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: Operative Note (V3)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.7 | Version: 2.2
Active as of 2022-05-13 | Computable Name: OperativeNote
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.7:2015-08-01

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.

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: 29 elements (15 nested mandatory elements)

Structures

This structure refers to these other structures:

- 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)
- Anesthesia Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.25)
- Complications Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.37)
- Preoperative Diagnosis Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.34)
- Procedure Estimated Blood Loss Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.18.2.9)
- Procedure Findings Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.28)
- Procedure Specimens Taken Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.31)
- Procedure Description Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.27)
- Postoperative Diagnosis Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.35)
- Procedure Implants Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.40)
- Operative Note Fluids Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.7.12)
- Operative Note Surgical Procedure Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.7.14)
- Plan of Treatment Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.10)
- Planned Procedure Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.30)
- Procedure Disposition Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.18.2.12)
- Procedure Indications Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.29)
- Surgical Drains Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.7.13)

Slices

This structure defines the following Slices:

- The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension
- The element ClinicalDocument.documentationOf.serviceEvent.performer is sliced based on the values of value:assignedEntity, value:typeCode, value:functionCode
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section

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 | 1198-32940: 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:1198-32940).
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.7
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE | The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
code |  | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
documentationOf |  | 1..* | DocumentationOf | A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
serviceEvent | I | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. 1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488). 1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058). 1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
Slices for performer |  | 0..* | Performer1 | This performer represents any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
performer:performer1 |  | 1..1 | Performer1 | This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
typeCode |  | 1..1 | code | Required Pattern: PPRF
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
performer:performer2 |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
typeCode |  | 1..1 | code | Required Pattern: SPRF
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
typeCode |  | 1..1 | code | Required Pattern: AUTH
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Required Pattern: CONS
moodCode |  | 1..1 | code | Required Pattern: EVN
statusCode |  | 1..1 | CS |
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 | AnesthesiaSection |
component:component2 |  | 1..1 | Element |
section |  | 1..1 | ComplicationsSection |
component:component3 |  | 1..1 | Element |
section |  | 1..1 | PreoperativeDiagnosisSection |
component:component4 |  | 1..1 | Element |
section |  | 1..1 | ProcedureEstimatedBloodLossSection |
component:component5 |  | 1..1 | Element |
section |  | 1..1 | ProcedureFindingsSection |
component:component6 |  | 1..1 | Element |
section |  | 1..1 | ProcedureSpecimensTakenSection |
component:component7 |  | 1..1 | Element |
section |  | 1..1 | ProcedureDescriptionSection |
component:component8 |  | 1..1 | Element |
section |  | 1..1 | PostoperativeDiagnosisSection |
component:component9 |  | 0..1 | Element |
section |  | 1..1 | ProcedureImplantsSection |
component:component10 |  | 0..1 | Element |
section |  | 1..1 | OperativeNoteFluidsSection |
component:component11 |  | 0..1 | Element |
section |  | 1..1 | OperativeNoteSurgicalProcedureSection |
component:component12 |  | 0..1 | Element |
section |  | 1..1 | PlanofTreatmentSection |
component:component13 |  | 0..1 | Element |
section |  | 1..1 | PlannedProcedureSection |
component:component14 |  | 0..1 | Element |
section |  | 1..1 | ProcedureDispositionSection |
component:component15 |  | 0..1 | Element |
section |  | 1..1 | ProcedureIndicationsSection |
component:component16 |  | 0..1 | Element |
section |  | 1..1 | SurgicalDrainsSection |
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 | 1198-32940: 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:1198-32940).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.7
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id | I | 1..1 | II |
code | I | 1..1 | CE | ​The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
setId | I | 0..1 | II |
versionNumber | I | 0..1 | INT |
copyTime |  | 0..1 | TS |
recordTarget |  | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
patientRole |  | 1..1 | PatientRole |
classCode |  | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..1 | II |
name | I | 1..* | USRealmPatientNamePTNUSFIELDED |
