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/2.16.840.1.113883.10.20.22.1.6 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: ProcedureNote | |||
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.6:2015-08-01 |
A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USRealmHeader
Summary
Mandatory: 22 elements (41 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 | 1198-32941: 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:1198-32941). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.6 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | |
code | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.6.1 (required) | |
Slices for participant | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode | |
participant:participant1 | 0..* | Participant1 | ||
typeCode | 1..1 | code | Required Pattern: IND | |
functionCode | 1..1 | CE | Required Pattern: PCP | |
associatedEntity | ||||
classCode | 1..1 | code | Required Pattern: PROV | |
associatedPerson | 1..1 | |||
Slices for documentationOf | 0..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent | |
documentationOf:documentationOf1 | 1..* | DocumentationOf | ||
serviceEvent | I | 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. 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). |
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). |
low | 1..1 | TS | ||
Slices for performer | 0..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode | |
performer:performer1 | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant. | |
typeCode | 1..1 | code | Required Pattern: PPRF | |
assignedEntity | 1..1 | AssignedEntity | ||
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
performer:performer2 | 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. | |
typeCode | 1..1 | code | Required Pattern: SPRF | |
assignedEntity | 1..1 | AssignedEntity | ||
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
authorization | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. | |
typeCode | 1..1 | code | Required Pattern: AUTH | |
consent | 1..1 | Consent | ||
classCode | 1..1 | code | Required Pattern: CONS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
statusCode | 1..1 | CS | ||
componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
encompassingEncounter | 1..1 | EncompassingEncounter | ||
id | 0..* | II | ||
code | 1..1 | CE | ||
Slices for encounterParticipant | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode | |
encounterParticipant:encounterParticipant1 | 0..1 | EncounterParticipant | ||
typeCode | 1..1 | code | Required Pattern: REF | |
location | 1..* | Element | ||
healthCareFacility | 1..1 | HealthCareFacility | ||
id | 1..* | II | ||
component | 1..1 | Component2 | ||
structuredBody | I | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:component1 | 1..1 | Element | ||
section | 1..1 | ComplicationsSection | ||
component:component2 | 1..1 | Element | ||
section | 1..1 | ProcedureDescriptionSection | ||
component:component3 | 1..1 | Element | ||
section | 1..1 | ProcedureIndicationsSection | ||
component:component4 | 1..1 | Element | ||
section | 1..1 | PostprocedureDiagnosisSection | ||
component:component5 | 0..1 | Element | ||
section | 1..1 | AssessmentSection | ||
component:component6 | 0..1 | Element | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component7 | 0..1 | Element | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component8 | 0..1 | Element | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component9 | 0..1 | Element | ||
section | 1..1 | AnesthesiaSection | ||
component:component10 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintSection | ||
component:component11 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component12 | 0..1 | Element | ||
section | 1..1 | FamilyHistorySection | ||
component:component13 | 0..1 | Element | ||
section | 1..1 | PastMedicalHistory | ||
component:component14 | 0..1 | Element | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component15 | 0..1 | Element | ||
section | 1..1 | MedicalGeneralHistorySection | ||
component:component16 | 0..1 | Element | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
section | 1..1 | MedicationsAdministeredSection | ||
component:component18 | 0..1 | Element | ||
section | 1..1 | PhysicalExamSection | ||
component:component19 | 0..1 | Element | ||
section | 1..1 | PlannedProcedureSection | ||
component:component20 | 0..1 | Element | ||
section | 1..1 | ProcedureDispositionSection | ||
component:component21 | 0..1 | Element | ||
section | 1..1 | ProcedureEstimatedBloodLossSection | ||
component:component22 | 0..1 | Element | ||
section | 1..1 | ProcedureFindingsSection | ||
component:component23 | 0..1 | Element | ||
section | 1..1 | ProcedureImplantsSection | ||
component:component24 | 0..1 | Element | ||
section | 1..1 | ProcedureSpecimensTakenSection | ||
component:component25 | 0..1 | Element | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component26 | 0..1 | Element | ||
section | 1..1 | ReasonforVisitSection | ||
component:component27 | 0..1 | Element | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component28 | 0..1 | Element | ||
section | 1..1 | SocialHistorySection | ||
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 | 1198-32941: 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:1198-32941). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.6 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | I | 1..1 | II | |
code | I | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: 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/2.16.840.1.113883.11.20.6.1 (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 | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode | |
participant:participant1 | I | 0..* | Participant1 | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: IND | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 1..1 | CE | Required Pattern: PCP | |
time | 0..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssociative (required) Required Pattern: PROV | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional content defined by implementations | |
value | 0..1 | string | Primitive value for code | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 0..1 | Person | ||
scopingOrganization | 0..1 | Organization | ||
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
order | 1..1 | Order | ||
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
Slices for documentationOf | 0..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent | |
