Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 United States of America flag

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 (HL7® FHIR® 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: Encounter Activity

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity Version: 4.0.0-ballot
Draft as of 2024-11-21 Computable Name: EncounterActivity
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01

This clinical statement describes an interaction between a patient and clinician. Interactions may include in-person encounters, telephone conversations, and email exchanges.

Usage:

Formal Views of Template Content

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

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C 1..1 Encounter XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs
... @moodCode 1..1 cs Fixed Value: EVN
... code C 1..1 CD 𝗨𝗦𝗖𝗗𝗜: Type
Binding: Encounter Type . (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1 ED SHOULD reference the portion of narrative corresponding to this code
..... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1 IVL_TS 𝗨𝗦𝗖𝗗𝗜: Time
... sdtcDischargeDispositionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
𝗨𝗦𝗖𝗗𝗜: Disposition
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: USEncounterDischargeDisposition (preferred)
... performer 0..* Performer2
.... assignedEntity 1..1 AssignedEntity
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... Slices for participant 0..* Participant2 Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..* Participant2 𝗨𝗦𝗖𝗗𝗜: Location
..... @typeCode 1..1 cs Fixed Value: LOC
..... participantRole 1..1 ServiceDeliveryLocation Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: RSON
..... observation 1..1 Indication Base for all types and resources
.... entryRelationship:diagnosis 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Diagnosis
..... act 1..1 EncounterDiagnosis Base for all types and resources
.... entryRelationship:observation 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Interpreter Needed Observation
..... observation 1..1 InterpreterNeededObservation Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Encounter.codepreferredEncounterType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.23
Encounter.sdtcDischargeDispositionCodepreferredUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066

Constraints

IdGradePath(s)DetailsRequirements
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C 1..1 Encounter XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: ENC
... @moodCode 1..1 cs Binding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... code C 1..1 CD 𝗨𝗦𝗖𝗗𝗜: Type
Binding: Encounter Type . (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1 ED SHOULD reference the portion of narrative corresponding to this code
..... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1 IVL_TS 𝗨𝗦𝗖𝗗𝗜: Time
... sdtcDischargeDispositionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
𝗨𝗦𝗖𝗗𝗜: Disposition
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: USEncounterDischargeDisposition (preferred)
... performer 0..* Performer2
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... Slices for participant 0..* Participant2 Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..* Participant2 𝗨𝗦𝗖𝗗𝗜: Location
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: LOC
..... participantRole C 1..1 ServiceDeliveryLocation Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
should-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
.... entryRelationship:diagnosis 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Diagnosis
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:observation 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Interpreter Needed Observation
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... observation C 1..1 InterpreterNeededObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.classCoderequiredFixed Value: ENC
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
Encounter.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.codepreferredEncounterType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.23
Encounter.sdtcDischargeDispositionCodepreferredUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
Encounter.participant:location.typeCoderequiredFixed Value: LOC
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:observation.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
indication-valueerrorEncounter.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.act, Encounter.entryRelationship:observation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C 1..1 Encounter XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:encounter-activity 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: ENC
... @moodCode 1..1 cs Binding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... id 1..* II 𝗨𝗦𝗖𝗗𝗜: Identifier
... code C 1..1 CD 𝗨𝗦𝗖𝗗𝗜: Type
Binding: Encounter Type . (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 0..1 cs
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED SHOULD reference the portion of narrative corresponding to this code
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
..... @integrityCheck 0..1 bin
..... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
..... @language 0..1 cs
..... @mediaType 0..1 cs Binding: MediaType (example)
..... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
..... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
..... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... thumbnail 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
.... @integrityCheck 0..1 bin
.... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1 cs
.... @mediaType 0..1 cs Binding: MediaType (example)
.... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
.... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 1..1 IVL_TS 𝗨𝗦𝗖𝗗𝗜: Time
... sdtcDischargeDispositionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
𝗨𝗦𝗖𝗗𝗜: Disposition
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: USEncounterDischargeDisposition (preferred)
... priorityCode 0..1 CE Binding: ActPriority (example)
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... sdtcFunctionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
.... time 0..1 IVL_TS
.... modeCode 0..1 CE
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
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
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... author 0..* Author
... informant 0..* Informant
... Slices for participant 0..* Participant2 Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..* Participant2 𝗨𝗦𝗖𝗗𝗜: Location
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: LOC
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... sdtcFunctionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1 IVL_TS
..... awarenessCode 0..1 CE
..... participantRole C 1..1 ServiceDeliveryLocation Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
should-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..* EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:diagnosis 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Diagnosis
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:observation 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Interpreter Needed Observation
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 InterpreterNeededObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.templateId:encounter-activity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.classCoderequiredFixed Value: ENC
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
Encounter.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.codepreferredEncounterType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.23
Encounter.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.code.originalText.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.code.originalText.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Encounter.code.originalText.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Encounter.code.originalText.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Encounter.code.originalText.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Encounter.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Encounter.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Encounter.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Encounter.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Encounter.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.sdtcDischargeDispositionCodepreferredUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
Encounter.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Encounter.performer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.typeCoderequiredFixed Value: PRF
http://terminology.hl7.org/ValueSet/v3-ParticipationPhysicalPerformer
Encounter.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
Encounter.participant:location.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.participant:location.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.participant:location.typeCoderequiredFixed Value: LOC
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
Encounter.participant:location.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
Encounter.entryRelationship:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:indication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:diagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:diagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:observation.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
indication-valueerrorEncounter.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.act, Encounter.entryRelationship:observation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Encounter