sdtcDesc |  | 0..1 | ED | XML: desc (urn:hl7-org:sdtc)
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | I | 1..1 | TS |
sdtcDeceasedInd |  | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc)
sdtcDeceasedTime |  | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc)
sdtcMultipleBirthInd |  | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc)
sdtcMultipleBirthOrderNumber |  | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
maritalStatusCode |  | 0..1 | CE | Binding: Marital Status (required)
religiousAffiliationCode |  | 0..1 | CE | Binding: Religious Affiliation (required)
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
sdtcRaceCode |  | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
sdtcEthnicGroupCode |  | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible)
guardian |  | 0..* | Guardian |
classCode |  | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required)
addr | I | 0..* | USRealmAddressADUSFIELDED |
telecom |  | 0..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
guardianPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
guardianOrganization |  | 0..1 | Organization |
birthplace |  | 0..1 | Birthplace |
classCode |  | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL
templateId |  | 0..* | II |
place |  | 1..1 | Place |
classCode |  | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 0..1 | EN |
addr | I | 1..1 | AD |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
isNotOrdered |  | 0..1 | boolean |
use |  | 0..* | code |
delimiter |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DEL
country |  | 0..1 | ADXP |
partType |  | 0..1 | code | Fixed Value: CNT
state |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STA
county |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CPA
city |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CTY
postalCode |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: ZIP
streetAddressLine |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: SAL
houseNumber |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: BNR
houseNumberNumeric |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: BNN
direction |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DIR
streetName |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STR
streetNameBase |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STB
streetNameType |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STTYP
additionalLocator |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: ADL
unitID |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: UNID
unitType |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: UNIT
careOf |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CAR
censusTract |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CEN
deliveryAddressLine |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DAL
deliveryInstallationType |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DINST
deliveryInstallationArea |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DINSTA
deliveryInstallationQualifier |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DINSTQ
deliveryMode |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DMOD
deliveryModeIdentifier |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DMODID
buildingNumberSuffix |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: BNS
postBox |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: POB
precinct |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: PRE
other |  | 0..1 | string |
useablePeriod[x] |  | 0..* |  |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS |  |  | IVL_TS |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS |  |  | EIVL_TS |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS |  |  | PIVL_TS |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS |  |  | SXPR_TS |
languageCommunication |  | 0..* | LanguageCommunication |
templateId |  | 0..* | II |
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
modeCode |  | 0..1 | CE | Binding: LanguageAbilityMode (required)
proficiencyLevelCode |  | 0..1 | CE | Binding: LanguageAbilityProficiency (required)
preferenceInd |  | 0..1 | BL |
providerOrganization |  | 0..1 | Organization |
classCode |  | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
name |  | 1..* | ON |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
addr | I | 1..* | USRealmAddressADUSFIELDED |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
author |  | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
assignedAuthor | I | 1..1 | AssignedAuthor |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root 1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
id:id1 |  | 0..1 | II |
nullFlavor |  | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Binding: Healthcare Provider Taxonomy (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 0..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
assignedAuthoringDevice |  | 0..1 | AuthoringDevice |
classCode |  | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
code |  | 0..1 | CE | Binding: EntityCode (extensible)
manufacturerModelName |  | 1..1 | SC |
softwareName |  | 1..1 | SC |
asMaintainedEntity |  | 0..* | MaintainedEntity |
representedOrganization |  | 0..1 | Organization |
dataEnterer |  | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 1..1 | TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for informant |  | 0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id | I | 1..* | II | 1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 0..* | TEL |
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
relatedEntity |  | 0..1 | RelatedEntity |
informant:informant2 |  | 0..* | Informant |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedCustodian |  | 1..1 | AssignedCustodian |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
