Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/HealthConcernAct | Version: 4.0.0-ballot | |||
| Draft as of 2024-12-19 | Computable Name: HealthConcernAct | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.132:2022-06-01 | ||||
This template represents a health concern.
It is a wrapper for a single health concern which may be derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.).
A Health Concern Act is used to track non-optimal physical or psychological situations drawing the patient to the healthcare system. These may be from the perspective of the care team or from the perspective of the patient. When the underlying condition is of concern (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest), the statusCode is active. Only when the underlying condition is no longer of concern is the statusCode set to completed. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, a prior heart attack may remain a concern). Health concerns require intervention(s) to increase the likelihood of achieving the goals of care for the patient and they specify the condition oriented reasons for creating the plan.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, 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 should-author: SHOULD contain author |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:health-concern-act |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.132 | |
  @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
 @classCode |
1..1 | cs | Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Functional status assessment note | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
 @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 |
| statusCode |
1..1 | CS | ||
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: ProblemAct statusCode  (required) | |
| effectiveTime |
0..1 | IVL_TS | ||
 author |
0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| Slices for entryRelationship |
0..* | EntryRelationship | When this Health Concern Act is a Social Determinant of Health Health Concern it **SHOULD** contain zero or more [0..*] entryRelationship subentries such that it contains an observation with an observation/value selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32962). Slice: Unordered, Open by profile:act, profile:observation, profile:organizer, value:typeCode | |
 entryRelationship:observations |
0..* | EntryRelationship | ||
 @typeCode |
1..1 | cs | Fixed Value: REFR | |
| observation |
1..1 | ProblemObservation, AllergyIntoleranceObservation, AssessmentScaleObservation, SelfCareActivitiesADLandIADL, MentalStatusObservation, SmokingStatusMeaningfulUse, FunctionalStatusObservation, NutritionAssessment, PregnancyStatusObservation, ReactionObservation, ResultObservation, SensoryStatus, SocialHistoryObservation, SubstanceOrDeviceAllergyIntoleranceObservation, TobaccoUse, VitalSignObservation, LongitudinalCareWoundObservation, ProblemObservation, CaregiverCharacteristics, CulturalandReligiousObservation, CharacteristicsofHomeEnvironment, NutritionalStatusObservation, PriorityPreference | Base for all types and resources | |
| entryRelationship:acts |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| act |
1..1 | EncounterDiagnosis, HospitalAdmissionDiagnosis, PostprocedureDiagnosis, PreoperativeDiagnosis, EntryReference | Base for all types and resources | |
| entryRelationship:organizers |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| organizer |
1..1 | FamilyHistoryOrganizer, ResultOrganizer | Base for all types and resources | |
| entryRelationship:related-entries |
0..* | EntryRelationship | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. This may also be used to refer to other Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding; while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| act |
1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:component-health-concern-acts |
C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair","Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. 4515-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| act |
1..1 | EntryReference | Base for all types and resources | |
 reference |
0..* | Reference | Where it is necessary to reference an external clinical document such as a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| externalDocument |
1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Act.statusCode.code | required | ProblemActStatusCode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19 |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-32745 | error | Act.entryRelationship:component-health-concern-acts | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). : %resource.descendants().ofType(CDA.Act).where(templateId.exists($this.root = '2.16.840.1.113883.10.20.22.4.132' and $this.extension = '2022-06-01') and id.exists($this.root = %context.act.id.first().root and $this.extension ~ %context.act.id.first().extension)) | |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, 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 should-author: SHOULD contain author |
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:health-concern-act |
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: 2.16.840.1.113883.10.20.22.4.132 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| code |
1..1 | CD | Functional status assessment note Binding: v3 Code System ActCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| 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 |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: ProblemAct statusCode (required) | |
| @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) | |
| effectiveTime |
0..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | When this Health Concern Act is a Social Determinant of Health Health Concern it **SHOULD** contain zero or more [0..*] entryRelationship subentries such that it contains an observation with an observation/value selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32962). Slice: Unordered, Open by profile:act, profile:observation, profile:organizer, value:typeCode | |
| entryRelationship:observations |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
 @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: REFR | |