documentationOf:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
documentationOf:documentationOf1 | 1..* | 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 | I | 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. 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). |
classCode | 1..1 | 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 | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
Slices for performer | 0..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode | |
performer:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
performer:performer1 | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant. | |
nullFlavor | 0..1 | 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 (required) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
performer:performer2 | 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 (required) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
relatedDocument | 0..* | RelatedDocument | ||
Slices for authorization | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. Slice: Unordered, Open by value:consent | |
authorization:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..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 | Binding: v3 Code System ActCode (extensible) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
code | 1..1 | Fixed Value: completed | ||
authorization:authorization1 | 0..* | Authorization | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
consent | 1..1 | Consent | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
code | 1..1 | Fixed Value: completed | ||
componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
encompassingEncounter | 1..1 | EncompassingEncounter | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 1..1 | CE | Binding: ActEncounterCode (extensible) | |
effectiveTime | 1..1 | IVL_TS | ||
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
responsibleParty | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
assignedEntity | 1..1 | AssignedEntity | ||
Slices for encounterParticipant | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode | |
encounterParticipant:encounterParticipant1 | 0..1 | EncounterParticipant | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: REF | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 0..1 | AssignedEntity | ||
location | 1..* | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
classCode | 1..1 | code | Binding: RoleClassServiceDeliveryLocation (required) | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: ServiceDeliveryLocationRoleType (extensible) | |
location | 0..1 | Place | ||
serviceProviderOrganization | 0..1 | Organization | ||
component | 1..1 | Component2 | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextConductionInd | 1..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
nonXMLBody | 0..1 | NonXMLBody | ||
structuredBody | I | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). |
classCode | 1..1 | code | Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
confidentialityCode | 0..1 | CE | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | Section | ||
component:component1 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ComplicationsSection | ||
component:component2 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureDescriptionSection | ||
component:component3 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureIndicationsSection | ||
component:component4 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PostprocedureDiagnosisSection | ||
component:component5 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentSection | ||
component:component6 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component7 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component8 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component9 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AnesthesiaSection | ||
component:component10 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintSection | ||
component:component11 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component12 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FamilyHistorySection | ||
component:component13 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PastMedicalHistory | ||
component:component14 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component15 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicalGeneralHistorySection | ||
component:component16 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsAdministeredSection | ||
component:component18 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PhysicalExamSection | ||
component:component19 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlannedProcedureSection | ||
component:component20 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureDispositionSection | ||
component:component21 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | I | 1..1 | ProcedureEstimatedBloodLossSection | |
component:component22 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureFindingsSection | ||
component:component23 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | I | 1..1 | ProcedureImplantsSection | |
component:component24 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | I | 1..1 | ProcedureSpecimensTakenSection | |
component:component25 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component26 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReasonforVisitSection | ||
component:component27 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component28 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | SocialHistorySection | ||
Documentation for this format |
This structure is derived from USRealmHeader
Summary
Mandatory: 22 elements (41 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 | 1198-32941: 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:1198-32941). |
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.6 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | |
code | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.6.1 (required) | |
Slices for participant | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode | |
participant:participant1 | 0..* | Participant1 | ||
typeCode | 1..1 | code | Required Pattern: IND | |
functionCode | 1..1 | CE | Required Pattern: PCP | |
associatedEntity | ||||
classCode | 1..1 | code | Required Pattern: PROV | |
associatedPerson | 1..1 | |||
Slices for documentationOf | 0..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent | |
