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: Unstructured Document

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.10 | Version: 2.2
Active as of 2022-05-13 | Computable Name: UnstructuredDocument
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.1.10:2015-08-01

An Unstructured Document (UD) document type can (1) include unstructured content, such as a graphic, directly in a text element with a mediaType attribute, or (2) reference a single document file, such as a word-processing document using a text/reference element. For guidance on how to handle multiple files, on the selection of media types for this IG, and on the identification of external files, see the examples that follow the constraints below. IHEs XDS-SD (Cross-Transaction Specifications and Content Specifications, Scanned Documents Module) profile addresses a similar, more restricted use case, specifically for scanned documents or documents electronically created from existing text sources, and limits content to PDF-A or text. This Unstructured Documents template is applicable not only for scanned documents in non-PDF formats, but also for clinical documents produced through word processing applications, etc. For conformance with both specifications, implementers need to ensure that their documents at a minimum conform with the SHALL constraints from either specification.

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: 12 elements

Slices

This structure defines the following Slices:

- The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension

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:primary | I | 1..1 | II | 1198-32944: 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:1198-32944).
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.10
extension |  | 1..1 | string | Required Pattern: 2015-08-01
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
patientRole |  | 1..1 | PatientRole |
id |  | 1..* | II |
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.
assignedCustodian |  | 1..1 | AssignedCustodian |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
component |  | 1..1 | Component2 |
nonXMLBody |  | 1..1 | NonXMLBody | An Unstructured Document must include a nonXMLBody component with a single text element. The text element can reference an external file using a reference element, or include unstructured content directly with a mediaType attribute. The nonXMLBody/text element also has a "compression" attribute that can be used to indicate that the unstructured content was compressed before being Base64Encoded. At a minimum, a compression value of "DF" for the deflate compression algorithm (RFC 1951 [URL:http://www.ietf.org/rfc/rfc1951.txt]) must be supported although it is not required that content be compressed.
text | I | 1..1 | ED | 1198-7624: If the text element does not contain a reference element with a value attribute, then it **SHALL** contain exactly one [1..1] @representation="B64" and exactly one [1..1] @mediaType (CONF:1198-7624). 1198-7623: The value of @mediaType, if present, **SHALL** be drawn from the value set 2.16.840.1.113883.11.20.7.1 SupportedFileFormats STATIC 2010-05-12 (CONF:1198-7623).
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 | I | 1..1 | II | 1198-32944: 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:1198-32944).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.10
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id | I | 1..1 | II |
code | I | 1..1 | CE | ​Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
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 |  | 0..* | DocumentationOf |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | dateTime |
inclusive |  | 0..1 | boolean |
operator |  | 0..1 | code |
low |  | 1..1 | TS |
high |  | 0..1 | TS |
width |  | 0..1 | PQ |
center |  | 0..1 | TS |
performer |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
Slices for authorization |  | 0..* | Authorization | The authorization element represents information about the patient?s consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent
authorization:authorization1 |  | 0..* | Authorization |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
componentOf |  | 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 |  | 1..1 | NonXMLBody | An Unstructured Document must include a nonXMLBody component with a single text element. The text element can reference an external file using a reference element, or include unstructured content directly with a mediaType attribute. The nonXMLBody/text element also has a "compression" attribute that can be used to indicate that the unstructured content was compressed before being Base64Encoded. At a minimum, a compression value of "DF" for the deflate compression algorithm (RFC 1951 [URL:http://www.ietf.org/rfc/rfc1951.txt]) must be supported although it is not required that content be compressed.
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
text | I | 1..1 | ED | 1198-7624: If the text element does not contain a reference element with a value attribute, then it **SHALL** contain exactly one [1..1] @representation="B64" and exactly one [1..1] @mediaType (CONF:1198-7624). 1198-7623: The value of @mediaType, if present, **SHALL** be drawn from the value set 2.16.840.1.113883.11.20.7.1 SupportedFileFormats STATIC 2010-05-12 (CONF:1198-7623).
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
structuredBody |  | 0..1 | StructuredBody |
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: 12 elements

Slices

This structure defines the following Slices:

- The element ClinicalDocument.templateId is sliced based on the values of value:root, value:extension