| @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 | ProblemObservation, AllergyIntoleranceObservation, AssessmentScaleObservation, SelfCareActivitiesADLandIADL, MentalStatusObservation, SmokingStatusMeaningfulUse, FunctionalStatusObservation, NutritionAssessment, PregnancyStatusObservation, ReactionObservation, ResultObservation, SensoryStatus, SocialHistoryObservation, SubstanceOrDeviceAllergyIntoleranceObservation, TobaccoUse, VitalSignObservation, LongitudinalCareWoundObservation, ProblemObservation, CaregiverCharacteristics, CulturalandReligiousObservation, CharacteristicsofHomeEnvironment, NutritionalStatusObservation, PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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:acts |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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, HospitalAdmissionDiagnosis, PostprocedureDiagnosis, PreoperativeDiagnosis, EntryReference | 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:organizers |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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 |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
C | 1..1 | FamilyHistoryOrganizer, ResultOrganizer | Base for all types and resources should-sdtctext-ref-value: SHOULD contain text/reference/@value |
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:related-entries |
0..* | EntryRelationship | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. This may also be used to refer to other Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding; while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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:component-health-concern-acts |
C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair","Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. 4515-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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 | ||
| reference |
0..* | Reference | Where it is necessary to reference an external clinical document such as a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber |
| 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) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:health-concern-act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.statusCode.code | required | ProblemActStatusCode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19 | |
| Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:observations.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:organizers.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:related-entries.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:component-health-concern-acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-32745 | error | Act.entryRelationship:component-health-concern-acts | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). : %resource.descendants().ofType(CDA.Act).where(templateId.exists($this.root = '2.16.840.1.113883.10.20.22.4.132' and $this.extension = '2022-06-01') and id.exists($this.root = %context.act.id.first().root and $this.extension ~ %context.act.id.first().extension)) | |
| II-1 | error | Act.typeId, Act.entryRelationship:observations.typeId, Act.entryRelationship:acts.typeId, Act.entryRelationship:organizers.typeId, Act.entryRelationship:related-entries.typeId, Act.entryRelationship:component-health-concern-acts.typeId, Act.reference.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-author | warning | Act.entryRelationship:observations.observation | SHOULD contain author : author.exists() | |
| should-sdtctext-ref-value | warning | Act.entryRelationship:organizers.organizer | SHOULD contain text/reference/@value : sdtcText.reference.value.exists() | |
| should-setId | warning | Act.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:observations.observation, Act.entryRelationship:acts.act, Act.entryRelationship:related-entries.act, Act.entryRelationship:component-health-concern-acts.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Act.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, 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 should-author: SHOULD contain author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:health-concern-act |
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: 2.16.840.1.113883.10.20.22.4.132 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| code |
1..1 | CD | Functional status assessment note Binding: v3 Code System ActCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| 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 |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: ProblemAct statusCode (required) | |
| @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) | |
| effectiveTime |
0..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | When this Health Concern Act is a Social Determinant of Health Health Concern it **SHOULD** contain zero or more [0..*] entryRelationship subentries such that it contains an observation with an observation/value selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32962). Slice: Unordered, Open by profile:act, profile:observation, profile:organizer, value:typeCode | |
| entryRelationship:observations |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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 | ProblemObservation, AllergyIntoleranceObservation, AssessmentScaleObservation, SelfCareActivitiesADLandIADL, MentalStatusObservation, SmokingStatusMeaningfulUse, FunctionalStatusObservation, NutritionAssessment, PregnancyStatusObservation, ReactionObservation, ResultObservation, SensoryStatus, SocialHistoryObservation, SubstanceOrDeviceAllergyIntoleranceObservation, TobaccoUse, VitalSignObservation, LongitudinalCareWoundObservation, ProblemObservation, CaregiverCharacteristics, CulturalandReligiousObservation, CharacteristicsofHomeEnvironment, NutritionalStatusObservation, PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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:acts |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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, HospitalAdmissionDiagnosis, PostprocedureDiagnosis, PreoperativeDiagnosis, EntryReference | 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:organizers |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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 |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
