The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348). : | |
1198-8343 | error | ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant | An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343). : | |
1198-30613 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) (CONF:1198-30613). : | |
1198-30614 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30614). : | |
1198-30615 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30615). : | |
1198-30616 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30616). : |