documentationOf:documentationOf1 | 1..* | DocumentationOf | ||
serviceEvent | I | 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. 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). |
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). |
low | 1..1 | TS | ||
Slices for performer | 0..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode | |
performer:performer1 | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant. | |
typeCode | 1..1 | code | Required Pattern: PPRF | |
assignedEntity | 1..1 | AssignedEntity | ||
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
performer:performer2 | 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. | |
typeCode | 1..1 | code | Required Pattern: SPRF | |
assignedEntity | 1..1 | AssignedEntity | ||
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required) | |
authorization | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. | |
typeCode | 1..1 | code | Required Pattern: AUTH | |
consent | 1..1 | Consent | ||
classCode | 1..1 | code | Required Pattern: CONS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
statusCode | 1..1 | CS | ||
componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
encompassingEncounter | 1..1 | EncompassingEncounter | ||
id | 0..* | II | ||
code | 1..1 | CE | ||
Slices for encounterParticipant | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode | |
encounterParticipant:encounterParticipant1 | 0..1 | EncounterParticipant | ||
typeCode | 1..1 | code | Required Pattern: REF | |
location | 1..* | Element | ||
healthCareFacility | 1..1 | HealthCareFacility | ||
id | 1..* | II | ||
component | 1..1 | Component2 | ||
structuredBody | I | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:component1 | 1..1 | Element | ||
section | 1..1 | ComplicationsSection | ||
component:component2 | 1..1 | Element | ||
section | 1..1 | ProcedureDescriptionSection | ||
component:component3 | 1..1 | Element | ||
section | 1..1 | ProcedureIndicationsSection | ||
component:component4 | 1..1 | Element | ||
section | 1..1 | PostprocedureDiagnosisSection | ||
component:component5 | 0..1 | Element | ||
section | 1..1 | AssessmentSection | ||
component:component6 | 0..1 | Element | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component7 | 0..1 | Element | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component8 | 0..1 | Element | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component9 | 0..1 | Element | ||
section | 1..1 | AnesthesiaSection | ||
component:component10 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintSection | ||
component:component11 | 0..1 | Element | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component12 | 0..1 | Element | ||
section | 1..1 | FamilyHistorySection | ||
component:component13 | 0..1 | Element | ||
section | 1..1 | PastMedicalHistory | ||
component:component14 | 0..1 | Element | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component15 | 0..1 | Element | ||
section | 1..1 | MedicalGeneralHistorySection | ||
component:component16 | 0..1 | Element | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
section | 1..1 | MedicationsAdministeredSection | ||
component:component18 | 0..1 | Element | ||
section | 1..1 | PhysicalExamSection | ||
component:component19 | 0..1 | Element | ||
section | 1..1 | PlannedProcedureSection | ||
component:component20 | 0..1 | Element | ||
section | 1..1 | ProcedureDispositionSection | ||
component:component21 | 0..1 | Element | ||
section | 1..1 | ProcedureEstimatedBloodLossSection | ||
component:component22 | 0..1 | Element | ||
section | 1..1 | ProcedureFindingsSection | ||
component:component23 | 0..1 | Element | ||
section | 1..1 | ProcedureImplantsSection | ||
component:component24 | 0..1 | Element | ||
section | 1..1 | ProcedureSpecimensTakenSection | ||
component:component25 | 0..1 | Element | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component26 | 0..1 | Element | ||
section | 1..1 | ReasonforVisitSection | ||
component:component27 | 0..1 | Element | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component28 | 0..1 | Element | ||
section | 1..1 | SocialHistorySection | ||
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 | 1198-32941: 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:1198-32941). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.6 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | I | 1..1 | II | |
code | I | 1..1 | CE | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: 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/2.16.840.1.113883.11.20.6.1 (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 | 0..* | Participant1 | The participant element in the Procedure Note header follows the General Header Constraints for participants. Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode | |
participant:participant1 | I | 0..* | Participant1 | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: IND | |
contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 1..1 | CE | Required Pattern: PCP | |
time | 0..1 | IVL_TS | ||
associatedEntity | 1..1 | AssociatedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssociative (required) Required Pattern: PROV | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional content defined by implementations | |
value | 0..1 | string | Primitive value for code | |
templateId | 0..* | II | ||
id | 0..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
associatedPerson | 0..1 | Person | ||
scopingOrganization | 0..1 | Organization | ||
inFulfillmentOf | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
order | 1..1 | Order | ||
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO | |
templateId | 0..* | II | ||
id | 1..* | II | ||
code | 0..1 | CE | Binding: v3 Code System ActCode (extensible) | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
Slices for documentationOf | 0..* | DocumentationOf | A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element. Slice: Unordered, Open by value:serviceEvent | |
documentationOf:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
serviceEvent | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. | |
classCode | 1..1 | code | Binding: ActClass (required) | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | ||
effectiveTime | 1..1 | IVL_TS | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
performer | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
documentationOf:documentationOf1 | 1..* | 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 | I | 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. 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). |