Summary

Mandatory: 7 elements(3 nested mandatory elements)
Fixed: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Encounter.templateId
  • The element 2 is sliced based on the values of Encounter.participant
  • The element 2 is sliced based on the values of Encounter.entryRelationship

Differential View

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C 1..1 Encounter XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs
... @moodCode 1..1 cs Fixed Value: EVN
... code C 1..1 CD 𝗨𝗦𝗖𝗗𝗜: Type
Binding: Encounter Type . (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1 ED SHOULD reference the portion of narrative corresponding to this code
..... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1 IVL_TS 𝗨𝗦𝗖𝗗𝗜: Time
... sdtcDischargeDispositionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
𝗨𝗦𝗖𝗗𝗜: Disposition
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: USEncounterDischargeDisposition (preferred)
... performer 0..* Performer2
.... assignedEntity 1..1 AssignedEntity
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... Slices for participant 0..* Participant2 Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..* Participant2 𝗨𝗦𝗖𝗗𝗜: Location
..... @typeCode 1..1 cs Fixed Value: LOC
..... participantRole 1..1 ServiceDeliveryLocation Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: RSON
..... observation 1..1 Indication Base for all types and resources
.... entryRelationship:diagnosis 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Diagnosis
..... act 1..1 EncounterDiagnosis Base for all types and resources
.... entryRelationship:observation 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Interpreter Needed Observation
..... observation 1..1 InterpreterNeededObservation Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Encounter.codepreferredEncounterType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.23
Encounter.sdtcDischargeDispositionCodepreferredUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066