C | 1..1 | FamilyHistoryOrganizer, ResultOrganizer | Base for all types and resources should-sdtctext-ref-value: SHOULD contain text/reference/@value |
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:related-entries |
0..* | EntryRelationship | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. This may also be used to refer to other Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding; while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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:component-health-concern-acts |
C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair","Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. 4515-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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 | ||
| reference |
0..* | Reference | Where it is necessary to reference an external clinical document such as a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber |
| 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) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:health-concern-act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.statusCode.code | required | ProblemActStatusCode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19 | |
| Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:observations.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:organizers.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:related-entries.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:component-health-concern-acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-32745 | error | Act.entryRelationship:component-health-concern-acts | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). : %resource.descendants().ofType(CDA.Act).where(templateId.exists($this.root = '2.16.840.1.113883.10.20.22.4.132' and $this.extension = '2022-06-01') and id.exists($this.root = %context.act.id.first().root and $this.extension ~ %context.act.id.first().extension)) | |
| II-1 | error | Act.typeId, Act.entryRelationship:observations.typeId, Act.entryRelationship:acts.typeId, Act.entryRelationship:organizers.typeId, Act.entryRelationship:related-entries.typeId, Act.entryRelationship:component-health-concern-acts.typeId, Act.reference.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-author | warning | Act.entryRelationship:observations.observation | SHOULD contain author : author.exists() | |
| should-sdtctext-ref-value | warning | Act.entryRelationship:organizers.organizer | SHOULD contain text/reference/@value : sdtcText.reference.value.exists() | |
| should-setId | warning | Act.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:observations.observation, Act.entryRelationship:acts.act, Act.entryRelationship:related-entries.act, Act.entryRelationship:component-health-concern-acts.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Act.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If 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 Act
Summary
Mandatory: 9 elements(6 nested mandatory elements)
Fixed: 8 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, 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 should-author: SHOULD contain author |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:health-concern-act |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.132 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @classCode |
1..1 | cs | Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Functional status assessment note | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 |
| statusCode |
1..1 | CS | ||
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: ProblemAct statusCode (required) | |
| effectiveTime |
0..1 | IVL_TS | ||
| author |
0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| Slices for entryRelationship |
0..* | EntryRelationship | When this Health Concern Act is a Social Determinant of Health Health Concern it **SHOULD** contain zero or more [0..*] entryRelationship subentries such that it contains an observation with an observation/value selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32962). Slice: Unordered, Open by profile:act, profile:observation, profile:organizer, value:typeCode | |
| entryRelationship:observations |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| observation |
1..1 | ProblemObservation, AllergyIntoleranceObservation, AssessmentScaleObservation, SelfCareActivitiesADLandIADL, MentalStatusObservation, SmokingStatusMeaningfulUse, FunctionalStatusObservation, NutritionAssessment, PregnancyStatusObservation, ReactionObservation, ResultObservation, SensoryStatus, SocialHistoryObservation, SubstanceOrDeviceAllergyIntoleranceObservation, TobaccoUse, VitalSignObservation, LongitudinalCareWoundObservation, ProblemObservation, CaregiverCharacteristics, CulturalandReligiousObservation, CharacteristicsofHomeEnvironment, NutritionalStatusObservation, PriorityPreference | Base for all types and resources | |
| entryRelationship:acts |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| act |
1..1 | EncounterDiagnosis, HospitalAdmissionDiagnosis, PostprocedureDiagnosis, PreoperativeDiagnosis, EntryReference | Base for all types and resources | |
| entryRelationship:organizers |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| organizer |
1..1 | FamilyHistoryOrganizer, ResultOrganizer | Base for all types and resources | |
| entryRelationship:related-entries |
0..* | EntryRelationship | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. This may also be used to refer to other Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding; while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| act |
1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:component-health-concern-acts |
C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair","Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. 4515-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| act |
1..1 | EntryReference | Base for all types and resources | |
| reference |
