Consolidated CDA (C-CDA)
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Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7ยฎ FHIRยฎ Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: EncounterActivity - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the EncounterActivity logical model.

Guidance on how to interpret the contents of this table can be found here

0. Encounter
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
2. Encounter.templateId
Control1..?
SlicingThis element introduces a set of slices on Encounter.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Encounter.templateId:encounter-activity
    Slice Nameencounter-activity
    Control1..1
    6. Encounter.templateId:encounter-activity.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.49
    8. Encounter.templateId:encounter-activity.extension
    Control1..?
    Pattern Value2015-08-01
    10. Encounter.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-8710).

    12. Encounter.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-8711).

    Fixed ValueEVN
    14. Encounter.id
    Short๐—จ๐—ฆ๐—–๐——๐—œ: Identifier
    Comments

    SHALL contain at least one [1..*] id (CONF:1198-8713).

    Control1..?
    16. Encounter.code
    Short๐—จ๐—ฆ๐—–๐——๐—œ: Type
    Comments

    In Encounter Summaries the Encounter Type will also be present in the document header at componentOf/encompassingEncounter/code, but for Patient Summaries, componentOf/encompassingEncounter SHALL NOT be present. Implementers should note that only conveying Encounter Type in the document header at componentOf/encompassingEncounter/code is insufficient.

    Control1..?
    BindingThe codes SHOULD be taken from Encounter Type .
    (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.23)
    Invariantsshould-otext-ref-value: SHOULD contain originalText/reference/@value (originalText.reference.value.exists())
    18. Encounter.code.originalText
    ShortSHOULD reference the portion of narrative corresponding to this code
    20. Encounter.code.originalText.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    22. Encounter.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    24. Encounter.text.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    26. Encounter.effectiveTime
    Short๐—จ๐—ฆ๐—–๐——๐—œ: Time
    Comments

    In Encounter Summaries the Encounter Time will also be present in the document header at componentOf/encompassingEncounter/effectiveTime, but for Patient Summaries, componentOf/encompassingEncounter SHALL NOT be present.

    Control1..?
    28. Encounter.sdtcDischargeDispositionCode
    Short๐—จ๐—ฆ๐—–๐——๐—œ: Disposition
    Comments

    Implementers should note that a Discharge Disposition is not appropriate for all document types. Hospital Discharge Summary documents SHOULD have a discharge disposition. Progress Notes, or H&P, typically wonโ€™t have a discharge disposition. In Encounter Summaries, the Encounter Disposition will also be present in the document header at componentOf/encompassingEncounter/dischargeDispositionCode, but in Patient Summaries, componentOf/encompassingEncounter SHALL NOT be present. While an Encounter Summary provides a snapshot of the patientโ€™s condition at the time of the encounter as authored by the clinician, a Patient summary provides the most current information available from the sending system across multiple encounters. CodeSystem-AHANUBCPatientDischargeStatus

    BindingThe codes SHOULD be taken from USEncounterDischargeDisposition
    (preferred to http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition)
    XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namedischargeDispositionCode.
    30. Encounter.performer
    Comments

    MAY contain zero or more [0..*] performer (CONF:1198-8725).

    32. Encounter.performer.assignedEntity
    Comments

    The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-8726).

    34. Encounter.performer.assignedEntity.code
    Comments

    This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-8727).

    BindingThe codes SHOULD be taken from Healthcare Provider Taxonomy .
    (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066)
    36. Encounter.participant
    SlicingThis element introduces a set of slices on Encounter.participant. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ participantRole
    • value @ typeCode
    • 38. Encounter.participant:location
      Slice Namelocation
      Short๐—จ๐—ฆ๐—–๐——๐—œ: Location
      Comments

      In Encounter Summaries the Encounter Location will also be present in the document header at componentOf/encompassingEncounter/location, but in Patient Summaries, componentOf/encompassingEncounter SHALL NOT be present.

      Control0..*
      40. Encounter.participant:location.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8740).

      Fixed ValueLOC
      42. Encounter.participant:location.participantRole
      Comments

      SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1198-14903).

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/ParticipantRole(Service Delivery Location)
      44. Encounter.entryRelationship
      SlicingThis element introduces a set of slices on Encounter.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ act
      • profile @ observation
      • 46. Encounter.entryRelationship:indication
        Slice Nameindication
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:1198-8722) such that it

        Control0..*
        48. Encounter.entryRelationship:indication.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8723).

        Fixed ValueRSON
        50. Encounter.entryRelationship:indication.observation
        Comments

        SHALL contain exactly one [1..1] Indication (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:1198-14899).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Indication)
        52. Encounter.entryRelationship:diagnosis
        Slice Namediagnosis
        Short๐—จ๐—ฆ๐—–๐——๐—œ: Diagnosis
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:1198-15492) such that it

        Control0..*
        54. Encounter.entryRelationship:diagnosis.act
        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act(Encounter Diagnosis)
        56. Encounter.entryRelationship:observation
        Slice Nameobservation
        Short๐—จ๐—ฆ๐—–๐——๐—œ: Interpreter Needed Observation
        Comments

        SHALL contain exactly one [1..1] Interpreter Needed Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.515:2025-05-01).

        Control0..*
        58. Encounter.entryRelationship:observation.observation
        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Interpreter Needed Observation)