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:primary | I | 1..1 | II | 1198-32944: 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:1198-32944).
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.10
extension |  | 1..1 | string | Required Pattern: 2015-08-01
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
patientRole |  | 1..1 | PatientRole |
id |  | 1..* | II |
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.
assignedCustodian |  | 1..1 | AssignedCustodian |
representedCustodianOrganization |  | 1..1 | CustodianOrganization |
component |  | 1..1 | Component2 |
nonXMLBody |  | 1..1 | NonXMLBody | An Unstructured Document must include a nonXMLBody component with a single text element. The text element can reference an external file using a reference element, or include unstructured content directly with a mediaType attribute. The nonXMLBody/text element also has a "compression" attribute that can be used to indicate that the unstructured content was compressed before being Base64Encoded. At a minimum, a compression value of "DF" for the deflate compression algorithm (RFC 1951 [URL:http://www.ietf.org/rfc/rfc1951.txt]) must be supported although it is not required that content be compressed.
text | I | 1..1 | ED | 1198-7624: If the text element does not contain a reference element with a value attribute, then it **SHALL** contain exactly one [1..1] @representation="B64" and exactly one [1..1] @mediaType (CONF:1198-7624). 1198-7623: The value of @mediaType, if present, **SHALL** be drawn from the value set 2.16.840.1.113883.11.20.7.1 SupportedFileFormats STATIC 2010-05-12 (CONF:1198-7623).
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 | I | 1..1 | II | 1198-32944: 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:1198-32944).
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.1.10
extension |  | 1..1 | string | Required Pattern: 2015-08-01
id | I | 1..1 | II |
code | I | 1..1 | CE | ​Binding: http://terminology.hl7.org/ValueSet/v3-DocumentType (extensible)
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 |  | 0..* | DocumentationOf |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
serviceEvent |  | 1..1 | ServiceEvent | A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
classCode |  | 1..1 | code | Binding: ActClass (required)
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE |
effectiveTime |  | 1..1 | IVL_TS |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value |  | 0..1 | dateTime |
inclusive |  | 0..1 | boolean |
operator |  | 0..1 | code |
low |  | 1..1 | TS |
high |  | 0..1 | TS |
width |  | 0..1 | PQ |
center |  | 0..1 | TS |
performer |  | 0..* | Performer1 | The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient?s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 1..1 | code | Binding: x_ServiceEventPerformer (required) Fixed Value: DOC
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
functionCode |  | 0..1 | CE |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 0..1 | string | Binding: Care Team Member Function (preferred)
codeSystem |  | 0..1 | string |
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
time |  | 0..1 | IVL_TS |
assignedEntity |  | 1..1 | AssignedEntity |
classCode |  | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 0..1 | string | Required Pattern: 2.16.840.1.113883.4.6
extension |  | 0..1 | string |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
relatedDocument |  | 0..* | RelatedDocument |
Slices for authorization |  | 0..* | Authorization | The authorization element represents information about the patient?s consent. The type of consent is conveyed in consent/code. Consents in the header have been finalized (consent/statusCode must equal Completed) and should be on file. This specification does not address how 'Privacy Consent' is represented, but does not preclude the inclusion of ?Privacy Consent?. The authorization consent is used for referring to consents that are documented elsewhere in the EHR or medical record for a health condition and/or treatment that is described in the CDA document. Slice: Unordered, Open by value:consent
authorization:authorization1 |  | 0..* | Authorization |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
typeCode |  | 0..1 | code | Binding: ParticipationType (required) Fixed Value: AUT
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
consent |  | 1..1 | Consent |
classCode |  | 1..1 | code | Binding: ActClass (required) Fixed Value: CONS
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
templateId |  | 0..* | II |
id |  | 0..* | II |
code |  | 0..1 | CE | The type of consent (e.g., a consent to perform the related serviceEvent) is conveyed in consent/code. Binding: v3 Code System ActCode (extensible)
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
code |  | 1..1 |  | Fixed Value: completed
componentOf |  | 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 |  | 1..1 | NonXMLBody | An Unstructured Document must include a nonXMLBody component with a single text element. The text element can reference an external file using a reference element, or include unstructured content directly with a mediaType attribute. The nonXMLBody/text element also has a "compression" attribute that can be used to indicate that the unstructured content was compressed before being Base64Encoded. At a minimum, a compression value of "DF" for the deflate compression algorithm (RFC 1951 [URL:http://www.ietf.org/rfc/rfc1951.txt]) must be supported although it is not required that content be compressed.
