Consolidated CDA Release 2.2
2.2 - CI Build

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: Diagnostic Imaging Report (V3)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.5 | Version: 2.2
Active as of 2022-05-13 | Computable Name: DiagnosticImagingReport
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.5:2015-08-01

A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialists interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patients medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

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.

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from USRealmHeader

Summary

Mandatory: 15 elements (22 nested mandatory elements)
Prohibited: 1 element

Structures

This structure refers to these other structures:

- US Realm Person Name (PN.US.FIELDED) (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.5.1.1)
- Physician Reading Study Performer (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.1)
- US Realm Date and Time (DT.US.FIELDED) (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.5.3)
- Physician of Record Participant (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.2)
- Findings Section (DIR) (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.1.2)
- DICOM Object Catalog Section - DCM 121181 (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.1.1)
- Fetus Subject Context (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.3)
- Observer Context (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.4)
- Procedure Context (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.5)
- Text Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.12)
- Code Observations (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.13)
- Quantity Measurement Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.14)
- SOP Instance Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.8)

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.participant is sliced based on the value of value:ClinicalDocument.associatedEntity
- The element ClinicalDocument.documentationOf is sliced based on the value of value:ClinicalDocument.serviceEvent
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section
- The element ClinicalDocument.component.structuredBody.component.section.author is sliced based on the value of value:assignedAuthor
- The element ClinicalDocument.component.structuredBody.component.section.entry is sliced based on the value of value:ClinicalDocument.section.structuredBody.component.section.entry