classCode |  | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
addr | I | 1..1 | USRealmAddressADUSFIELDED |
informationRecipient |  | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
intendedRecipient |  | 1..1 | IntendedRecipient |
classCode |  | 1..1 | code |
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
informationRecipient |  | 0..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
receivedOrganization |  | 0..1 | Organization |
classCode |  | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..* | II |
name |  | 1..1 | ON |
telecom |  | 0..* | TEL |
addr |  | 0..* | AD |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
legalAuthenticator |  | 0..1 | LegalAuthenticator | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: LA
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
signatureCode |  | 1..1 | CS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: S
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for authenticator |  | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. Slice: Unordered, Open by value:signatureCode, value:assignedEntity
authenticator:authenticator1 |  | 0..* | Authenticator |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
signatureCode |  | 1..1 | CS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: S
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Healthcare Provider Taxonomy (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for participant |  | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). Slice: Unordered, Open by
participant:participant1 | I | 0..* | Participant1 | 1198-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). 1198-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
inFulfillmentOf |  | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
order |  | 1..1 | Order |
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
documentationOf |  | 1..* | DocumentationOf | A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent | I | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. 1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488). 1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058). 1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | dateTime |
inclusive |  | 0..1 | boolean |
operator |  | 0..1 | code |
low |  | 1..1 | TS |
high |  | 0..1 | TS |
width |  | 0..1 | PQ |
center |  | 0..1 | TS |
Slices for performer |  | 0..* | Performer1 | This performer represents any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
performer:All Slices |  |  |  | Content/Rules for all slices
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer1 |  | 1..1 | Performer1 | This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer2 |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
Slices for authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. Slice: Unordered, Open by value:consent
authorization:All Slices |  |  |  | Content/Rules for all slices
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
authorization:authorization1 |  | 0..* | Authorization |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
encompassingEncounter |  | 1..1 | EncompassingEncounter |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime |  | 1..1 | IVL_TS |
sdtcAdmissionReferralSourceCode |  | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode |  | 0..1 | CE | ​Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible)
responsibleParty |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP
assignedEntity |  | 1..1 | AssignedEntity |
encounterParticipant |  | 0..* | EncounterParticipant |
location |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
component |  | 1..1 | Component2 |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
contextConductionInd |  | 1..1 | boolean |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody |  | 1..1 | StructuredBody |
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section
component:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
component:component1 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | AnesthesiaSection |
component:component2 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ComplicationsSection |
component:component3 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PreoperativeDiagnosisSection |
component:component4 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | ProcedureEstimatedBloodLossSection |
component:component5 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureFindingsSection |
component:component6 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | ProcedureSpecimensTakenSection |
component:component7 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureDescriptionSection |
component:component8 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PostoperativeDiagnosisSection |
component:component9 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | ProcedureImplantsSection |
component:component10 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | OperativeNoteFluidsSection |
component:component11 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | OperativeNoteSurgicalProcedureSection |
component:component12 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PlanofTreatmentSection |
component:component13 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PlannedProcedureSection |
component:component14 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureDispositionSection |
component:component15 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureIndicationsSection |
component:component16 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | SurgicalDrainsSection |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
ClinicalDocument |  | 1..1 | USRealmHeader |
Documentation for this format