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
text | I | 1..1 | ED | 1198-7624: If the text element does not contain a reference element with a value attribute, then it **SHALL** contain exactly one [1..1] @representation="B64" and exactly one [1..1] @mediaType (CONF:1198-7624). 1198-7623: The value of @mediaType, if present, **SHALL** be drawn from the value set 2.16.840.1.113883.11.20.7.1 SupportedFileFormats STATIC 2010-05-12 (CONF:1198-7623).
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
structuredBody |  | 0..1 | StructuredBody |
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.code | extensible | ​http://terminology.hl7.org/ValueSet/v3-DocumentType
ClinicalDocument.confidentialityCode | preferred | HL7 BasicConfidentialityKind
ClinicalDocument.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.typeCode | required | Fixed Value: RCT
ClinicalDocument.recordTarget.contextControlCode | required | Fixed Value: OP
ClinicalDocument.recordTarget.patientRole.classCode | required | Fixed Value: PAT
ClinicalDocument.recordTarget.patientRole.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode | required | Administrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.maritalStatusCode | required | MaritalStatus
ClinicalDocument.recordTarget.patientRole.patient.religiousAffiliationCode | required | Religious Affiliation
ClinicalDocument.recordTarget.patientRole.patient.raceCode | required | Race Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.sdtcRaceCode | extensible | RaceValueSet
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCode | required | Ethnicity
ClinicalDocument.recordTarget.patientRole.patient.sdtcEthnicGroupCode | extensible | DetailedEthnicity
ClinicalDocument.recordTarget.patientRole.patient.guardian.classCode | required | Fixed Value: GUARD
ClinicalDocument.recordTarget.patientRole.patient.guardian.code | required | Personal And Legal Relationship Role Type
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.guardian.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.recordTarget.patientRole.patient.guardian.guardianPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.classCode | required | Fixed Value: BIRTHPL
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.classCode | required | Fixed Value: PLC
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.patient.birthplace.place.addr.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.languageCode | required | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.modeCode | required | LanguageAbilityMode
ClinicalDocument.recordTarget.patientRole.patient.languageCommunication.proficiencyLevelCode | required | LanguageAbilityProficiency
ClinicalDocument.recordTarget.patientRole.providerOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.recordTarget.patientRole.providerOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.recordTarget.patientRole.providerOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.recordTarget.patientRole.providerOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.providerOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.author.nullFlavor | required | NullFlavor
ClinicalDocument.author.typeCode | required | Fixed Value: AUT
ClinicalDocument.author.contextControlCode | required | Fixed Value: OP
ClinicalDocument.author.assignedAuthor.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.author.assignedAuthor.id:id1.nullFlavor | required | Pattern: UNK
ClinicalDocument.author.assignedAuthor.code | extensible | RoleCode
ClinicalDocument.author.assignedAuthor.code.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.code.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.author.assignedAuthor.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.author.assignedAuthor.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.author.assignedAuthor.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.author.assignedAuthor.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.classCode | required | Fixed Value: DEV
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.author.assignedAuthor.assignedAuthoringDevice.code | extensible | EntityCode
ClinicalDocument.dataEnterer.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.typeCode | required | Fixed Value: ENT
ClinicalDocument.dataEnterer.contextControlCode | required | Fixed Value: OP
ClinicalDocument.dataEnterer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.dataEnterer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.dataEnterer.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.dataEnterer.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.dataEnterer.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant1.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant1.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.informant:informant1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.informant:informant1.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informant:informant2.nullFlavor | required | NullFlavor
ClinicalDocument.informant:informant2.typeCode | required | Fixed Value: INF
ClinicalDocument.informant:informant2.contextControlCode | required | Fixed Value: OP
ClinicalDocument.custodian.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.typeCode | required | Fixed Value: ENT
ClinicalDocument.custodian.assignedCustodian.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.id.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.informationRecipient.nullFlavor | required | NullFlavor