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 | 1198-32937: 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:1198-32937).
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.5
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id |  | 1..1 | II |
root | I | 1..1 | string | 1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+ 1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
code |  | 1..1 | CE | Preferred code is 18748-4 LOINC Diagnostic Imaging Report
code |  | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5 (preferred)
informant |  | 0..0 |  |
informationRecipient | I | 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. 1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412). 1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
Slices for participant |  | 0..* | Participant1 | If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF). Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
participant:participant1 |  | 0..1 | Participant1 |
associatedEntity |  | 1..1 | AssociatedEntity |
associatedPerson |  | 1..1 | Person |
name |  | 1..1 | USRealmPersonNamePNUSFIELDED |
inFulfillmentOf |  | 0..* | InFulfillmentOf | An inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
order |  | 1..1 | Order |
id |  | 1..* | II | DICOM Accession Number in the DICOM imaging and report data
Slices for documentationOf |  | 0..* | DocumentationOf | Each serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure. Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
documentationOf:documentationOf1 |  | 1..1 | DocumentationOf |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Required Pattern: ACT
id |  | 0..* | II |
code | I | 1..1 | CE | 1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
performer |  | 0..* | PhysicianReadingStudyPerformer | The performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
relatedDocument | I | 0..1 | RelatedDocument | A DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document. 1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
parentDocument |  | 1..1 | ParentDocument |
id | I | 1..1 | II | 1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031). 1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
componentOf |  | 0..1 | ComponentOf | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
encompassingEncounter |  | 1..1 | EncompassingEncounter | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
id | I | 1..* | II | 1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
effectiveTime |  | 1..1 | USRealmDateandTimeDTUSFIELDED |
responsibleParty |  | 0..1 | Element |
assignedEntity | I | 1..1 | AssignedEntity | 1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
encounterParticipant |  | 0..1 | PhysicianofRecordParticipant |
component |  | 1..1 | Component2 |
structuredBody |  | 1..1 | StructuredBody |
Slices for component |  | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section
component:component1 |  | 1..1 | Element |
section |  | 1..1 | FindingsSectionDIR |
component:component2 |  | 0..1 | Element |
section | I | 1..1 | DICOMObjectCatalogSectionDCM121181 | 1198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
component:component3 |  | 0..* | Element |
section | I | 1..1 | Section | 1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211). 1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
code |  | 1..1 | CE |
code |  | 1..1 | string | The section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (preferred)
title |  | 0..1 | ED | There is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
text | I | 0..1 | xhtml | 1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060). 1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061). 1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
subject |  | 0..* | Element |
relatedSubject |  | 1..1 | FetusSubjectContext |
Slices for author |  | 0..* | Author | This author element is used when the author of a section is different from the author(s) listed in the Header Slice: Unordered, Open by value:assignedAuthor
author:author1 |  | 0..* | Author |
assignedAuthor |  | 1..1 | ObserverContext |
Slices for entry |  | 0..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
entry |  | 0..* | Element | If the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
act |  | 1..1 | ProcedureContext |
entry:textObs |  | 0..* | Element |
observation |  | 1..1 | TextObservation |
entry:entry3 |  | 0..* | Element |
observation |  | 1..1 | CodeObservations |
entry:entry4 |  | 0..* | Element |
observation |  | 1..1 | QuantityMeasurementObservation |
entry:entry5 |  | 0..* | Element |
observation |  | 1..1 | SOPInstanceObservation |
component | I | 0..* | Element | 1198-31210: **SHALL** contain child elements (CONF:1198-31210).
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 | 1198-32937: 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:1198-32937).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.5
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id | I | 1..1 | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root | I | 1..1 | string | 1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+ 1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
extension |  | 0..1 | string |
code | I | 1..1 | CE | ​Preferred code is 18748-4 LOINC Diagnostic Imaging Report 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/1.3.6.1.4.1.12009.10.2.5 (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 |
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 |
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 | I | 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. 1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412). 1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
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 | If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF). Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
participant:participant1 | I | 0..1 | Participant1 |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssociative (required)
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
associatedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..1 | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 0..* | InFulfillmentOf | An inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
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 | DICOM Accession Number in the DICOM imaging and report data
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
Slices for documentationOf |  | 0..* | DocumentationOf | Each serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure. Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | dateTime |
inclusive |  | 0..1 | boolean |
operator |  | 0..1 | code |
low |  | 1..1 | TS |
high |  | 0..1 | TS |
width |  | 0..1 | PQ |
center |  | 0..1 | TS |
performer |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
documentationOf:documentationOf1 |  | 1..1 | DocumentationOf |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Binding: ActClass (required) Required Pattern: ACT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code | I | 1..1 | CE | 1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
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..* | PhysicianReadingStudyPerformer | The performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument | I | 0..1 | RelatedDocument | A DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document. 1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
parentDocument |  | 1..1 | ParentDocument |
classCode |  | 1..1 | code | Binding: ActClassClinicalDocument (required) Fixed Value: DOCCLIN
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id | I | 1..1 | II | 1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031). 1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
code |  | 0..1 | CD | ​Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
text |  | 0..1 | ED |
setId |  | 0..1 | II |
versionNumber |  | 0..1 | INT |
Slices for authorization |  | 0..* | Authorization | The authorization element represents information about the patient?s consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent
authorization:authorization1 |  | 0..* | Authorization |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
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 | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id | I | 1..* | II | 1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
code |  | 0..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED |
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 | I | 1..1 | AssignedEntity | 1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
encounterParticipant |  | 0..1 | PhysicianofRecordParticipant |
location |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
component |  | 1..1 | Component2 |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
contextConductionInd |  | 1..1 | boolean |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody |  | 1..1 | StructuredBody |
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 1..* | Element | Slice: Unordered, Open by 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 | I | 1..1 | FindingsSectionDIR |
component:component2 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | DICOMObjectCatalogSectionDCM121181 | 1198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
component:component3 |  | 0..* | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | Section | 1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211). 1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCSECT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | The section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (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 |
title |  | 0..1 | ED | There is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
text | S I | 0..1 | xhtml | 1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060). 1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061). 1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
awarenessCode |  | 0..1 | CE | Binding: TargetAwareness (extensible)
relatedSubject |  | 1..1 | FetusSubjectContext |
Slices for author |  | 0..* | Author | This author element is used when the author of a section is different from the author(s) listed in the Header Slice: Unordered, Open by value:assignedAuthor
author:author1 |  | 0..* | Author |
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 |  | 1..1 | TS |
assignedAuthor | I | 1..1 | ObserverContext |
informant |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 0..1 | RelatedEntity |
Slices for entry | I | 0..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
entry:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
(Choice of one) |  | 1..1 |  |
observation |  | 0..1 | Observation |
regionOfInterest |  | 0..1 | RegionOfInterest |
observationMedia |  | 0..1 | ObservationMedia |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
procedure |  | 0..1 | Procedure |
encounter |  | 0..1 | Encounter |
organizer |  | 0..1 | Organizer |
act |  | 0..1 | Act |
entry | I | 0..* | Element | If the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act | I | 1..1 | ProcedureContext |
entry:textObs | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | TextObservation |
entry:entry3 | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation | I | 1..1 | CodeObservations |
entry:entry4 | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | QuantityMeasurementObservation |
entry:entry5 | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | SOPInstanceObservation |
component | I | 0..* | Element | 1198-31210: **SHALL** contain child elements (CONF:1198-31210).
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader |
component |  | 1..1 | Component2 |
structuredBody |  | 1..1 | StructuredBody |
component:component3 |  | 0..* | Element |
section | I | 1..1 | Section | 1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211). 1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
text | I | 0..1 | xhtml | 1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060). 1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061). 1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
Documentation for this format