This structure is derived from USRealmHeader

Summary

Mandatory: 29 elements (15 nested mandatory elements)

Structures

This structure refers to these other structures:

- 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)
- Anesthesia Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.25)
- Complications Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.37)
- Preoperative Diagnosis Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.34)
- Procedure Estimated Blood Loss Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.18.2.9)
- Procedure Findings Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.28)
- Procedure Specimens Taken Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.31)
- Procedure Description Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.27)
- Postoperative Diagnosis Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.35)
- Procedure Implants Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.40)
- Operative Note Fluids Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.7.12)
- Operative Note Surgical Procedure Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.7.14)
- Plan of Treatment Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.10)
- Planned Procedure Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.30)
- Procedure Disposition Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.18.2.12)
- Procedure Indications Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.29)
- Surgical Drains Section (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.7.13)

Slices

This structure defines the following Slices:

- The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension
- The element ClinicalDocument.documentationOf.serviceEvent.performer is sliced based on the values of value:assignedEntity, value:typeCode, value:functionCode
- The element ClinicalDocument.component.structuredBody.component is sliced based on the value of value:ClinicalDocument.section

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 | 1198-32940: 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:1198-32940).
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.7
extension |  | 1..1 | string | Required Pattern: 2015-08-01
code |  | 1..1 | CE | The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
code |  | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
documentationOf |  | 1..* | DocumentationOf | A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
serviceEvent | I | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. 1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488). 1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058). 1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
Slices for performer |  | 0..* | Performer1 | This performer represents any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
performer:performer1 |  | 1..1 | Performer1 | This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
typeCode |  | 1..1 | code | Required Pattern: PPRF
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
performer:performer2 |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
typeCode |  | 1..1 | code | Required Pattern: SPRF
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
typeCode |  | 1..1 | code | Required Pattern: AUTH
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Required Pattern: CONS
moodCode |  | 1..1 | code | Required Pattern: EVN
statusCode |  | 1..1 | CS |
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 | AnesthesiaSection |
component:component2 |  | 1..1 | Element |
section |  | 1..1 | ComplicationsSection |
component:component3 |  | 1..1 | Element |
section |  | 1..1 | PreoperativeDiagnosisSection |
component:component4 |  | 1..1 | Element |
section |  | 1..1 | ProcedureEstimatedBloodLossSection |
component:component5 |  | 1..1 | Element |
section |  | 1..1 | ProcedureFindingsSection |
component:component6 |  | 1..1 | Element |
section |  | 1..1 | ProcedureSpecimensTakenSection |
component:component7 |  | 1..1 | Element |
section |  | 1..1 | ProcedureDescriptionSection |
component:component8 |  | 1..1 | Element |
section |  | 1..1 | PostoperativeDiagnosisSection |
component:component9 |  | 0..1 | Element |
section |  | 1..1 | ProcedureImplantsSection |
component:component10 |  | 0..1 | Element |
section |  | 1..1 | OperativeNoteFluidsSection |
component:component11 |  | 0..1 | Element |
section |  | 1..1 | OperativeNoteSurgicalProcedureSection |
component:component12 |  | 0..1 | Element |
section |  | 1..1 | PlanofTreatmentSection |
component:component13 |  | 0..1 | Element |
section |  | 1..1 | PlannedProcedureSection |
component:component14 |  | 0..1 | Element |
section |  | 1..1 | ProcedureDispositionSection |
component:component15 |  | 0..1 | Element |
section |  | 1..1 | ProcedureIndicationsSection |
component:component16 |  | 0..1 | Element |
section |  | 1..1 | SurgicalDrainsSection |
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 | 1198-32940: 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:1198-32940).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.7
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id | I | 1..1 | II |
code | I | 1..1 | CE | ​The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Binding: http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1 (required)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ED | The title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
effectiveTime | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
confidentialityCode |  | 1..1 | CE | Binding: HL7 BasicConfidentialityKind (preferred)
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
setId | I | 0..1 | II |
versionNumber | I | 0..1 | INT |
copyTime |  | 0..1 | TS |
recordTarget |  | 1..* | RecordTarget | The recordTarget records the administrative and demographic data of the patient whose health information is described by the clinical document; each recordTarget must contain at least one patientRole element
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: RCT
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
patientRole |  | 1..1 | PatientRole |
classCode |  | 1..1 | code | Binding: RoleClassRelationshipFormal (required) Fixed Value: PAT
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
patient |  | 1..1 | Patient |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..1 | II |
name | I | 1..* | USRealmPatientNamePTNUSFIELDED |
sdtcDesc |  | 0..1 | ED | XML: desc (urn:hl7-org:sdtc)
administrativeGenderCode |  | 1..1 | CE | Binding: Administrative Gender (HL7 V3) (required)
