Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

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

Resource Profile: Progress Note (V3)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.9 Version: 2.2
Active as of 2022-05-13 Computable Name: ProgressNote
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.9:2015-08-01

This template represents a patients clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.

Tabers medical dictionary defines a Progress Note as An ongoing record of a patient’s illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.

Mosbys medical dictionary defines a Progress Note as Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient’s condition and the treatment given or planned.

A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report.

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USRealmHeader

Summary

Mandatory: 15 elements (20 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension
  • The element ClinicalDocument.documentationOf.serviceEvent.templateId is sliced based on the value of value:root
  • The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.classCodeextensibleFixed Value: DOCCLIN
ClinicalDocument.moodCoderequiredFixed Value: EVN
ClinicalDocument.typeId.nullFlavorrequiredNullFlavor
ClinicalDocument.templateId:primary.nullFlavorrequiredNullFlavor
ClinicalDocument.templateId:secondary.nullFlavorrequiredNullFlavor
ClinicalDocument.codeextensiblehttp://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.code.nullFlavorrequiredNullFlavor
ClinicalDocument.code.coderequiredhttp://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.8.1
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.typeCoderequiredFixed Value: RCT
ClinicalDocument.recordTarget.contextControlCoderequiredFixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCoderequiredFixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCoderequiredMaritalStatus
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCoderequiredReligious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCodeextensibleRaceValueSet
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCodeextensibleDetailedEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCoderequiredFixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.coderequiredPersonal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCoderequiredFixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCoderequiredFixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCoderequiredLanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCoderequiredLanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavorrequiredNullFlavor
ClinicalDocument.author.typeCoderequiredFixed Value: AUT
ClinicalDocument.author.contextControlCoderequiredFixed Value: OP
ClinicalDocument.author.assignedAuthor.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavorrequiredPattern: UNK
ClinicalDocument.author.assignedAuthor.codeextensibleRoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.code.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.author.assignedAuthor.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCoderequiredFixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.codeextensibleEntityCode
ClinicalDocument.dataEnterer.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.typeCoderequiredFixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCoderequiredFixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant1.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavorrequiredNullFlavor
ClinicalDocument.informant:informant2.typeCoderequiredFixed Value: INF
ClinicalDocument.informant:informant2.contextControlCoderequiredFixed Value: OP
ClinicalDocument.custodian.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.typeCoderequiredFixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavorrequiredNullFlavor
ClinicalDocument.informationRecipient.typeCoderequiredParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCoderequiredFixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCoderequiredFixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.typeCoderequiredFixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCoderequiredFixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.typeCoderequiredFixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.codeextensibleRoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavorrequiredNullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
ClinicalDocument.participant:participant1.nullFlavorrequiredNullFlavor
ClinicalDocument.participant:participant1.typeCoderequiredParticipationType
ClinicalDocument.participant:participant1.contextControlCoderequiredFixed Value: OP
ClinicalDocument.inFulfillmentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.inFulfillmentOf.typeCoderequiredFixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCoderequiredActClass
ClinicalDocument.inFulfillmentOf.order.moodCoderequiredFixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.codeextensibleActCode
ClinicalDocument.inFulfillmentOf.order.priorityCodeextensibleActPriority
ClinicalDocument.documentationOf.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCoderequiredPattern: PCPR
ClinicalDocument.documentationOf.serviceEvent.moodCoderequiredFixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.templateId:secondary.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCoderequiredFixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.codepreferredCare Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavorrequiredNullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy
ClinicalDocument.authorization:authorization1.nullFlavorrequiredNullFlavor
ClinicalDocument.authorization:authorization1.typeCoderequiredFixed Value: AUT
ClinicalDocument.authorization:authorization1.consent.classCoderequiredFixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCoderequiredFixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.codeextensibleActCode
ClinicalDocument.authorization:authorization1.consent.statusCoderequiredActStatus
ClinicalDocument.componentOf.nullFlavorrequiredNullFlavor
ClinicalDocument.componentOf.typeCoderequiredFixed Value: AUT
ClinicalDocument.componentOf.encompassingEncounter.classCoderequiredFixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCoderequiredFixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.codeextensibleActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.effectiveTime.nullFlavorrequiredNullFlavor
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCodeextensiblehttp://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCoderequiredFixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.typeCoderequiredFixed Value: LOC
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.classCoderequiredRoleClassServiceDeliveryLocation
ClinicalDocument.componentOf.encompassingEncounter.location.healthCareFacility.codeextensibleServiceDeliveryLocationRoleType
ClinicalDocument.component.nullFlavorrequiredNullFlavor
ClinicalDocument.component.typeCoderequiredFixed Value: AUT
ClinicalDocument.component.structuredBody.classCoderequiredFixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCoderequiredFixed Value: EVN
ClinicalDocument.component.structuredBody.languageCoderequiredHumanLanguage