This structure is derived from USRealmHeader

Summary

Mandatory: 15 elements (22 nested mandatory elements)
Prohibited: 1 element

Structures

This structure refers to these other structures:

- US Realm Person Name (PN.US.FIELDED) (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.5.1.1)
- Physician Reading Study Performer (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.1)
- US Realm Date and Time (DT.US.FIELDED) (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.5.3)
- Physician of Record Participant (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.2)
- Findings Section (DIR) (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.1.2)
- DICOM Object Catalog Section - DCM 121181 (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.1.1)
- Fetus Subject Context (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.3)
- Observer Context (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.4)
- Procedure Context (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.5)
- Text Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.12)
- Code Observations (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.13)
- Quantity Measurement Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.14)
- SOP Instance Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.8)

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.participant is sliced based on the value of value:ClinicalDocument.associatedEntity
- The element ClinicalDocument.documentationOf is sliced based on the value of value:ClinicalDocument.serviceEvent
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section
- The element ClinicalDocument.component.structuredBody.component.section.author is sliced based on the value of value:assignedAuthor
- The element ClinicalDocument.component.structuredBody.component.section.entry is sliced based on the value of value:ClinicalDocument.section.structuredBody.component.section.entry

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 | 1198-32937: 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:1198-32937).
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.5
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id |  | 1..1 | II |
root | I | 1..1 | string | 1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+ 1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
code |  | 1..1 | CE | Preferred code is 18748-4 LOINC Diagnostic Imaging Report
code |  | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5 (preferred)
informant |  | 0..0 |  |
informationRecipient | I | 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. 1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412). 1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
Slices for participant |  | 0..* | Participant1 | If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF). Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
participant:participant1 |  | 0..1 | Participant1 |
associatedEntity |  | 1..1 | AssociatedEntity |
associatedPerson |  | 1..1 | Person |
name |  | 1..1 | USRealmPersonNamePNUSFIELDED |
inFulfillmentOf |  | 0..* | InFulfillmentOf | An inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
order |  | 1..1 | Order |
id |  | 1..* | II | DICOM Accession Number in the DICOM imaging and report data
Slices for documentationOf |  | 0..* | DocumentationOf | Each serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure. Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
documentationOf:documentationOf1 |  | 1..1 | DocumentationOf |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Required Pattern: ACT
id |  | 0..* | II |
code | I | 1..1 | CE | 1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
performer |  | 0..* | PhysicianReadingStudyPerformer | The performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
relatedDocument | I | 0..1 | RelatedDocument | A DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document. 1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
parentDocument |  | 1..1 | ParentDocument |
id | I | 1..1 | II | 1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031). 1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
componentOf |  | 0..1 | ComponentOf | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
encompassingEncounter |  | 1..1 | EncompassingEncounter | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
id | I | 1..* | II | 1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
effectiveTime |  | 1..1 | USRealmDateandTimeDTUSFIELDED |
responsibleParty |  | 0..1 | Element |
assignedEntity | I | 1..1 | AssignedEntity | 1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
encounterParticipant |  | 0..1 | PhysicianofRecordParticipant |
component |  | 1..1 | Component2 |
structuredBody |  | 1..1 | StructuredBody |
Slices for component |  | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section
component:component1 |  | 1..1 | Element |
section |  | 1..1 | FindingsSectionDIR |
component:component2 |  | 0..1 | Element |
section | I | 1..1 | DICOMObjectCatalogSectionDCM121181 | 1198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
component:component3 |  | 0..* | Element |
section | I | 1..1 | Section | 1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211). 1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
code |  | 1..1 | CE |
code |  | 1..1 | string | The section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (preferred)
title |  | 0..1 | ED | There is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
text | I | 0..1 | xhtml | 1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060). 1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061). 1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
subject |  | 0..* | Element |
relatedSubject |  | 1..1 | FetusSubjectContext |
Slices for author |  | 0..* | Author | This author element is used when the author of a section is different from the author(s) listed in the Header Slice: Unordered, Open by value:assignedAuthor
author:author1 |  | 0..* | Author |
assignedAuthor |  | 1..1 | ObserverContext |
Slices for entry |  | 0..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
entry |  | 0..* | Element | If the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
act |  | 1..1 | ProcedureContext |
entry:textObs |  | 0..* | Element |
observation |  | 1..1 | TextObservation |
entry:entry3 |  | 0..* | Element |
observation |  | 1..1 | CodeObservations |
entry:entry4 |  | 0..* | Element |
observation |  | 1..1 | QuantityMeasurementObservation |