Constraints

IdGradePath(s)DetailsRequirements
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C 1..1 Encounter XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: ENC
... @moodCode 1..1 cs Binding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... code C 1..1 CD 𝗨𝗦𝗖𝗗𝗜: Type
Binding: Encounter Type . (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1 ED SHOULD reference the portion of narrative corresponding to this code
..... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1 IVL_TS 𝗨𝗦𝗖𝗗𝗜: Time
... sdtcDischargeDispositionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
𝗨𝗦𝗖𝗗𝗜: Disposition
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: USEncounterDischargeDisposition (preferred)
... performer 0..* Performer2
.... assignedEntity 1..1 AssignedEntity
..... id 1..* II
..... code 0..1 CE Binding: Healthcare Provider Taxonomy . (preferred)
... Slices for participant 0..* Participant2 Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..* Participant2 𝗨𝗦𝗖𝗗𝗜: Location
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: LOC
..... participantRole C 1..1 ServiceDeliveryLocation Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
should-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
.... entryRelationship:diagnosis 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Diagnosis
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:observation 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Interpreter Needed Observation
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... observation C 1..1 InterpreterNeededObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.classCoderequiredFixed Value: ENC
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
Encounter.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.codepreferredEncounterType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.23
Encounter.sdtcDischargeDispositionCodepreferredUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
Encounter.participant:location.typeCoderequiredFixed Value: LOC
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:observation.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
indication-valueerrorEncounter.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.act, Encounter.entryRelationship:observation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C 1..1 Encounter XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
.... templateId:encounter-activity 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: ENC
... @moodCode 1..1 cs Binding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... id 1..* II 𝗨𝗦𝗖𝗗𝗜: Identifier
... code C 1..1 CD 𝗨𝗦𝗖𝗗𝗜: Type
Binding: Encounter Type . (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 0..1 cs
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED SHOULD reference the portion of narrative corresponding to this code
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
..... @integrityCheck 0..1 bin
..... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
..... @language 0..1 cs
..... @mediaType 0..1 cs Binding: MediaType (example)
..... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
..... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
..... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... thumbnail 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
.... @integrityCheck 0..1 bin
.... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1 cs
.... @mediaType 0..1 cs Binding: MediaType (example)
.... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
.... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 1..1 IVL_TS 𝗨𝗦𝗖𝗗𝗜: Time
... sdtcDischargeDispositionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
𝗨𝗦𝗖𝗗𝗜: Disposition
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: USEncounterDischargeDisposition (preferred)
... priorityCode 0..1 CE Binding: ActPriority (example)
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... sdtcFunctionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
.... time 0..1 IVL_TS
.... modeCode 0..1 CE
.... assignedEntity 1..1 AssignedEntity
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
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
..... sdtcPatient 0..1 Base XML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1 II XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... author 0..* Author
... informant 0..* Informant
... Slices for participant 0..* Participant2 Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..* Participant2 𝗨𝗦𝗖𝗗𝗜: Location
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: LOC
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... sdtcFunctionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1 IVL_TS
..... awarenessCode 0..1 CE
..... participantRole C 1..1 ServiceDeliveryLocation Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
should-addr: SHOULD contain addr
should-telecom: SHOULD contain telecom
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..* EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:diagnosis 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Diagnosis
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:observation 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Interpreter Needed Observation
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 InterpreterNeededObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.templateId:encounter-activity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.classCoderequiredFixed Value: ENC
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
Encounter.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.codepreferredEncounterType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.23
Encounter.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.code.originalText.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.code.originalText.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Encounter.code.originalText.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Encounter.code.originalText.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Encounter.code.originalText.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Encounter.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Encounter.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Encounter.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Encounter.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Encounter.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.sdtcDischargeDispositionCodepreferredUSEncounterDischargeDisposition
http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
Encounter.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Encounter.performer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.typeCoderequiredFixed Value: PRF
http://terminology.hl7.org/ValueSet/v3-ParticipationPhysicalPerformer
Encounter.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
http://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
Encounter.participant:location.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.participant:location.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.participant:location.typeCoderequiredFixed Value: LOC
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
Encounter.participant:location.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
Encounter.entryRelationship:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:indication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:diagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:diagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Encounter.entryRelationship:observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Encounter.entryRelationship:observation.typeCoderequiredXActRelationshipEntryRelationship
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
indication-valueerrorEncounter.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.act, Encounter.entryRelationship:observation.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Encounter

Summary

Mandatory: 7 elements(3 nested mandatory elements)
Fixed: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Encounter.templateId
  • The element 2 is sliced based on the values of Encounter.participant
  • The element 2 is sliced based on the values of Encounter.entryRelationship

 

Other representations of profile: CSV, Excel