classCode | 1..1 | 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 | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8513: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
value | 0..1 | dateTime | ||
inclusive | 0..1 | boolean | ||
operator | 0..1 | code | ||
low | 1..1 | TS | ||
high | 0..1 | TS | ||
width | 0..1 | PQ | ||
center | 0..1 | TS | ||
Slices for performer | 0..* | Performer1 | This performer identifies any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode | |
performer:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
functionCode | 0..1 | CE | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 0..1 | string | Binding: Care Team Member Function (preferred) | |
codeSystem | 0..1 | string | ||
codeSystemName | 0..1 | string | ||
codeSystemVersion | 0..1 | string | ||
displayName | 0..1 | string | ||
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
originalText | 0..1 | ED | ||
translation | 0..* | CD | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 1..1 | AssignedEntity | ||
classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
templateId | 0..* | II | ||
id | 1..* | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6 | |
extension | 0..1 | string | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
performer:performer1 | 1..1 | Performer1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant. | |
nullFlavor | 0..1 | 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 (required) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
performer:performer2 | 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 (required) | |
addr | 0..* | AD | ||
telecom | 0..* | TEL | ||
assignedPerson | 0..1 | Person | ||
representedOrganization | 0..1 | Organization | ||
relatedDocument | 0..* | RelatedDocument | ||
Slices for authorization | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. Slice: Unordered, Open by value:consent | |
authorization:All Slices | Content/Rules for all slices | |||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..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 | Binding: v3 Code System ActCode (extensible) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
code | 1..1 | Fixed Value: completed | ||
authorization:authorization1 | 0..* | Authorization | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
consent | 1..1 | Consent | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible) | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
code | 1..1 | Fixed Value: completed | ||
componentOf | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section. | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
encompassingEncounter | 1..1 | EncompassingEncounter | ||
classCode | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
templateId | 0..* | II | ||
id | 0..* | II | ||
code | 1..1 | CE | Binding: ActEncounterCode (extensible) | |
effectiveTime | 1..1 | IVL_TS | ||
sdtcAdmissionReferralSourceCode | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc) | |
dischargeDispositionCode | 0..1 | CE | Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible) | |
responsibleParty | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP | |
assignedEntity | 1..1 | AssignedEntity | ||
Slices for encounterParticipant | 0..* | EncounterParticipant | Slice: Unordered, Open by value:typeCode | |
encounterParticipant:encounterParticipant1 | 0..1 | EncounterParticipant | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: REF | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
time | 0..1 | IVL_TS | ||
assignedEntity | 0..1 | AssignedEntity | ||
location | 1..* | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC | |
healthCareFacility | 1..1 | HealthCareFacility | ||
classCode | 1..1 | code | Binding: RoleClassServiceDeliveryLocation (required) | |
templateId | 0..* | II | ||
id | 1..* | II | ||
sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
code | 0..1 | CE | Binding: ServiceDeliveryLocationRoleType (extensible) | |
location | 0..1 | Place | ||
serviceProviderOrganization | 0..1 | Organization | ||
component | 1..1 | Component2 | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
typeCode | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT | |
contextConductionInd | 1..1 | boolean | ||
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
templateId | 0..* | II | ||
nonXMLBody | 0..1 | NonXMLBody | ||
structuredBody | I | 1..1 | StructuredBody | 1198-30412: 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:1198-30412). 1198-30414: 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:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). |
classCode | 1..1 | code | Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY | |
moodCode | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
confidentialityCode | 0..1 | CE | ||
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
Slices for component | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section | |
component:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | Section | ||
component:component1 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ComplicationsSection | ||
component:component2 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureDescriptionSection | ||
component:component3 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureIndicationsSection | ||
component:component4 | 1..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PostprocedureDiagnosisSection | ||
component:component5 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentSection | ||
component:component6 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AssessmentandPlanSection | ||
component:component7 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlanofTreatmentSection | ||
component:component8 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AllergiesAndIntolerancesSectionEntriesOptional | ||
component:component9 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | AnesthesiaSection | ||
component:component10 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintSection | ||
component:component11 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ChiefComplaintandReasonforVisitSection | ||
component:component12 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | FamilyHistorySection | ||
component:component13 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PastMedicalHistory | ||
component:component14 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | HistoryofPresentIllnessSection | ||