entry:entry5 |  | 0..* | Element |
observation |  | 1..1 | SOPInstanceObservation |
component | I | 0..* | Element | 1198-31210: **SHALL** contain child elements (CONF:1198-31210).
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 | 1198-32937: 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:1198-32937).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.5
extension |  | 1..1 | string | Required Pattern: 2014-06-09
id | I | 1..1 | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root | I | 1..1 | string | 1198-30934: The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+ 1198-30935: OIDs SHALL be no more than 64 characters in length (CONF:1198-30935).
extension |  | 0..1 | string |
code | I | 1..1 | CE | ​Preferred code is 18748-4 LOINC Diagnostic Imaging Report 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/1.3.6.1.4.1.12009.10.2.5 (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 |
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 |
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 | I | 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. 1198-8412: The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412). 1198-8413: When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413).
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 | If participant is present, the associatedEntity/associatedPerson element SHALL be present and SHALL represent the physician requesting the imaging procedure (the referring physician AssociatedEntity that is the target of ClincalDocument/participant@typeCode=REF). Slice: Unordered, Open by value:ClinicalDocument.associatedEntity
participant:participant1 | I | 0..1 | Participant1 |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssociative (required)
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
associatedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..1 | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
scopingOrganization |  | 0..1 | Organization |
inFulfillmentOf |  | 0..* | InFulfillmentOf | An inFulfillmentOf element represents the Placer Order that is either a group of orders (modeled as PlacerGroup in the Placer Order RMIM of the Orders & Observations domain) or a single order item (modeled as ObservationRequest in the same RMIM). This optionality reflects two major approaches to the grouping of procedures as implemented in the installed base of imaging information systems. These approaches differ in their handling of grouped procedures and how they are mapped to identifiers in the Digital Imaging and Communications in Medicine (DICOM) image and structured reporting data. The example of a CT examination covering chest, abdomen, and pelvis will be used in the discussion below. In the IHE Scheduled Workflow model, the Chest CT, Abdomen CT, and Pelvis CT each represent a Requested Procedure, and all three procedures are grouped under a single Filler Order. The Filler Order number maps directly to the DICOM Accession Number in the DICOM imaging and report data. A widely deployed alternative approach maps the requested procedure identifiers directly to the DICOM Accession Number. The Requested Procedure ID in such implementations may or may not be different from the Accession Number, but is of little identifying importance because there is only one Requested Procedure per Accession Number. There is no identifier that formally connects the requested procedures ordered in this group.
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 | DICOM Accession Number in the DICOM imaging and report data
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
Slices for documentationOf |  | 0..* | DocumentationOf | Each serviceEvent indicates an imaging procedure that the provider describes and interprets in the content of the DIR. The main activity being described by this document is the interpretation of the imaging procedure. This is shown by setting the value of the @classCode attribute of the serviceEvent element to ACT, and indicating the duration over which care was provided in the effectiveTime element. Within each documentationOf element, there is one serviceEvent element. This event is the unit imaging procedure corresponding to a billable item. The type of imaging procedure may be further described in the serviceEvent/code element. This guide makes no specific recommendations about the vocabulary to use for describing this event. In IHE Scheduled Workflow environments, one serviceEvent/id element contains the DICOM Study Instance UID from the Modality Worklist, and the second serviceEvent/id element contains the DICOM Requested Procedure ID from the Modality Worklist. These two ids are in a single serviceEvent. The effectiveTime for the serviceEvent covers the duration of the imaging procedure being reported. This event should have one or more performers, which may participate at the same or different periods of time. Service events map to DICOM Requested Procedures. That is, serviceEvent/id is the ID of the Requested Procedure. Slice: Unordered, Open by value:ClinicalDocument.serviceEvent
documentationOf:All Slices |  |  |  | Content/Rules for all slices
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | dateTime |
inclusive |  | 0..1 | boolean |
operator |  | 0..1 | code |
low |  | 1..1 | TS |
high |  | 0..1 | TS |
width |  | 0..1 | PQ |
center |  | 0..1 | TS |
performer |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
documentationOf:documentationOf1 |  | 1..1 | DocumentationOf |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Binding: ActClass (required) Required Pattern: ACT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code | I | 1..1 | CE | 1198-8420: The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420).