birthTime | I | 1..1 | TS |
sdtcDeceasedInd |  | 0..1 | BL | XML: deceasedInd (urn:hl7-org:sdtc)
sdtcDeceasedTime |  | 0..1 | TS | XML: deceasedTime (urn:hl7-org:sdtc)
sdtcMultipleBirthInd |  | 0..1 | BL | XML: multipleBirthInd (urn:hl7-org:sdtc)
sdtcMultipleBirthOrderNumber |  | 0..1 | INT_POS | XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
maritalStatusCode |  | 0..1 | CE | Binding: Marital Status (required)
religiousAffiliationCode |  | 0..1 | CE | Binding: Religious Affiliation (required)
raceCode |  | 1..1 | CE | Binding: Race Category Excluding Nulls (required)
sdtcRaceCode |  | 0..* | CE | XML: raceCode (urn:hl7-org:sdtc) Binding: Race Value Set (extensible)
ethnicGroupCode |  | 1..1 | CE | Binding: Ethnicity (required)
sdtcEthnicGroupCode |  | 0..* | CE | XML: ethnicGroupCode (urn:hl7-org:sdtc) Binding: Detailed Ethnicity (extensible)
guardian |  | 0..* | Guardian |
classCode |  | 1..1 | code | Binding: RoleClassAgent (required) Fixed Value: GUARD
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Personal And Legal Relationship Role Type (required)
addr | I | 0..* | USRealmAddressADUSFIELDED |
telecom |  | 0..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
guardianPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
guardianOrganization |  | 0..1 | Organization |
birthplace |  | 0..1 | Birthplace |
classCode |  | 1..1 | code | Binding: RoleClassPassive (required) Fixed Value: BIRTHPL
templateId |  | 0..* | II |
place |  | 1..1 | Place |
classCode |  | 1..1 | code | Binding: EntityClassPlace (required) Fixed Value: PLC
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name |  | 0..1 | EN |
addr | I | 1..1 | AD |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
isNotOrdered |  | 0..1 | boolean |
use |  | 0..* | code |
delimiter |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DEL
country |  | 0..1 | ADXP |
partType |  | 0..1 | code | Fixed Value: CNT
state |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STA
county |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CPA
city |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CTY
postalCode |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: ZIP
streetAddressLine |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: SAL
houseNumber |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: BNR
houseNumberNumeric |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: BNN
direction |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DIR
streetName |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STR
streetNameBase |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STB
streetNameType |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: STTYP
additionalLocator |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: ADL
unitID |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: UNID
unitType |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: UNIT
careOf |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CAR
censusTract |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: CEN
deliveryAddressLine |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DAL
deliveryInstallationType |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DINST
deliveryInstallationArea |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DINSTA
deliveryInstallationQualifier |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DINSTQ
deliveryMode |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DMOD
deliveryModeIdentifier |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: DMODID
buildingNumberSuffix |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: BNS
postBox |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: POB
precinct |  | 0..* | ADXP |
partType |  | 0..1 | code | Fixed Value: PRE
other |  | 0..1 | string |
useablePeriod[x] |  | 0..* |  |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/IVL-TS |  |  | IVL_TS |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/EIVL-TS |  |  | EIVL_TS |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/PIVL-TS |  |  | PIVL_TS |
useablePeriodHttp://hl7.org/fhir/cda/StructureDefinition/SXPR-TS |  |  | SXPR_TS |
languageCommunication |  | 0..* | LanguageCommunication |
templateId |  | 0..* | II |
languageCode |  | 1..1 | CS | Binding: VSAC 2.16.840.1.113883.1.11.11526 (required)
modeCode |  | 0..1 | CE | Binding: LanguageAbilityMode (required)
proficiencyLevelCode |  | 0..1 | CE | Binding: LanguageAbilityProficiency (required)
preferenceInd |  | 0..1 | BL |
providerOrganization |  | 0..1 | Organization |
classCode |  | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
name |  | 1..* | ON |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
addr | I | 1..* | USRealmAddressADUSFIELDED |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
author |  | 1..* | Author | The author element represents the creator of the clinical document. The author may be a device or a person.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
assignedAuthor | I | 1..1 | AssignedAuthor |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
Slices for id | I | 1..* | II | Slice: Unordered, Open by value:root 1198-5449: If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449).
id:id1 |  | 0..1 | II |
nullFlavor |  | 0..1 | code | If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then Binding: NullFlavor (required) Required Pattern: UNK
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code. Binding: v3 Code System RoleCode (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Binding: Healthcare Provider Taxonomy (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 0..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
assignedAuthoringDevice |  | 0..1 | AuthoringDevice |
classCode |  | 1..1 | code | Binding: EntityClassDevice (required) Fixed Value: DEV
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
code |  | 0..1 | CE | Binding: EntityCode (extensible)
manufacturerModelName |  | 1..1 | SC |
softwareName |  | 1..1 | SC |
asMaintainedEntity |  | 0..* | MaintainedEntity |
representedOrganization |  | 0..1 | Organization |
dataEnterer |  | 0..1 | DataEnterer | The dataEnterer element represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content found within the header or body of a document, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time |  | 1..1 | TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for informant |  | 0..* | Informant | The informant element describes an information source (who is not a provider) for any content within the clinical document. This informant would be used when the source of information has a personal relationship with the patient or is the patient. Slice: Unordered, Open by value:relatedEntity