0..* | Reference | Where it is necessary to reference an external clinical document such as a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| externalDocument |
1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Act.statusCode.code | required | ProblemActStatusCode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19 |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-32745 | error | Act.entryRelationship:component-health-concern-acts | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). : %resource.descendants().ofType(CDA.Act).where(templateId.exists($this.root = '2.16.840.1.113883.10.20.22.4.132' and $this.extension = '2022-06-01') and id.exists($this.root = %context.act.id.first().root and $this.extension ~ %context.act.id.first().extension)) | |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, 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 should-author: SHOULD contain author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:health-concern-act |
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: 2.16.840.1.113883.10.20.22.4.132 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| code |
1..1 | CD | Functional status assessment note Binding: v3 Code System ActCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| 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 |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: ProblemAct statusCode (required) | |
| @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) | |
| effectiveTime |
0..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | When this Health Concern Act is a Social Determinant of Health Health Concern it **SHOULD** contain zero or more [0..*] entryRelationship subentries such that it contains an observation with an observation/value selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32962). Slice: Unordered, Open by profile:act, profile:observation, profile:organizer, value:typeCode | |
| entryRelationship:observations |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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 | ProblemObservation, AllergyIntoleranceObservation, AssessmentScaleObservation, SelfCareActivitiesADLandIADL, MentalStatusObservation, SmokingStatusMeaningfulUse, FunctionalStatusObservation, NutritionAssessment, PregnancyStatusObservation, ReactionObservation, ResultObservation, SensoryStatus, SocialHistoryObservation, SubstanceOrDeviceAllergyIntoleranceObservation, TobaccoUse, VitalSignObservation, LongitudinalCareWoundObservation, ProblemObservation, CaregiverCharacteristics, CulturalandReligiousObservation, CharacteristicsofHomeEnvironment, NutritionalStatusObservation, PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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:acts |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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, HospitalAdmissionDiagnosis, PostprocedureDiagnosis, PreoperativeDiagnosis, EntryReference | 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:organizers |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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 |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
C | 1..1 | FamilyHistoryOrganizer, ResultOrganizer | Base for all types and resources should-sdtctext-ref-value: SHOULD contain text/reference/@value |
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:related-entries |
0..* | EntryRelationship | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. This may also be used to refer to other Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding; while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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:component-health-concern-acts |
C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair","Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. 4515-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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 | ||
| reference |
0..* | Reference | Where it is necessary to reference an external clinical document such as a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber |
| 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) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:health-concern-act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.statusCode.code | required | ProblemActStatusCode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19 | |
| Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:observations.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:organizers.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:related-entries.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:component-health-concern-acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-32745 | error | Act.entryRelationship:component-health-concern-acts | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). : %resource.descendants().ofType(CDA.Act).where(templateId.exists($this.root = '2.16.840.1.113883.10.20.22.4.132' and $this.extension = '2022-06-01') and id.exists($this.root = %context.act.id.first().root and $this.extension ~ %context.act.id.first().extension)) | |
| II-1 | error | Act.typeId, Act.entryRelationship:observations.typeId, Act.entryRelationship:acts.typeId, Act.entryRelationship:organizers.typeId, Act.entryRelationship:related-entries.typeId, Act.entryRelationship:component-health-concern-acts.typeId, Act.reference.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-author | warning | Act.entryRelationship:observations.observation | SHOULD contain author : author.exists() | |
| should-sdtctext-ref-value | warning | Act.entryRelationship:organizers.organizer | SHOULD contain text/reference/@value : sdtcText.reference.value.exists() | |
| should-setId | warning | Act.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:observations.observation, Act.entryRelationship:acts.act, Act.entryRelationship:related-entries.act, Act.entryRelationship:component-health-concern-acts.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Act.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, 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 should-author: SHOULD contain author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:health-concern-act |