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..* | PhysicianReadingStudyPerformer | The performer is the Physician Reading Study Performer defined in serviceEvent and is usually different from the attending physician. The reading physician interprets the images and evidence of the study (DICOM Definition).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument | I | 0..1 | RelatedDocument | A DIR may have three types of parent document: ? A superseded version that the present document wholly replaces (typeCode = RPLC). DIRs may go through stages of revision prior to being legally authenticated. Such early stages may be drafts from transcription, those created by residents, or other preliminary versions. Policies not covered by this specification may govern requirements for retention of such earlier versions. Except for forensic purposes, the latest version in a chain of revisions represents the complete and current report. ? An original version that the present document appends (typeCode = APND). When a DIR is legally authenticated, it can be amended by a separate addendum document that references the original. ? A source document from which the present document is transformed (typeCode = XFRM). A DIR may be created by transformation from a DICOM Structured Report (SR) document or from another DIR. An example of the latter case is the creation of a derived document for inclusion of imaging results in a clinical document. 1198-8433: When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
parentDocument |  | 1..1 | ParentDocument |
classCode |  | 1..1 | code | Binding: ActClassClinicalDocument (required) Fixed Value: DOCCLIN
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id | I | 1..1 | II | 1198-10031: OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031). 1198-10032: OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032).
code |  | 0..1 | CD | ​Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
text |  | 0..1 | ED |
setId |  | 0..1 | II |
versionNumber |  | 0..1 | INT |
Slices for authorization |  | 0..* | Authorization | The authorization element represents information about the patient?s consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent
authorization:authorization1 |  | 0..* | Authorization |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
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 | The id element of the encompassingEncounter represents the identifier for the encounter. When the diagnostic imaging procedure is performed in the context of a hospital stay or an outpatient visit for which there is an Encounter Number, that number should be present as the ID of the encompassingEncounter. The effectiveTime represents the time interval or point in time in which the encounter took place. The encompassing encounter might be that of the hospital or office visit in which the diagnostic imaging procedure was performed. If the effective time is unknown, a nullFlavor attribute can be used.
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id | I | 1..* | II | 1198-30942: In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942).
code |  | 0..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED |
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 | I | 1..1 | AssignedEntity | 1198-30947: **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947).
encounterParticipant |  | 0..1 | PhysicianofRecordParticipant |
location |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
component |  | 1..1 | Component2 |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
contextConductionInd |  | 1..1 | boolean |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody |  | 1..1 | StructuredBody |
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 1..* | Element | Slice: Unordered, Open by 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 | I | 1..1 | FindingsSectionDIR |
component:component2 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | DICOMObjectCatalogSectionDCM121181 | 1198-31206: The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206).
component:component3 |  | 0..* | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | Section | 1198-31211: All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211). 1198-31212: **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212).
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCSECT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | The section/code SHOULD be selected from LOINC or DICOM for sections not listed in the DIR Section Type Codes table undefined Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59 (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 |
title |  | 0..1 | ED | There is no equivalent to section/title in DICOM SR, so for a CDA to SR transformation, the section/code will be transferred and the title element will be dropped.
text | S I | 0..1 | xhtml | 1198-31060: If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060). 1198-31061: All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061). 1198-31062: The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062).
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
awarenessCode |  | 0..1 | CE | Binding: TargetAwareness (extensible)
relatedSubject |  | 1..1 | FetusSubjectContext |
Slices for author |  | 0..* | Author | This author element is used when the author of a section is different from the author(s) listed in the Header Slice: Unordered, Open by value:assignedAuthor
author:author1 |  | 0..* | Author |
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 |  | 1..1 | TS |
assignedAuthor | I | 1..1 | ObserverContext |
informant |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 0..1 | RelatedEntity |
Slices for entry | I | 0..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section.structuredBody.component.section.entry
entry:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
(Choice of one) |  | 1..1 |  |
observation |  | 0..1 | Observation |
regionOfInterest |  | 0..1 | RegionOfInterest |
observationMedia |  | 0..1 | ObservationMedia |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
procedure |  | 0..1 | Procedure |
encounter |  | 0..1 | Encounter |
organizer |  | 0..1 | Organizer |
act |  | 0..1 | Act |
entry | I | 0..* | Element | If the service context of a section is different from the value specified in documentationOf/serviceEvent, then the section SHALL contain one or more entries containing Procedure Context (templateId 2.16.840.1.113883.10.20.6.2.5), which will reset the context for any clinical statements nested within those elements
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
act | I | 1..1 | ProcedureContext |
entry:textObs | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | TextObservation |
entry:entry3 | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation | I | 1..1 | CodeObservations |
entry:entry4 | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | QuantityMeasurementObservation |
entry:entry5 | I | 0..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation |  | 1..1 | SOPInstanceObservation |
component | I | 0..* | Element | 1198-31210: **SHALL** contain child elements (CONF:1198-31210).
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