informant:informant1 |  | 0..* | Informant | The informant element describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id | I | 1..* | II | 1198-9946: If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946).
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 0..* | TEL |
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
relatedEntity |  | 0..1 | RelatedEntity |
informant:informant2 |  | 0..* | Informant |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: INF
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 1..1 | RelatedEntity |
custodian |  | 1..1 | Custodian | The custodian element represents the organization that is in charge of maintaining and is entrusted with the care of the document. There is only one custodian per CDA document. Allowing that a CDA document may not represent the original form of the authenticated document, the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: ENT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
assignedCustodian |  | 1..1 | AssignedCustodian |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
classCode |  | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
name |  | 1..1 | ON |
telecom |  | 1..1 | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
addr | I | 1..1 | USRealmAddressADUSFIELDED |
informationRecipient |  | 0..* | InformationRecipient | The informationRecipient element records the intended recipient of the information at the time the document was created. In cases where the intended recipient of the document is the patient's health chart, set the receivedOrganization to the scoping organization for that chart.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
intendedRecipient |  | 1..1 | IntendedRecipient |
classCode |  | 1..1 | code |
templateId |  | 0..* | II |
id |  | 0..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
informationRecipient |  | 0..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
receivedOrganization |  | 0..1 | Organization |
classCode |  | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
id |  | 0..* | II |
name |  | 1..1 | ON |
telecom |  | 0..* | TEL |
addr |  | 0..* | AD |
standardIndustryClassCode |  | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible)
asOrganizationPartOf |  | 0..1 | OrganizationPartOf |
legalAuthenticator |  | 0..1 | LegalAuthenticator | The legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. A clinical document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. Based on local practice, clinical documents may be released before legal authentication. All clinical documents have the potential for legal authentication, given the appropriate credentials. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the clinical document. In these cases, the legal authenticator is a person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: LA
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
signatureCode |  | 1..1 | CS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: S
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for authenticator |  | 0..* | Authenticator | The authenticator identifies a participant or participants who attest to the accuracy of the information in the document. Slice: Unordered, Open by value:signatureCode, value:assignedEntity
authenticator:authenticator1 |  | 0..* | Authenticator |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUTHEN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
time | I | 1..1 | USRealmDateandTimeDTMUSFIELDED |
signatureCode |  | 1..1 | CS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: S
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
sdtcSignatureText |  | 0..1 | ED | XML: signatureText (urn:hl7-org:sdtc)
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: v3 Code System RoleCode (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Healthcare Provider Taxonomy (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
addr | I | 1..* | USRealmAddressADUSFIELDED |
telecom |  | 1..* | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | uri |
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..1 | code | Binding: Telecom Use (US Realm Header) (required)
assignedPerson |  | 1..1 | Person |
classCode |  | 1..1 | code | Binding: EntityClassLivingSubject (required) Fixed Value: PSN
determinerCode |  | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE
templateId |  | 0..* | II |
name | I | 1..* | USRealmPersonNamePNUSFIELDED |
sdtcAsPatientRelationship |  | 0..* | CE | XML: asPatientRelationship (urn:hl7-org:sdtc)
representedOrganization |  | 0..1 | Organization |
Slices for participant |  | 0..* | Participant1 | The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin). Slice: Unordered, Open by
participant:participant1 | I | 0..* | Participant1 | 1198-10006: **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). 1198-10007: When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required)
contextControlCode |  | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
time |  | 0..1 | IVL_TS |
associatedEntity |  | 1..1 | AssociatedEntity |
inFulfillmentOf |  | 0..* | InFulfillmentOf | The inFulfillmentOf element represents orders that are fulfilled by this document such as a radiologists? report of an x-ray.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: FLFS
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
order |  | 1..1 | Order |
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMoodIntent (required) Fixed Value: RQO
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
documentationOf |  | 1..* | DocumentationOf | A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent | I | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. 1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487).
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime | I | 1..1 | USRealmDateandTimeDTUSFIELDED | 1198-8488: The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488). 1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058). 1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | dateTime |
inclusive |  | 0..1 | boolean |
operator |  | 0..1 | code |
low |  | 1..1 | TS |
high |  | 0..1 | TS |
width |  | 0..1 | PQ |
center |  | 0..1 | TS |
Slices for performer |  | 0..* | Performer1 | This performer represents any assistants. Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode
performer:All Slices |  |  |  | Content/Rules for all slices
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer1 |  | 1..1 | Performer1 | This performer represents a clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
performer:performer2 |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE | Binding: Care Team Member Function (preferred)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (required)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
Slices for authorization |  | 0..1 | Authorization | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. Slice: Unordered, Open by value:consent
authorization:All Slices |  |  |  | Content/Rules for all slices
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
authorization:authorization1 |  | 0..* | Authorization |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
componentOf |  | 0..1 | ComponentOf | The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
encompassingEncounter |  | 1..1 | EncompassingEncounter |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: ENC
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: ActEncounterCode (extensible)
effectiveTime |  | 1..1 | IVL_TS |
sdtcAdmissionReferralSourceCode |  | 0..1 | CE | XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode |  | 0..1 | CE | ​Binding: http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition (extensible)
responsibleParty |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationType (required) Fixed Value: RESP
assignedEntity |  | 1..1 | AssignedEntity |
encounterParticipant |  | 0..* | EncounterParticipant |
location |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility |  | 1..1 | HealthCareFacility |
component |  | 1..1 | Component2 |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
contextConductionInd |  | 1..1 | boolean |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
nonXMLBody |  | 0..1 | NonXMLBody |
structuredBody |  | 1..1 | StructuredBody |
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCBODY
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
Slices for component |  | 1..* | Element | Slice: Unordered, Open by value:ClinicalDocument.section
component:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
component:component1 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | AnesthesiaSection |
component:component2 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ComplicationsSection |
component:component3 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PreoperativeDiagnosisSection |
component:component4 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | ProcedureEstimatedBloodLossSection |
component:component5 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureFindingsSection |
component:component6 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | ProcedureSpecimensTakenSection |
component:component7 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureDescriptionSection |
component:component8 |  | 1..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PostoperativeDiagnosisSection |
component:component9 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | ProcedureImplantsSection |
component:component10 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | OperativeNoteFluidsSection |
component:component11 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | OperativeNoteSurgicalProcedureSection |
component:component12 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PlanofTreatmentSection |
component:component13 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | PlannedProcedureSection |
component:component14 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureDispositionSection |
component:component15 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | ProcedureIndicationsSection |
component:component16 |  | 0..1 | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section | I | 1..1 | SurgicalDrainsSection |
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.code | extensible | ​http://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.code.nullFlavor | required | NullFlavor
ClinicalDocument.code.code | required | http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.11.20.1.1
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | extensible | RaceValueSet
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | extensible | DetailedEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavor | required | NullFlavor
ClinicalDocument.author.typeCode | required | Fixed Value: AUT
ClinicalDocument.author.contextControlCode | required | Fixed Value: OP
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Pattern: UNK
ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode
ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP
ClinicalDocument.custodian.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor
ClinicalDocument.informationRecipient.typeCode | required | ParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor
ClinicalDocument.participant:participant1.typeCode | required | ParticipationType
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode
ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority
ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer1.assignedEntity.code | required | HealthcareProviderTaxonomy
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer:performer2.assignedEntity.code | required | HealthcareProviderTaxonomy
ClinicalDocument.authorization.nullFlavor | required | NullFlavor
ClinicalDocument.authorization.typeCode | required | Fixed Value: AUT
ClinicalDocument.authorization.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization.consent.code | extensible | ActCode
ClinicalDocument.authorization.consent.statusCode | required | ActStatus
ClinicalDocument.authorization:authorization1.nullFlavor | required | NullFlavor
ClinicalDocument.authorization:authorization1.typeCode | required | Fixed Value: AUT
ClinicalDocument.authorization:authorization1.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.code | extensible | ActCode
ClinicalDocument.authorization:authorization1.consent.statusCode | required | ActStatus
ClinicalDocument.componentOf.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.typeCode | required | Fixed Value: AUT
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | ​http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.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