ClinicalDocument.informationRecipient.typeCode | required | ParticipationType
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.classCode | required | Fixed Value: PSN
ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.classCode | required | Fixed Value: ORG
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.informationRecipient.intendedRecipient.receivedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS
ClinicalDocument.legalAuthenticator.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.typeCode | required | Fixed Value: LA
ClinicalDocument.legalAuthenticator.contextControlCode | required | Fixed Value: OP
ClinicalDocument.legalAuthenticator.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.legalAuthenticator.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.legalAuthenticator.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.legalAuthenticator.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.authenticator:authenticator1.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.typeCode | required | Fixed Value: AUTHEN
ClinicalDocument.authenticator:authenticator1.signatureCode.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.authenticator:authenticator1.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code | extensible | RoleCode
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.code.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.nullFlavor | required | NullFlavor
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.use | required | Telecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.classCode | required | Fixed Value: PSN
ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.determinerCode | required | Fixed Value: INSTANCE
ClinicalDocument.participant:participant1.nullFlavor | required | NullFlavor
ClinicalDocument.participant:participant1.typeCode | required | ParticipationType
ClinicalDocument.participant:participant1.contextControlCode | required | Fixed Value: OP
ClinicalDocument.inFulfillmentOf.nullFlavor | required | NullFlavor
ClinicalDocument.inFulfillmentOf.typeCode | required | Fixed Value: FLFS
ClinicalDocument.inFulfillmentOf.order.classCode | required | ActClass
ClinicalDocument.inFulfillmentOf.order.moodCode | required | Fixed Value: RQO
ClinicalDocument.inFulfillmentOf.order.code | extensible | ActCode
ClinicalDocument.inFulfillmentOf.order.priorityCode | extensible | ActPriority
ClinicalDocument.documentationOf.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.classCode | required | ActClass
ClinicalDocument.documentationOf.serviceEvent.moodCode | required | Fixed Value: EVN
ClinicalDocument.documentationOf.serviceEvent.effectiveTime.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.typeCode | required | Fixed Value: DOC
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.functionCode.code | preferred | Care Team Member Function
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.id.nullFlavor | required | NullFlavor
ClinicalDocument.documentationOf.serviceEvent.performer.assignedEntity.code | preferred | HealthcareProviderTaxonomy
ClinicalDocument.authorization:authorization1.nullFlavor | required | NullFlavor
ClinicalDocument.authorization:authorization1.typeCode | required | Fixed Value: AUT
ClinicalDocument.authorization:authorization1.consent.classCode | required | Fixed Value: CONS
ClinicalDocument.authorization:authorization1.consent.moodCode | required | Fixed Value: EVN
ClinicalDocument.authorization:authorization1.consent.code | extensible | ActCode
ClinicalDocument.authorization:authorization1.consent.statusCode | required | ActStatus
ClinicalDocument.componentOf.nullFlavor | required | NullFlavor
ClinicalDocument.componentOf.typeCode | required | Fixed Value: AUT
ClinicalDocument.componentOf.encompassingEncounter.classCode | required | Fixed Value: ENC
ClinicalDocument.componentOf.encompassingEncounter.moodCode | required | Fixed Value: EVN
ClinicalDocument.componentOf.encompassingEncounter.code | extensible | ActEncounterCode
ClinicalDocument.componentOf.encompassingEncounter.dischargeDispositionCode | extensible | ​http://terminology.hl7.org/ValueSet/v3-EncounterDischargeDisposition
ClinicalDocument.componentOf.encompassingEncounter.responsibleParty.typeCode | required | Fixed Value: RESP
ClinicalDocument.componentOf.encompassingEncounter.location.typeCode | required | Fixed Value: LOC
ClinicalDocument.component.nullFlavor | required | NullFlavor
ClinicalDocument.component.typeCode | required | Fixed Value: AUT
ClinicalDocument.component.nonXMLBody.classCode | required | Fixed Value: DOCBODY
ClinicalDocument.component.nonXMLBody.moodCode | required | Fixed Value: EVN
ClinicalDocument.component.nonXMLBody.languageCode | required | HumanLanguage

#### Constraints

Id | Grade | Path | Details | Requirements
1198-32944 | error | ClinicalDocument.templateId:primary | 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:1198-32944). : |
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). : |
1198-7624 | error | ClinicalDocument.component.nonXMLBody.text | If the text element does not contain a reference element with a value attribute, then it **SHALL** contain exactly one [1..1] @representation="B64" and exactly one [1..1] @mediaType (CONF:1198-7624). : |
1198-7623 | error | ClinicalDocument.component.nonXMLBody.text | The value of @mediaType, if present, **SHALL** be drawn from the value set 2.16.840.1.113883.11.20.7.1 SupportedFileFormats STATIC 2010-05-12 (CONF:1198-7623). : |