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.id.nullFlavor | required | NullFlavor
ClinicalDocument.code | extensible | ​http://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.code.nullFlavor | required | NullFlavor
ClinicalDocument.code.code | preferred | http://hl7.org/fhir/ccda/ValueSet/1.3.6.1.4.1.12009.10.2.5
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | extensible | RaceValueSet
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | extensible | DetailedEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavor | required | NullFlavor
ClinicalDocument.author.typeCode | required | Fixed Value: AUT
ClinicalDocument.author.contextControlCode | required | Fixed Value: OP
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Pattern: UNK
ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode
ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP
ClinicalDocument.custodian.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor
ClinicalDocument.informationRecipient.typeCode | required | ParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor
ClinicalDocument.participant:participant1.typeCode | required | ParticipationType
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.participant:participant1.associatedEntity.classCode | required | RoleClassAssociative
ClinicalDocument.participant:participant1.associatedEntity.code | extensible | RoleCode
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode
ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority
ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.documentationOf:documentationOf1.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf:documentationOf1.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf:documentationOf1.serviceEvent.classCode | required | Pattern: ACT
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.relatedDocument.nullFlavor | required | NullFlavor
ClinicalDocument.relatedDocument.typeCode | required | ParticipationType
ClinicalDocument.relatedDocument.parentDocument.classCode | required | Fixed Value: DOCCLIN
ClinicalDocument.relatedDocument.parentDocument.moodCode | required | Fixed Value: EVN
ClinicalDocument.relatedDocument.parentDocument.code | extensible | ​http://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.authorization:authorization1.nullFlavor | required | NullFlavor
ClinicalDocument.authorization:authorization1.typeCode | required | Fixed Value: AUT
ClinicalDocument.authorization:authorization1.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.code | extensible | ActCode
ClinicalDocument.authorization:authorization1.consent.statusCode | required | ActStatus
ClinicalDocument.componentOf.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.typeCode | required | Fixed Value: AUT
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | ​http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC
ClinicalDocument.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.typeCode | required | Fixed Value: AUT
ClinicalDocument.component.structuredBody.classCode | required | Fixed Value: DOCBODY
ClinicalDocument.component.structuredBody.moodCode | required | Fixed Value: EVN
ClinicalDocument.component.structuredBody.languageCode | required | HumanLanguage
ClinicalDocument.component.structuredBody.component:component3.section.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component3.section.classCode | required | Fixed Value: DOCSECT
ClinicalDocument.component.structuredBody.component:component3.section.moodCode | required | Fixed Value: EVN
ClinicalDocument.component.structuredBody.component:component3.section.code | extensible | DocumentSectionType
ClinicalDocument.component.structuredBody.component:component3.section.code.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component3.section.code.code | preferred | http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.9.59
ClinicalDocument.component.structuredBody.component:component3.section.languageCode | required | HumanLanguage
ClinicalDocument.component.structuredBody.component:component3.section.subject.typeCode | required | Fixed Value: SBJ
ClinicalDocument.component.structuredBody.component:component3.section.subject.contextControlCode | required | Fixed Value: OP
ClinicalDocument.component.structuredBody.component:component3.section.subject.awarenessCode | extensible | TargetAwareness
ClinicalDocument.component.structuredBody.component:component3.section.author:author1.nullFlavor | required | NullFlavor
ClinicalDocument.component.structuredBody.component:component3.section.author:author1.typeCode | required | Fixed Value: AUT
ClinicalDocument.component.structuredBody.component:component3.section.author:author1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.component.structuredBody.component:component3.section.informant.typeCode | required | Fixed Value: INF
ClinicalDocument.component.structuredBody.component:component3.section.informant.contextControlCode | required | Fixed Value: OP

#### Constraints

Id | Grade | Path | Details | Requirements
1198-32937 | 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:1198-32937). : |
1198-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:1198-9991). : |
1198-30934 | error | ClinicalDocument.id.root | The ClinicalDocument/id/@root attribute SHALL be a syntactically correct OID, and SHALL NOT be a UUID (CONF:1198-30934). OIDs SHALL be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID SHALL be in the form of the regular expression: ([0-2])(.([1-9][0-9]*|0))+ : |
1198-30935 | error | ClinicalDocument.id.root | OIDs SHALL be no more than 64 characters in length (CONF:1198-30935). : |
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). : |
1198-8412 | warning | ClinicalDocument.informationRecipient | The physician requesting the imaging procedure (ClinicalDocument/participant[@typeCode=REF]/associatedEntity), if present, **SHOULD** also be recorded as an informationRecipient, unless in the local setting another physician (such as the attending physician for an inpatient) is known to be the appropriate recipient of the report (CONF:1198-8412). : |
1198-8413 | warning | ClinicalDocument.informationRecipient | When no referring physician is present, as in the case of self-referred screening examinations allowed by law, the intendedRecipient **MAY** be absent. The intendedRecipient **MAY** also be the health chart of the patient, in which case the receivedOrganization **SHALL** be the scoping organization of that chart (CONF:1198-8413). : |
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). : |
81-9371 | error | ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.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.participant:participant1.associatedEntity.associatedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
1198-8420 | error | ClinicalDocument.documentationOf:documentationOf1.serviceEvent.code | The value of serviceEvent/code **SHALL NOT** conflict with the ClininicalDocument/code. When transforming from DICOM SR documents that do not contain a procedure code, an appropriate nullFlavor **SHALL** be used on serviceEvent/code (CONF:1198-8420). : |
1198-8433 | warning | ClinicalDocument.relatedDocument | When a Diagnostic Imaging Report has been transformed from a DICOM SR document, relatedDocument/@typeCode **SHALL** be XFRM, and relatedDocument/parentDocument/id **SHALL** contain the SOP Instance UID of the original DICOM SR document (CONF:1198-8433). : |
1198-10031 | error | ClinicalDocument.relatedDocument.parentDocument.id | OIDs **SHALL** be represented in dotted decimal notation, where each decimal number is either 0 or starts with a nonzero digit. More formally, an OID **SHALL** be in the form of the regular expression: ([0-2])(.([1-9][0-9][*]|0))+ (CONF:1198-10031). : |
1198-10032 | error | ClinicalDocument.relatedDocument.parentDocument.id | OIDs **SHALL** be no more than 64 characters in length (CONF:1198-10032). : |
1198-30942 | warning | ClinicalDocument.componentOf.encompassingEncounter.id | In the case of transformed DICOM SR documents, an appropriate null flavor **MAY** be used if the id is unavailable (CONF:1198-30942). : |
81-10078 | error | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.componentOf.encompassingEncounter.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
1198-30947 | warning | ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.assignedEntity | **SHOULD** contain zero or one [0..1] assignedPerson *OR* contain zero or one [0..1] representedOrganization (CONF:1198-30947). : |
81-8532 | warning | ClinicalDocument.component.structuredBody.component:component1.section | This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532). : |
81-8527 | warning | ClinicalDocument.component.structuredBody.component:component2.section | A DICOM Object Catalog SHALL be present if the document contains references to DICOM Images. If present, it SHALL be the first section in the document (CONF:81-8527). : |
1198-31206 | error | ClinicalDocument.component.structuredBody.component:component2.section | The DICOM Object Catalog section (templateId 2.16.840.1.113883.10.20.6.1.1), if present, **SHALL** be the first section in the document Body (CONF:1198-31206). : |
1198-31211 | error | ClinicalDocument.component.structuredBody.component:component3.section | All sections defined in the DIR Section Type Codes table **SHALL** be top-level sections (CONF:1198-31211). : |
1198-31212 | error | ClinicalDocument.component.structuredBody.component:component3.section | **SHALL** contain at least one text element or one or more component elements (CONF:1198-31212). : |
1198-31060 | error | ClinicalDocument.component.structuredBody.component:component3.section.text | If clinical statements are present, the section/text **SHALL** represent faithfully all such statements and **MAY** contain additional text (CONF:1198-31060). : |
1198-31061 | error | ClinicalDocument.component.structuredBody.component:component3.section.text | All text elements **SHALL** contain content. Text elements **SHALL** contain PCDATA or child elements (CONF:1198-31061). : |
1198-31062 | warning | ClinicalDocument.component.structuredBody.component:component3.section.text | The text elements (and their children) **MAY** contain Web Access to DICOM Persistent Object (WADO) references to DICOM objects by including a linkHtml element where @href is a valid WADO URL and the text content of linkHtml is the visible text of the hyperlink (CONF:1198-31062). : |
81-9198 | error | ClinicalDocument.component.structuredBody.component:component3.section.author:author1.assignedAuthor | Either assignedPerson or assignedAuthoringDevice SHALL be present (CONF:81-9198). : |
only-one-statement | error | ClinicalDocument.component.structuredBody.component:component3.section.entry | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
81-9199 | warning | ClinicalDocument.component.structuredBody.component:component3.section.entry.act | Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199). : |
only-one-statement | error | ClinicalDocument.component.structuredBody.component:component3.section.entry | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
81-9199 | warning | ClinicalDocument.component.structuredBody.component:component3.section.entry.act | Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199). : |
only-one-statement | error | ClinicalDocument.component.structuredBody.component:component3.section.entry:textObs | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
only-one-statement | error | ClinicalDocument.component.structuredBody.component:component3.section.entry:entry3 | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
81-9310 | warning | ClinicalDocument.component.structuredBody.component:component3.section.entry:entry3.observation | Code Observations SHALL be rendered into section/text in separate paragraphs (CONF:81-9310). : |
only-one-statement | error | ClinicalDocument.component.structuredBody.component:component3.section.entry:entry4 | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
only-one-statement | error | ClinicalDocument.component.structuredBody.component:component3.section.entry:entry5 | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
1198-31210 | error | ClinicalDocument.component.structuredBody.component:component3.section.component | **SHALL** contain child elements (CONF:1198-31210). : |