#### Constraints

Id | Grade | Path | Details | Requirements
1198-32940 | 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:1198-32940). : |
1198-9991 | warning | ClinicalDocument.id | This id **SHALL** be a globally unique identifier for the document (CONF:1198-9991). : |
1198-9992 | error | ClinicalDocument.code | This code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:1198-9992). : |
1198-32948 | error | ClinicalDocument.code | This code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:1198-32948). : |
81-10127 | error | ClinicalDocument.effectiveTime | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.effectiveTime | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
1198-6380 | error | ClinicalDocument.setId | If setId is present versionNumber **SHALL** be present (CONF:1198-6380). : |
1198-6387 | error | ClinicalDocument.versionNumber | If versionNumber is present setId **SHALL** be present (CONF:1198-6387). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-7278 | error | ClinicalDocument.recordTarget.patientRole.patient.name | **SHALL NOT** have mixed content except for white space (CONF:81-7278). : |
1198-5299 | error | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHALL** be precise to year (CONF:1198-5299). : |
1198-5300 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **SHOULD** be precise to day (CONF:1198-5300). : |
1198-32418 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthTime | **MAY** be precise to the minute (CONF:1198-32418). For cases where information about newborn's time of birth needs to be captured. : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
1198-5402 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **SHALL** contain exactly one [1..1] state, which **SHALL** be selected from ValueSet StateValueSet 2.16.840.1.113883.3.88.12.80.1 *DYNAMIC* (CONF:1198-5402). : |
1198-5403 | warning | ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr | If country is US, this addr **MAY** contain zero or one [0..1] postalCode, which **SHALL** be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 *DYNAMIC* (CONF:1198-5403). : |
81-7296 | error | ClinicalDocument.recordTarget.patientRole.providerOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-10127 | error | ClinicalDocument.author.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.author.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.author.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.author.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
1198-16790 | error | ClinicalDocument.author.assignedAuthor | There **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:1198-16790). : |
1198-5449 | null | ClinicalDocument.author.assignedAuthor.id | If this assignedAuthor is not an assignedPerson, this assignedAuthor SHALL contain at least one [1..*] id (CONF:1198-5449). : |
81-7296 | error | ClinicalDocument.author.assignedAuthor.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.author.assignedAuthor.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-7296 | error | ClinicalDocument.dataEnterer.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
1198-9946 | warning | ClinicalDocument.informant:informant1.assignedEntity.id | If assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-9946). : |
81-7296 | error | ClinicalDocument.informant:informant1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-7296 | error | ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10127 | error | ClinicalDocument.legalAuthenticator.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.legalAuthenticator.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.legalAuthenticator.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.legalAuthenticator.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
81-7296 | error | ClinicalDocument.legalAuthenticator.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
81-10127 | error | ClinicalDocument.authenticator:authenticator1.time | **SHALL** be precise to the day (CONF:81-10127). : |
81-10128 | warning | ClinicalDocument.authenticator:authenticator1.time | **SHOULD** be precise to the minute (CONF:81-10128). : |
81-10129 | warning | ClinicalDocument.authenticator:authenticator1.time | **MAY** be precise to the second (CONF:81-10129). : |
81-10130 | warning | ClinicalDocument.authenticator:authenticator1.time | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10130). : |
81-7296 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.addr | **SHALL NOT** have mixed content except for white space (CONF:81-7296). : |
81-9371 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371). : |
81-9372 | error | ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name | The string **SHALL NOT** contain name parts (CONF:81-9372). : |
1198-10006 | error | ClinicalDocument.participant:participant1 | **SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:1198-10006). : |
1198-10007 | warning | ClinicalDocument.participant:participant1 | When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC 2011-09-30* (CONF:1198-10007). : |
1198-8487 | error | ClinicalDocument.documentationOf.serviceEvent | The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487). : |
81-10078 | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | **SHALL** be precise to the day (CONF:81-10078). : |
81-10079 | warning | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | **SHOULD** be precise to the minute (CONF:81-10079). : |
81-10080 | warning | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | **MAY** be precise to the second (CONF:81-10080). : |
81-10081 | warning | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | If more precise than day, **SHOULD** include time-zone offset (CONF:81-10081). : |
1198-8488 | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488). : |
1198-10058 | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058). : |
1198-10060 | error | ClinicalDocument.documentationOf.serviceEvent.effectiveTime | When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060). : |
81-8741 | warning | ClinicalDocument.component.structuredBody.component:component4.section | The Estimated Blood Loss section SHALL include a statement providing an estimate of the amount of blood lost during the procedure, even if the estimate is text, such as "minimal" or "none" (CONF:81-8741). : |
81-8742 | warning | ClinicalDocument.component.structuredBody.component:component6.section | The Procedure Specimens Taken section SHALL list all specimens removed or SHALL explicitly state that no specimens were taken (CONF:81-8742). : |
81-8769 | error | ClinicalDocument.component.structuredBody.component:component9.section | The Procedure Implants section **SHALL** include a statement providing details of the implants placed, or assert no implants were placed (CONF:81-8769). : |
81-8052 | warning | ClinicalDocument.component.structuredBody.component:component10.section | If the Operative Note Fluids section is present, there SHALL be a statement providing details of the fluids administered or SHALL explicitly state there were no fluids administered (CONF:81-8052). : |
81-8054 | warning | ClinicalDocument.component.structuredBody.component:component11.section | If the surgical procedure section is present there SHALL be text indicating the procedure performed (CONF:81-8054). : |
81-8056 | warning | ClinicalDocument.component.structuredBody.component:component16.section | If the Surgical Drains section is present, there SHALL be a statement providing details of the drains placed or SHALL explicitly state there were no drains placed (CONF:81-8056). : |