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: 2.16.840.1.113883.10.20.22.4.132 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| code |
1..1 | CD | Functional status assessment note Binding: v3 Code System ActCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75310-3 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| 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 |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: ProblemAct statusCode (required) | |
| @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) | |
| effectiveTime |
0..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | When this Health Concern Act is a Social Determinant of Health Health Concern it **SHOULD** contain zero or more [0..*] entryRelationship subentries such that it contains an observation with an observation/value selected from ValueSet [Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.788/expansion) **DYNAMIC** (CONF:4515-32962). Slice: Unordered, Open by profile:act, profile:observation, profile:organizer, value:typeCode | |
| entryRelationship:observations |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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 | ProblemObservation, AllergyIntoleranceObservation, AssessmentScaleObservation, SelfCareActivitiesADLandIADL, MentalStatusObservation, SmokingStatusMeaningfulUse, FunctionalStatusObservation, NutritionAssessment, PregnancyStatusObservation, ReactionObservation, ResultObservation, SensoryStatus, SocialHistoryObservation, SubstanceOrDeviceAllergyIntoleranceObservation, TobaccoUse, VitalSignObservation, LongitudinalCareWoundObservation, ProblemObservation, CaregiverCharacteristics, CulturalandReligiousObservation, CharacteristicsofHomeEnvironment, NutritionalStatusObservation, PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
| 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:acts |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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, HospitalAdmissionDiagnosis, PostprocedureDiagnosis, PreoperativeDiagnosis, EntryReference | 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:organizers |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @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 |
0..1 | Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
C | 1..1 | FamilyHistoryOrganizer, ResultOrganizer | Base for all types and resources should-sdtctext-ref-value: SHOULD contain text/reference/@value |
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:related-entries |
0..* | EntryRelationship | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. This may also be used to refer to other Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding; while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: REFR | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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:component-health-concern-acts |
C | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair","Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. 4515-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | EntryReference | 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 | ||
| reference |
0..* | Reference | Where it is necessary to reference an external clinical document such as a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| seperatableInd |
0..1 | BL | ||
| externalAct |
0..1 | ExternalAct | ||
| externalObservation |
0..1 | ExternalObservation | ||
| externalProcedure |
0..1 | ExternalProcedure | ||
| externalDocument |
C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber |
| 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) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:health-concern-act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.statusCode.code | required | ProblemActStatusCode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19 | |
| Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:observations.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:observations.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:acts.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:organizers.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:organizers.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:related-entries.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:related-entries.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.entryRelationship:component-health-concern-acts.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:component-health-concern-acts.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Act.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-32745 | error | Act.entryRelationship:component-health-concern-acts | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:4515-32745). : %resource.descendants().ofType(CDA.Act).where(templateId.exists($this.root = '2.16.840.1.113883.10.20.22.4.132' and $this.extension = '2022-06-01') and id.exists($this.root = %context.act.id.first().root and $this.extension ~ %context.act.id.first().extension)) | |
| II-1 | error | Act.typeId, Act.entryRelationship:observations.typeId, Act.entryRelationship:acts.typeId, Act.entryRelationship:organizers.typeId, Act.entryRelationship:related-entries.typeId, Act.entryRelationship:component-health-concern-acts.typeId, Act.reference.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-author | warning | Act.entryRelationship:observations.observation | SHOULD contain author : author.exists() | |
| should-sdtctext-ref-value | warning | Act.entryRelationship:organizers.organizer | SHOULD contain text/reference/@value : sdtcText.reference.value.exists() | |
| should-setId | warning | Act.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:observations.observation, Act.entryRelationship:acts.act, Act.entryRelationship:related-entries.act, Act.entryRelationship:component-health-concern-acts.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Act.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If 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 Act
Summary
Mandatory: 9 elements(6 nested mandatory elements)
Fixed: 8 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-12-19
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