component:component15 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicalGeneralHistorySection | ||
component:component16 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsSectionEntriesOptional | ||
component:component17 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | MedicationsAdministeredSection | ||
component:component18 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PhysicalExamSection | ||
component:component19 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | PlannedProcedureSection | ||
component:component20 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureDispositionSection | ||
component:component21 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | I | 1..1 | ProcedureEstimatedBloodLossSection | |
component:component22 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProcedureFindingsSection | ||
component:component23 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | I | 1..1 | ProcedureImplantsSection | |
component:component24 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | I | 1..1 | ProcedureSpecimensTakenSection | |
component:component25 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ProceduresSectionEntriesOptional | ||
component:component26 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReasonforVisitSection | ||
component:component27 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | ReviewofSystemsSection | ||
component:component28 | 0..1 | Element | ||
typeCode | 1..1 | code | Fixed Value: COMP | |
contextConductionInd | 1..1 | boolean | ||
section | 1..1 | SocialHistorySection | ||
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/2.16.840.1.113883.11.20.6.1 |
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 | Pattern: IND |
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP |
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | Pattern: PROV |
ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode |
ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor |
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS |
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass |
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO |
ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode |
ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority |
ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass |
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN |
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.documentationOf:documentationOf1.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode | required | ActClass |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.moodCode | required | Fixed Value: EVN |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer1.assignedEntity.code | required | HealthcareProviderTaxonomy |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer2.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer2.typeCode | required | Fixed Value: DOC |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer2.functionCode.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer2.functionCode.code | preferred | Care Team Member Function |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer2.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer2.assignedEntity.id.nullFlavor | required | NullFlavor |
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.performer:performer2.assignedEntity.code | required | HealthcareProviderTaxonomy |
ClinicalDocument.authorization.nullFlavor | required | NullFlavor |
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUT |
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS |
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN |
ClinicalDocument.authorization.consent.code | extensible | ActCode |
ClinicalDocument.authorization.consent.statusCode | required | ActStatus |
ClinicalDocument.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.encounterParticipant:encounterParticipant1.nullFlavor | required | NullFlavor |
ClinicalDocument.componentOf.encompassingEncounter.encounterParticipant:encounterParticipant1.typeCode | required | Pattern: REF |
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC |
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCode | required | RoleClassServiceDeliveryLocation |
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.code | extensible | ServiceDeliveryLocationRoleType |
ClinicalDocument.component.nullFlavor | required | NullFlavor |
ClinicalDocument.component.typeCode | required | Fixed Value: 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 |
1198-32941 | 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:1198-32941). : | |
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). : | |
1198-10006 | 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). : | |
ele-1 | error | ClinicalDocument.participant:participant1.associatedEntity.classCode.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | ClinicalDocument.participant:participant1.associatedEntity.classCode.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
1198-8511 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent | The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). : | |
81-10078 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : | |
81-10079 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : | |
81-10080 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : | |
81-10081 | warning | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : | |
1198-8513 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). : | |
1198-8514 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). : | |
1198-8515 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). : | |
1198-30412 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL** contain an Assessment and Plan Section (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:1198-30412). : | |
1198-30414 | 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:1198-30414). : | |
1198-30415 | error | ClinicalDocument.component.structuredBody | This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). : | |
81-8741 | warning | ClinicalDocument.component.structuredBody.component:component21.section | The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741). : | |
81-8769 | error | ClinicalDocument.component.structuredBody.component:component23.section | The Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769). : | |
81-8742 | warning | ClinicalDocument.component.structuredBody.component:component24.section | The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742). : |