Constraints

IdGradePathDetailsRequirements
1198-32942errorClinicalDocument.templateId:secondaryWhen 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:1198-32942).
:
1198-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:1198-9991).
:
1198-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992).
:
1198-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948).
:
81-10127errorClinicalDocument.effectiveTime**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTimeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
1198-6380errorClinicalDocument.setIdIf setId is present versionNumber **SHALL** be present (CONF:1198-6380).
:
1198-6387errorClinicalDocument.versionNumberIf versionNumber is present setId **SHALL** be present (CONF:1198-6387).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
1198-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:1198-5299).
:
1198-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:1198-5300).
:
1198-32418warningClinicalDocument.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.
:
81-7296errorClinicalDocument.recordTarget.patientRole.patient.guardian.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
1198-5402warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf 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).
:
1198-5403warningClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addrIf 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).
:
81-7296errorClinicalDocument.recordTarget.patientRole.providerOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-10127errorClinicalDocument.author.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.author.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.author.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.author.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
1198-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790).
:
1198-5449nullClinicalDocument.author.assignedAuthor.idIf this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
:
81-7296errorClinicalDocument.author.assignedAuthor.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.author.assignedAuthor.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.author.assignedAuthor.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-7296errorClinicalDocument.dataEnterer.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.dataEnterer.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
1198-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf 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).
:
81-7296errorClinicalDocument.informant:informant1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-7296errorClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.legalAuthenticator.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.legalAuthenticator.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.legalAuthenticator.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.legalAuthenticator.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
81-7296errorClinicalDocument.legalAuthenticator.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
81-7296errorClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
1198-10006errorClinicalDocument.participant:participant1**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006).
:
1198-10007warningClinicalDocument.participant:participant1When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
:
81-10078errorClinicalDocument.documentationOf.serviceEvent.effectiveTime**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningClinicalDocument.documentationOf.serviceEvent.effectiveTime**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningClinicalDocument.documentationOf.serviceEvent.effectiveTime**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
1198-9482warningClinicalDocument.documentationOf.serviceEvent.effectiveTimeThe serviceEvent/effectiveTime element **SHOULD** be present with effectiveTime/low element (CONF:1198-9482).
:
1198-10066errorClinicalDocument.documentationOf.serviceEvent.effectiveTimeIf a width element is not present, the serviceEvent **SHALL** include effectiveTime/high (CONF:1198-10066).
:
81-10078errorClinicalDocument.componentOf.encompassingEncounter.effectiveTime**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningClinicalDocument.componentOf.encompassingEncounter.effectiveTime**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningClinicalDocument.componentOf.encompassingEncounter.effectiveTime**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningClinicalDocument.componentOf.encompassingEncounter.effectiveTimeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
1198-30657errorClinicalDocument.component.structuredBodyThis 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:1198-30657).
:
1198-30658errorClinicalDocument.component.structuredBodyThis 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:1198-30658).
: